Independence is dedicated to enhancing the health and well-being of the
people and communities we serve. Our Quality Management Program regularly
reviews the care and service our members receive and promotes clinical,
network, and service quality through its activities. Examples include member
safety and wellness initiatives, disseminating clinical practice guidelines and
standards of care, collecting member feedback on their care, and investigating
quality-of-care and service concerns. As a participating provider, you have
agreed to cooperate with, participate in, and abide by Independence's Quality
Management Program.
Standards of care
As a health care provider in our network, you are responsible for ensuring
that our members receive quality care. Please review our standards of care in
our Quality Management Program with your staff to confirm your office is
meeting our standard of care requirements:
- Access and availability standards. To ensure our managed
care networks meet the needs of our members, we provide standards for
appointment access, the minimum number of office hours per practice per week,
the maximum number of patients scheduled per hour per physician, and
availability after hours. Our access and availability standards are in
accordance with applicable regulatory requirements.
- Member rights and responsibilities. All Independence
members have defined rights and responsibilities, including the right to be
treated with respect, and the right to voice dissatisfaction about the quality
of care or service they received to their health plan.
- Privacy and confidentiality. Independence, our
contractors, and our affiliates are required to protect the privacy and
confidentiality of our members’ personal and health information in
accordance with applicable state and federal laws and regulations.
- Medical record keeping standards. Appropriate clinical
documentation is fundamental to facilitating continuous and coordinated care.
Medical records should be current, detailed, and organized as required by
applicable regulatory requirements. We regularly review compliance with these
standards and monitor the processes and procedures used to facilitate the
delivery of effective and appropriate plans of care.
- Utilization review. Our utilization review process is
intended to promote appropriate health care resource management and minimize
clinically inappropriate interventions. Utilization review decisions are
evidence-based and include a standardized review of the medical necessity of
health care services and supplies related to the benefits available under the
member’s coverage. We encourage peer-to-peer discussion by giving
physicians direct access to Independence Medical Directors to discuss coverage
decisions based on medical necessity. Additionally, clinical review criteria
are available upon request.
Member safety and wellness initiatives
The following member safety and wellness initiatives aim to promote
efficient utilization of services, facilitate coordination of care, promote
adherence to the plan of care, and help to improve outcomes:
- Complex case management. Members with complex medical
conditions like diabetes, asthma, high risk pregnancy, etc. may be eligible for
case management programs. You can refer members online or by calling 1-800-313-8628.
- Drug Utilization Review. Targeted drug utilization reports
are generated annually to identify opportunities for education related to
prescribing and care coordination practices. Reports are sent via mail to your
practice.
- Occurrence investigation. Our clinical staff, with Medical
Director oversight, review all reported occurrences for quality issues. Our
staff will request and review pertinent medical records, perform a detailed
analysis, and request a corrective action plan from the facility or provider,
if necessary. Please cooperate with all requests as outlined in your
contract.
- Blue Distinction® Specialty Care. Our
Quality Management Program is responsible for recognizing facilities as Blue
Distinction® Centers and Blue Distinction®
Centers+ through the Blue Distinction® Specialty Care program
when they meet stringent, objective national criteria for excellence in
outcomes. Our members can see this designation in our online Commercial and Medicare Advantage Find a Doctor
tools.
Learn more
For more information about our Quality Management Program, including our
goals and activities, visit our website or call Customer Service at 1-800-ASK-BLUE
(1-800-275-2583).
Information can also be found in the Provider Manual for Participating
Professional Providers and/or the Hospital Manual for Participating
Hospitals, Ancillary Facilities, and Ancillary Providers, which are
available through the NaviNet® web portal (NaviNet Open). Paper
copies of the manuals can be ordered online.
NaviNet® is a
registered trademark of NantHealth, an independent company.