Organizational Structure of The QI Program

Function

The Quality Peer Review Committee (QPRC) reviews potential quality of care issues that are referred to the QPRC. The goal is to ensure that Horizon members are receiving quality medical, behavioral health care and excellent service. The Quality Peer Review Committee reports to the Quality Improvement Committee (QIC) for each respective line of business.

The committee reviews quality of care and service issues that were referred because of an issue that directly affects the quality of care members receive. Referrals may be received from members, providers and external agencies as well as internal departments. The Quality Peer Review Committee addresses deviations from accepted standards of professional practice through education, requests for plans of correction and when indicated, sanctions. The committee reviews, trends, and analyzes data concerning the QPRC Program and reports findings to the Quality Improvement Committee. A Horizon Medical Director or designee chairs the committee. Participants consist of voting members, presenters and Legal Counsel when needed. A quorum is 3 voting members. Voting members are identified at the start of the meeting.

Voting members of QPRC action items include:

• Horizon Medical Director(s)
• At least one external board certified participating physician not employed by Horizon with an unrestricted license to practice medicine in the State of New Jersey

In the event of a sanctioning appeal, voting members include:

• Three (3) physician members who have not participated in the original sanctioning determination, including one external board certified participating provider.

In order to guarantee peer representation on the QPRC, ad hoc members will be added to the committee for specialized circumstances as deemed necessary.

Other medical and non-medical personnel may attend and participate without vote.

Non-voting members or their designee, down to a manager level, who attend the meetings on a regular basis include:

• Assistant General Counsel
• Director, Quality Management Clinical Operations
• Director, Behavioral Health Clinical Operations
• Manager, Quality Management & Administration
• Quality Risk Manager
• Quality Management Nurses
• Care/Case Disease Management Nurses
• Behavioral Health Quality Auditors
• Managed Long Term Services and Supports (MLTSS)
• Dual Special Needs (DSNP)

Accountability

QPRC is charged with the following responsibilities:

• Review potential deviations from accepted standards of professional practice
• Determine if a deviation of care exists
• Assign a level of care sanction as appropriate
• Recommend actions to address the deviation to include, but not limited to; education, Corrective Action Plan (CAP), or sanctions
• Review and approve policies related to the scope of QPRC
• Track quality indicators quarterly
• Serve as a forum for education and discussion regarding Quality of Care (QOC)
• Refer Quality of Service issues to the appropriate internal Horizon Committee(s)

Frequency of Meetings

This committee meets a minimum of six (6) times per year. In addition, this committee may meet on an ad hoc basis if necessary.

Function

The Medical Management Committee serves as a supporting committee to the QIC. This committee is responsible for reviewing, analyzing and trending Horizon Medical Management and Complex Case Management data and their respective lines of business, Commercial (HMO, POS, Direct Access, EPO, PPO, Indemnity), Horizon’s Marketplace Products, FEHBP and self-funded accounts, such as SHBP, that elect to participate in the Medical Management and Complex Case Management Programs, but excluding Government Programs products.

Accountability

The responsibilities of the Medical Management Committee include, but are not limited to:

• Annual approval of the Medical Management Program Description, Program Evaluation and Work Plan, including the Complex Case Management Program.
• Annual evaluation of the Medical Management Work Plan.
• Annual approval of the Pharmacy Medical Management Program Description and Evaluation.
• Approval of Medical Management Programs and Program Evaluations as applicable to the delegates.
• Annual review of clinical criteria.
• Monitoring of inpatient hospitalization data.
• Annual review of administrative policies pertaining to Medical Management/Case management (MM/CM).
• Monitoring of appeals data.
• Monitoring of utilization data, including patterns of over and underutilization.
• Review of program and / or product specific initiatives (e.g. – FEP).
• Selection and monitoring of MM and CM initiatives.
• Monitoring of the Prior Authorization Process.
• Evaluation of Physician, Nurse, Behavioral Health Clinician, and Physical Therapist Inter-rater reports.
• Monitoring of Delegate utilization data.
• Monitoring of Case Management Program outcomes.
• Monitoring of MM and CM compliance with external accreditation standards and regulatory requirements.
• Assessment of member/covered person and provider satisfaction with the Medical Management and Complex Case Management process.
• Identification and referral of data, policy, and quality issues, as appropriate, to the Quality Improvement Committee, Appeals Subcommittee, Clinical Issue Subcommittee, Medical Policy Subcommittee, Delegate and Vendor Oversight Subcommittee, Quality Case Review Subcommittee and/or Credentialing Subcommittee.
• Follow-up for Medical Management and Complex Case Management activities, as appropriate.

Frequency of Meetings

The Medical Management Committee meets no less than six (6) times per year.

Committee Composition

• Senior Medical Director, HCM&T (Chairperson and tie breaker voting member)
• Medical Director – HCM&T (2 voting members)
• Director – Quality Assurance (1 voting member)
• Executive/Senior Medical Director, Medical Policy (1 voting member)
• Manager, Utilization Management Appeals (1 voting member)
• Directors/Managers, Clinical Operations and other Clinical Directors/Managers, (3 voting members)
• Medical Director (Behavioral Health) (1 voting member)
• Director/Manager, Delegate & Vendor Oversight (1 voting member)
• External Participating Physicians (1-2 voting members)
• Director Clinical Behavioral Health (1 voting member)
• Manager, Manager Pharmacy (1 voting member)
• Other representatives as requested by Chairperson or person officially in “acting position” for any of the above positions – (non-voting)

Function

The Committee reviews Stage 2 medical appeals brought by members/covered persons pursuant to Horizon’s Member Medical Appeals policy. The Committee’s voting membership consists of a chairperson (tie breaker), participating physicians who are board-certified with valid unrestricted licensure to practice in New Jersey (up to 3 voting members), at least two (2) but no more than four (4) community representatives/non-Horizon employees or providers; a minimum of 1 must be a Horizon member, and participating physicians practicing in the appropriate specialties, as needed (nonvoting members).

Accountability

The member, provider acting on behalf of a member with the member’s consent, and/or duly authorized representative receives notice of a final determination and confirmation, in writing, within the timeframes provided for in the Member Appeals policy and procedure. The written notification documents the reasons for the decision and advises members on how they can file an external appeal, if applicable.

• Urgent medical appeals are reviewed by the Expedited Member Appeals Committee and communicated via telephone to the appellant. Written confirmation will follow. The whole process does not exceed the timeframes set forth in the Member Medical Appeals policy and procedure.
• The Member Appeals Committee reports quarterly to the Quality Improvement Committee (QIC).
• The Member Appeals Committee complies with applicable state or federal regulations and/or requirements.
• The Committee chair, Sr. Medical Director of Utilization Management (UM) or his/her designee appoints committee members to serve a one (1) year term of office. The members may be re-appointed annually. All prospective members are subject to approval by a majority vote of current members.

Frequency of Meetings

The member Appeals Committee meets at least once a month. Additional meetings will be scheduled as needed.

Function

The Delegate and Vendor Oversight Committee (DVOC) of the QIC is an interdisciplinary committee that provides oversight of vendor healthcare contracts and selected vendor non-healthcare contracts. The Delegate and Vendor Oversight Committee reports quarterly to QIC. The Committee’s voting membership consists of the Director, Network Program and DVO (tie breaker), Manager, ICI DVOD (1 voting member), Manager, Horizon Medical Policy Medical Director (1 voting member), Manager, Customer Service Operations (1 voting member), Director, Clinical Operations (1voting member), Director/Manager, Utilization Management (UM) Appeals (1 voting member), Director/Manager, Network Contracting (1 voting member), Director, Pharmacy Operations (1 voting member), Manager, Quality/Accreditation Management (1 voting member), Manager, Services and Partner Management (1 voting member), Manager, Sourcing & Supplier Management (1 voting member), Manager, Physician Data Management (1 voting member), Director Delegate Vendor Contract Management/Vetting and Implementation (1 voting member), Director, Clinical SNP, Director, Managed Care Long Term Services and Support (MLTSS) (1 voting member) and Medical Director, Dental Operations (1 voting member).

Accountability

The annual QI work plan approved by the QIC may include action items assigned to the Delegate and Vendor Oversight Committee. The committee is then responsible for the creation of a committee work plan that will include the QIC assignments and other issues identified within the committee. Updates to this plan are given to the QIC on a quarterly basis, and/or on as needed.

• The committee is responsible for the annual review of policies that fall within its scope of responsibility.
• The committee ensures that all new delegates have received a pre-delegation review.
• The committee reviews, makes recommendations and votes to approve or disapprove quarterly reports for each delegated function (i.e. Continuous Quality Improvement, Utilization Management, Case Management, Customer Service and Provider Credentialing activities) and for vendors and providers as appropriate.
• The committee reviews annual audits of the delegates’ clinical and administrative policy and procedures manuals, committee minutes, Quality Improvement studies and corrective action plans, operational results (claims, correspondence, complaints and customer service), and periodically participates in the delegate’s quality meetings.
• The committee is the primary body charged with carrying out the Delegate and Vendor Oversight Policy. Recommendations, including corrective action plans made by the Committee, will be addressed by the Delegate and Vendor Oversight Department. In addition, the committee is responsible for ensuring that all delegates comply with external accreditation standards, compliant with State and Federal regulations, and meet contractual performance measures.
• The committee reviews, makes recommendations and votes to approve or disapprove reports submitted by contracted delegates, certain vendors, and certain ancillary providers as defined in the Delegate and Vendor Oversight Policy.
• The committee reviews, makes recommendations and votes to approve or disapprove quarterly reports of certain non-healthcare and healthcare vendors with whom Horizon contracts. The delegate/vendor oversight process will monitor vendor performance and compliance with contractual and regulatory requirements on an enterprise-wide basis.

Frequency of Meetings

The Delegate and Vendor Oversight Committee meets at least quarterly and more frequently as needed. Committee meetings may be scheduled on an ad hoc basis as needed.

Function

The Credentials Committee is a committee of the QIC established for the purpose of implementation and oversight of a program for credentialing and re-credentialing of physicians, healthcare professionals, facilities, and ancillary providers who fall under the scope and authority of the Credentials Committee Charter and Credentialing and Recredentialing Administrative Policies. Voting members consist of the Medical Director / chair (tie breaker), physicians and/or other healthcare professionals that are participating in the Horizon Managed Care Network, Horizon PPO Network and/or Horizon NJ Health Medicaid Networks (between 2 and 5 voting members), medical directors (between 3 and 7 voting members) representing the following Department: Healthcare Management, Government Programs, Transformation and Behavioral Health.

Consultant voting members of the Credentials Committee may be appointed, as necessary, to conduct the business of the Credentials Committee with regard to the credentialing and re-credentialing, certification and re-certification of specialist physicians, healthcare professionals and ancillary providers and facilities.

Accountability

• The Credentials Committee reports to the QIC regarding credentialing and re-credentialing decisions which are made, and advises and makes recommendations to the QIC with respect to the following:
  • The establishment of criteria for participation in the Horizon Managed Care, Horizon PPO, Horizon NJ Health and Horizon Casualty Services Networks (collectively “Networks”).
  • The establishment of guidelines for submission and review of initial and renewal applications for participation in the Networks.
  • The establishment and annual review of policies and procedures as may be appropriate for the Credentials Committee to carry out its purpose and function.
  • Monitoring of Credentialing and Re-credentialing compliance with accreditation and regulatory requirements.
• The Credentials Committee engages in other activities designated by the QIC and/or as may be necessary for the Credentials Committee to carry out its responsibilities.
• The Credentials Committee determines the eligibility of initial applicants and renewal applicants for participation in the Networks, and certification and/or re-certification as required by Horizon.
• The Credentials Committee provides guidance to organization staff on the overall direction of the credentialing program.
• The Credentials Committee evaluates and reports to organization management on the effectiveness of the credentialing program.

Frequency of Meetings

The Credentials Committee meets no less than ten (10) times per year, at least every 45 days.

Function

The role of the Member Appeals Committee-Benefit Issues Complaints (MAC-BIC) relates to the review of a Member appeal regarding a benefit-based adverse benefit determination. The MAC-BIC is an interdisciplinary Committee that reviews unresolved benefit-related appeals received by Horizon. Committee composition shall consist of up to 8 voting members with at least a minimum of 4 Committee members attending each meeting. For expedited meetings, the Committee shall consist of at least 3 voting members. Attendance consists of any combination of the following: Chairperson (attendance required/tie breaker), a Manager from Service Operations, a Network Relations Representative, a Medical Director, and a Medical Management Team Representative. The Committee may also contract with up to three (3) external consumer advocates.

Accountability

The MAC-BIC Committee hears benefit appeals per the procedures described in the Members/Covered Persons Inquiries, Complaints and Appeals Policy. The member/covered person or authorized representative receives a final written determination following the MAC-BIC Committee meeting. The written notification documents the reason for the decision and advises members of any additional appeal rights if the outcome is not favorable to the member. If the member or their authorized representative participates in the meeting via teleconference or in-person, they will be informed of the decision via telephone by close of business the day after the MAC-BIC Committee meets. On a quarterly basis, the summary information pertaining to the Committee’s determinations submitted to the QIC.

Frequency of Meetings

The MAC-BIC Committee meets at least once a week, with additional meetings scheduled as needed.

Function

The Pharmacy and Therapeutics Committee (the “P&T Committee”) of Horizon is a multi-disciplinary committee of health care professionals that is charged with identifying opportunities for quality improvement and cost-effectiveness by reviewing therapeutic classes of drugs and new drug therapies, developing medical guidelines and a process to work with those practitioners licensed to prescribe in achieving quality and appropriate prescribing patterns within the health plans underwritten or administered by Horizon. The P&T Committee also makes tiering decisions, and develops and documents procedures to ensure appropriate drug review and inclusion. Additionally the P&T Committee will ensure that the formulary drug list covers a range of drugs across a broad distribution of therapeutic categories and classes and regimens that does not discourage enrollment by any group. The committee will also provide appropriate access to drugs that are included in broadly accepted treatment guidelines and that are indicative of general best practices at the time of the analysis. Additionally, the committee conducts a quarterly evaluation of treatment protocols, policies and procedures related to the plan's formulary and its operations, which includes, but is not limited to, the medical necessity criteria for formulary drugs, which drugs on the formulary are subject to prior authorization or other utilization review activities, and the procedures associated with such activities. As part of such evaluation process, the P&T and Horizon will implement any necessary updates to its treatment protocols, policies and procedures.

There must be at least ten (10) voting members, excluding the Chairperson and Co-chair. At least two-thirds (2/3) of the P&T Committee members shall be practicing physicians and pharmacists.

Accountability

• The P&T Committee shall objectively review the medical usefulness of all available pharmaceuticals for safety and effectiveness and provides input into drug utilization review activities and the analysis of adverse reactions of drug therapy Cost analysis of the available pharmaceuticals must also be considered. In addition, when requested by Horizon, the P&T Committee will provide input on recommendations Horizon may make to the Horizon physician networks regarding the appropriate use of pharmaceuticals, methods to measure the quality of drug prescribing and educational programs for Horizon members and providers.

• All actions of the P&T Committee are reported to the Quality Improvement Committee on a quarterly basis.

Frequency of Meetings

The P&T Committee holds quarterly meetings. Special meetings may be held if the chairperson determines it to be necessary and appropriate.

Function

The Member Provider Service Satisfaction Committee (MPSSC) reports to the QIC and reviews, approves and oversees improvement activities that have an impact on provider and member services and satisfaction. The committee consists of at least 15, but not more than 20 members. The MPSSC reports quarterly to the QIC.

Accountability

The committee focus is oversight and direction of provider and member service improvement initiatives. The committee:

• Monitors provider and member service quality data.
• Identifies quality improvement opportunities.
• Conducts root cause analyses and barrier analyses.
• Measures and analyzes results with respect to overall goals.
• Monitors ongoing QI activities for improvement and recommends revisions as necessary.

The committee oversees collection, reporting and trending of member and provider service quality data including but not limited to the following:

• NCQA and other accreditation information.
• Focus is on HMO, POS/DA, PPO, EPO, and Horizon’s Marketplace Products.
• Member and provider contact volume.
• Member and provider call Average Speed of Answer rates.
• Member and provider call abandonment rates.
• Member complaints and appeals volume, status and turnaround time.
• Provider complaints and appeals volume, status and turnaround time.
• Annual and on-going member and provider satisfaction data (CAHPS – Office Managers-Member Experience – First Call Resolution – Member Touchpoint Measures).

The committee reviews all activities pertaining to member/provider service quality issues, except clinical care issues. A quarterly summary of actions, recommendations and process improvement activities are reviewed and approved. The committee reviews recommended activities and reports submitted and appoints appropriate staff or workgroup from:

• Service Division
• HealthCare Management
• Market Business Units

The committee ensures appropriate resources are assigned and accountable for approved and recommended activities.

The co-chairpersons of the committee appoint work teams to develop action plans and proposals related to specific issues. The committee annually oversees and approves all policies and procedures related to compliance with regulatory and accreditation requirements. Member’s rights and responsibilities are also reviewed annually and updated as appropriate.

Frequency of Meetings

The MPSSC meets quarterly throughout the year.

Function

The Clinical Policy Committee (CPC) is responsible for the following functions:

• Identify, prioritize and develop medical policies for the commercial products underwritten by Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc. and Horizon Insurance Company, and for the self-insured products, as applicable. Medical policies, as approved by the commercial Horizon Clinical Policy Committee, may also apply to Government Programs products if Government Programs has no comparable medical policy or other guidance.
• Provide medical expertise and experience in policy development.
• Assist in researching medical issues, obtaining specialty consultations and feedback from the medical community on policy issues.
• Review and update existing medical policies, as necessary.

The CPC reports to the Quality Improvement Committee (QIC) and reviews and advises the QIC on the clinical content, validity and appropriateness of medical and pharmacy policies. Voting members consist of the chairperson, who is the Medical Director for Medical Policy or his/her designee (tie breaker voting member), at least one (1) but no more than three (3) participating providers, at least two (2) but no more than four (4) Horizon medical directors from the Health Care Management Division, one (1) Medical Director of Major/National Accounts and one (1) Horizon Behavioral Health Medical Director.

Accountability

Review and advise on the content and quality of physical, behavioral and pharmacy policies including but not limited to:

• Evidence based data from clinical trials, studies and articles, published in peer-reviewed literature.
• Accessibility to health care for members.
• Utilization and medical necessity, indication or appropriateness of medical services.
• Provider and member education.

The Clinical Policy Committee shall also have the accountability for the following:

• Developing medical policies that reflect evidence-based best medical practice, promote high standard of quality care, promote efficient and appropriate use of resources, and minimize risk to our members.
• Evaluating emerging and new technologies.
• Identifying services that result in improved clinical outcomes.
• Assisting in the education of internal and external customers regarding medical policy.

Frequency of Meetings

The Clinical Policy Committee meets no fewer than ten (10) times per year.

Function

The Value Based Programs’ Quality Advisory Committee (QAC) is comprised of members representing various disciplines within Horizon Blue Cross Blue Shield of New Jersey whose diverse knowledge will provide clinical and healthcare administration expertise representation from a variety of specialties relating to the development of Value Based Programs’ initiatives. In addition, committee members will act as ambassadors to the Enterprise to communicate Value Based Programs’ goals and strategies. The committee consists of the Executive Medical Director, Population Health, Healthcare Management (HCM) Vice Chairperson, (voting member); HCM Committee Administrator (non-voting member); Director, New Models and Episodes of Care (EOC) (voting member); Director Healthcare Marketplace Innovations, (voting member); Medical Directors, including the following Healthcare Management and Transformation (HCM & T) areas: Quality Management, Medical Policy, Population Health, Partner Transformation (voting members); Directors, including the following Healthcare Management and Transformation areas: Partner Transformation Value Based Programs and Community Health (voting members) and various Representatives, including but not limited to the following areas: Pharmacy Analytics, Value based contracting, Quality Management, Medical Policy, Healthcare Management and Transformation, (non-voting members).

Accountability

• Assesses and advises Horizon’s value based programs quality metrics on a quarterly or ad hoc basis as needed.
• Reviews and monitors quality performance of Value Based and Episode of Care provider partners including but not limited to recommending corrective action plans if appropriate.
• Evaluates quality as an integral component of shared savings opportunities with partners in value based programs.
• On an annual basis, documents Horizon’s enterprise-wide value based programs’ strategies for the year.
• Reports all actions to Horizon’s Quality Improvement Committee following all QAC meetings.
• Forms a QAC sub-committee when necessary for the efficient functioning of the Value Based Programs to meet project deadlines or as otherwise directed.

Frequency of Meetings

The Value Based Programs Quality Advisory Committee Team will meet on a quarterly basis, additional communications may occur as required.

The President and CEO is responsible for the overall operations of the Quality Improvement Program.

The Vice President and Chief Medical Officer reports to the Executive Vice President of Healthcare Management, chairs the Quality Committee of the Board and is responsible for design and implementation of the Quality Improvement Program. He/she ensures that quality activities are prioritized based on membership needs and integrates the Medical Management (including population health management activities) and Credentialing programs with the Quality Improvement Program.

The Chief Pharmacy Officer plans and directs pharmacy benefit management activity, including specialty pharmacy management. This includes oversight of the P&T Committee, clinical development activity, utilization and quality management and medication safety, benefit administration, operations, sales and marketing support and business development. The Chief Pharmacy Officer is responsible for the contracted PBM. Performance measurement is managed in conjunction with the Delegate and Vendor Oversight Committee which is part of the Quality structure and reports to the Quality Improvement Committee.

Senior Medical Directors may be assigned specific oversight of key functions and areas of importance as determined by the Chief Medical Officer, including designated chair of the Quality Improvement Committee, and also chairs/or participates in Medical Management Committee, Provider Appeals Committee, Member Appeals Committee, and the Quality Committee of the Board. Their roles include overseeing the implementation of the QI Program that involve or affect clinical care, patient safety, and the overall development and evaluation of the QI Program.

The Medical Directors are responsible for conducting peer and utilization management review, and may be delegated to chair various committees or to serve on committees

The BH Medical Director is the designated behavioral health care practitioner who is actively involved in the behavioral health care aspects of the QI program. Some of his/her responsibilities consist of coordination of the and development of the BH activities included in the Quality Improvement Program Description, Quality Work Plan, mid-year Quality Work Plan Update, and the annual QI Program Evaluation. The Medical Director is also responsible for the implementation and review of the behavioral health safety program and adherence to corporate compliance policies and procedures.

The Director of Quality Performance and Stars reports to the VP & Chief Medical Officer. The director has experience in Continuous Quality Improvement (CQI) methodology, state contractual requirements, and NCQA, and CMS quality standards. The director has a master’s degree in business administration, with concentrations in management information systems and risk management. The director is responsible for design, development, and implementation of on-going improvement and maintenance of quality improvement initiatives necessary for attaining NCQA accreditation, and meeting CMS contractual requirements. The director provides leadership for implementing, monitoring and evaluating the Quality Improvement Program. The director leads and directs processes and overall quality improvement activities that produce better patient care and more efficient operations. The director is also responsible for the oversight of the business areas within the Quality Management Department including HEDIS, Star Ratings, pay for performance and population health.

The Team Quality Managers oversee the day-to-day operations of the Quality Improvement programs. Additionally, they manage clinical quality complaints, adverse events, Member Advocacy, management of HEDIS® program, training and quality audits, and accreditation.

In the event a position becomes vacant, the Medical Director and/or Quality Management Director will delegate the responsibilities in coordination with other team members.