Quality assurance

Healthy Blue maintains a comprehensive quality assurance program to objectively monitor and systematically evaluate the care and service provided to members. The scope and content of the program reflects the demographic and epidemiological needs of the population served. Studies are planned across the continuum of care and service, with ongoing proactive evaluation and refinement of the program.

Medical management model

Our Utilization Management (UM) program uses an integrated medical management model based on the physical, behavioral, and social needs of members. The UM program, in collaboration with other departments such as Case Management and Disease Management, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

By collecting individualized data from intake information upon enrollment, historical claims data, and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactable. The care plans developed based on this information are specific to a member needs. The members’ provider(s) are also engaged in the development and execution of the plan so the care is integrated across physical, behavioral and social spectrums.

Care management model

Our member-centric care management model integrates behavioral, physical, and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health, and a “member home” approach that promotes collaboration among members, family, service coordinators, providers, and community resources.

This approach to care management was specifically designed to meet the needs of Medicaid recipients, including those with disabilities and special health care needs.

Clinical Practice Guidelines

Related information

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).