Program Scope

The Quality Improvement Program provides a mechanism for the coordination of both quality improvement and quality management activities. The scope of this program includes the objective and systematic monitoring of the quality and safety of health care services provided to Horizon members. In an effort to improve organization performance, collaborative and specific indicators of both processes and outcomes of care are developed, measured and assessed by all appropriate departments in a timely manner.

The membership served by the Quality Improvement Program is from the following product lines: Commercial including Qualified Health Plans, HMO, POS, Direct Access, EPO, PPO, FEHBP, and self-funded accounts (e.g. SHBP). It does not include products aligned to the Government Programs division (e.g. Medicare, MLTSS, FIDE SNP and Medicaid).

The program has two major components: clinical and service. The range of the clinical activities is extensive, encompassing preventive care, acute care, chronic care, and care provided for special populations, including behavioral health. It monitors provider credentialing and compliance, member education, health outcomes, screening, practice guidelines, delegation and medical record documentation. The service component of the program monitors availability and accessibility of care, network adequacy, member/provider satisfaction, and member complaints and appeals.