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QI Program’s Function/Process

Detailed processes and methodology are used to determine the overall efficacy of performance improvement activities and programs. The monitoring of specific indicators is designed, measured and assessed by all appropriate departments, disciplines and services to reveal trends and performance improvement opportunities in an effort to improve organizational performance. These indicators are objective, measurable, based on current scientific knowledge and clinical experience, broadly recognized in the industry and are structured to produce statistically valid performance measures of care and services provided.


  • Identification of important issues that reflect significant aspects of care and service.
  • Selection and/or development of adequate metrics.
  • Selection of goals and/or benchmarks for each measure/metric.
  • Measurement, tracking and trending.
  • Identification of opportunities for improvement based available data.
  • Root cause analysis.
  • Implementation of interventions or corrective actions referring to the identified opportunities for improvement.
  • Re-measure to determine the effectiveness of the interventions based on statistical significant improvement and/or reaching a goal or benchmark.

Member Safety

Horizon has a dedicated commitment to patient safety; it is of the utmost importance to Horizon and its membership. Promoting patient safety encompasses a wide range of activities in the Quality Improvement domain:

  • Drug-Drug Interaction Reject (DDIR) Program to identify potential serious drug interactions at the point of service.
  • Reducing prescribing errors by encouraging and supporting e-prescribing.
  • Retrospective analysis and evaluation of clinical data through Drug Utilization Reviews (DUR) Program.
  • Identification of potential drug-drug interactions through Point of Service edits.
  • Prior Authorization Program: This is a program in which certain prescription drugs require Horizon’s prior authorization before the prescription drug can be dispensed. If prior authorization is not obtained for the requested prescription drug, the requested drug rejects at the point-of-service. Specific prescription drugs may require prior authorization due to any of the following factors:
    • The drug has the potential for significant inappropriate use or abuse
    • Use of the drug carries a significant safety concern (adverse events could occur or patient monitoring needed)
  • Quantity Limit and Age Limit Programs are safety edits in the adjudication system based on FDA approved product labeling and clinical pivotal trials to allow dispensing of the drugs up to the FDA recommended maximum dosage and to not allow drug coverage for certain populations, such as pediatrics, based on limited clinical data.
  • Dose Optimization Program: This program is part of the dispensing limit requirements, for drugs that are FDA approved for once a day dosing. This program encourages the use of higher strengths once a day and discourages the use of lower strengths which require multiple dosing throughout the day, thus generally improving the likelihood of patient compliance.
  • Drug Recalls, Black Box Warnings and Safety Alerts: When a drug is withdrawn / recalled from the market or when a drug has a new black box warning, Horizon’s Pharmacy Benefit Manager on behalf of Horizon Pharmacy Services, will notify participating providers and affected members.
  • Duplicate Therapy: Through this program a licensed pharmacist retrospectively reviews member and pharmacy claims for potential duplicate therapies dispensed in the previous quarter to help ensure safe and appropriate utilization.
  • Clinical programs with a focus on safety, underutilization and overutilization.
  • Opioid Management Program, to reduce inappropriate prescribing and utilization through case based reviews and physician outreach. The purpose of the narcotic management program is to reduce inappropriate prescribing and inappropriate utilization through case based reviews. Different Horizon departments, such as case management and investigations, collaborate to assist in making effective interventions.
  • Horizon maintains a website with a drug to drug interaction tool and a drug database that informs members regarding drug therapy, how to take drugs, potential side effects, etc.
  • Newsletters: Pharmacy related topics are published in the member and provider newsletters on various drug information such as, drug coverage and other clinical programs annually and quarterly respectively.
  • Gaps in Care Program to promote appropriate drug therapy and improve quality of life for our members through avoidance of medical complications and slowing disease progression.
  • The use of HEDIS results to identify areas for improvement and to ensure that our members are continuously receiving safe and appropriate care (i.e. Diabetes treatment, Rheumatoid Arthritis, Adherence and High Risk Medications).
  • Maintaining a safety conscious provider network through diligent credentialing.
  • Monitoring continuity of care across treatment sites and between physical and behavioral health.
  • Monitoring adherence to clinical practice guidelines at the provider level.

Disparities in Health

Disparities in health reduce the overall quality of care provided within the health care system while adding to overall health care costs. In 2022, to address the multiplicity of the needs of the membership, the QI Program will continue to identify and address disparities in health outcomes among different member populations. Horizon programs to reduce disparities in health will be driven by discussions held during Disparities Workgroup and QIC meetings, as well as recommendations made by the QIC. The interventions selected to reduce health care disparities in clinical and service areas will be instituted during 2022 and will be included in the 2022 QI Work Plan. Current topics under the review include: Breast Cancer Screening (BCS); Cervical Cancer Screening (CS); Prostate Cancer Screening: and Social Determinants of Health. Horizon’s ongoing efforts to reduce disparities will be coordinated and monitored through the QIC. The goal of is to implement interventions and community health events which reduce disparities between differing member populations.

Cultural Competency and Health Literacy

Horizon recognizes the cultural diversity and health literacy needs of its health plan members. The Plan is committed to promoting cultural competency, increasing health literacy, and decreasing health care disparities regardless of gender, age, race, ethnicity, disability, gender identity or sexual orientation. Horizon utilizes data from multiple sources to develop and implement policies and programs that increase cultural competency and health literacy. All staff and participating providers receive training on diversity, bias or inclusion. Additionally, efforts are made to promote diversity in hiring and recruiting.

Members speaking a language other than English have access to the AT&T language line whenever they need to interact with Horizon, and they can look for a provider speaking their language in the provider directory. Horizon also has a bilingual website dedicated to Spanish speaking members.

All members have translation services and materials available in Spanish, which is the predominant non-English language among Horizon’s members. Documents can be requested in other languages upon request.

Complex Health Needs

The mission of the Horizon Chronic Care Program is to promote the wellbeing of members with chronic illnesses by empowering them to actively participate and take responsibility for their own health. Through the provision of education, coaching/counseling, and access to quality healthcare, members are better able to self-manage their disease(s) and enjoy an improved quality of life. The Chronic Care Program maintains open business hours of operation between 8AM and 5PM EST Monday through Friday. The Chronic Care Program is available through the Federal Employee Program (FEP) and Horizon Employee Program (HEU).

The Chronic Care Program is a multidisciplinary, continuum-based approach to health care delivery that proactively identifies populations with, or at risk for, chronic physical conditions. It includes coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Chronic care supports the practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing cost effective, evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

The Chronic Care Program focuses on the following chronic conditions:

  1. Asthma
  2. Coronary Artery Disease (CAD)
  3. Diabetes
  4. Heart Failure (HF)
  5. Chronic Obstructive Pulmonary Disease (COPD)

The Chronic Care Programs have disease-specific interventions based on the stratification level or severity of the member’s condition. Stratification and assessment are inter-related, and both provide data used to assign a member to a risk level for intensity of specific interventions. Eligible members are assigned to one of three risk levels, or stratifications, based on the predictive model application or through an assessment accomplished with the input of the member. Low Risk is the lowest risk level and High Risk is the highest risk level, which requires the highest intensity.

Members are identified for the Chronic Care Program using Horizon BCBSNJ’s own clinical identification algorithms, based on medical, laboratory, and pharmacy claims data, member medication compliance reports, individual utilization profiles, and using the Health Status Indicator (HSI) Specifications and Clinical Exclusion List.

Member Interventions: Member interventions include: educational mailings, telephonic educational coaching, assisting the member to understand treatment options, education on appropriate use of medications, appropriate nutrition, avoiding disease exacerbations, improving communication with his/her physician, and connecting members with community resources.

Outcomes: The FEP Chronic Care program assessment is completed annually through a member satisfaction survey.

Quality Assurance

Quality Improvement Program Components

The following are brief descriptions of the various components of the Quality Improvement Program. For a full description of the programmatic elements as well as to which lines of Horizon’s business they apply, see the relevant administrative policies relating to that function.

Preventive Health and Wellness

The goal of Horizon’s Preventive Health and Wellness Program is to improve the member’s quality of health by encouraging them to pursue healthy lifestyles and maintain optimal wellness. Key components of the program include assisting members/covered persons to obtain needed immunizations and screening tests, and educating members on preventive health care, known to reduce illness, and accidents, and promote the early detection of potential disease conditions. The program uses a variety of reminder techniques for this purpose such as automated reminder telephone calls; health risk appraisals, interactive tools through the member portal; newsletters targeted to a specific populations; mailings, and preventive health calendars. The aim is to reach members in a manner to which they can easily relate.

Horizon’s Preventive Health Program is based on preventive health care guidelines that are selected and maintained by Horizon. These guidelines were adopted from national organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics; the American Academy of Family Physicians; the Agency for Health Care Policy and Research; American Cancer Society and the American Diabetes Association. The guidelines are age, gender, and risk-status specific and describe the prevention or early detection interventions recommended along with frequency and conditions under which the interventions are required. Target preventive health activities include, but are not limited to: childhood and adult immunizations, women’s health needs, nutrition, high blood pressure, smoking cessation, and depression.

Internal staff members who utilize Clinical Practice Guidelines (CPGs) access information through the Lotus Notes database. CPGs can also be accessed through the Care Radius medical management system.

Horizon updates the preventive health guidelines and distributes them to participating physicians and members via newsletters. Providers can also access information via the provider portal.

Population Health Management

Horizon manages Commercial and Marketplace members through multiple programs to increase member satisfaction, improve health outcomes and reduce cost, known as the Triple Aim. The Plan utilizes a data-driven approach to population health management of its member population. This approach includes stratifying the population into four quadrants (Healthy, Rising Risk, Complex Care and Safety and Outcomes). In addition, the population is also segmented by location (zip code, city or county), age and gender.

The objective of the Population Health Management Program is to improve the overall health and wellness of the population through programs that encourage preventive health services, health and disease maintenance programs and appropriate utilization of practitioner and other provider services. Through population analysis, interventions are designed based on the target population’s needs and barriers to help them achieve their best health. The Population Health Program is available to all active enrolled members, who may opt out via a telephone call to be placed on a do not contact list.

Annually, Horizon reviews and assesses the characteristics of the Commercial and Marketplace populations and selects subpopulations to ensure that adequate programs, staff and community resources are available to meet the health care needs of our members. Those subpopulations are children and adolescents, members with disabilities, and members with severe and persistent mental illness. Findings are presented, reviewed, and approved annually by the Quality Improvement Committee (QIC).

Care Management

Care Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a member’s physical and psychological needs. Its primary focus is the coordination of appropriate quality health care in the most cost-effective manner for members with complex physical and behavioral conditions. The intensity of care management activities varies based on a multitude of factors including, but not limited to:

  • Clinical features of the individual case as reported by a member or attending/treating provider;
  • Evaluation/treatment setting resources available
  • The member’s clinical needs and situation; and
  • The opportunity for case management intervention to have a positive impact on the member’s circumstances. Care Management activities and the result of these activities are summarized and reported to the Medical Management Committee.

The objectives of the Care Management Program are as follows:

  • To assure timely patient access to the appropriate type and level of care as early as possible.
  • To manage health care benefits as effectively as possible while pursuing all members needs from a patient advocacy perspective.
  • To identify needs that follow an acute care episode and assists with interventions for long–term health problems.
  • To identify members who may benefit from educational programs, materials and other services that can be offered, including community services and provides evidence-based tools and resources.
  • To identify members, based upon eligibility under their benefits contract, which might benefit from referral to Horizon internal or contracted services such as the Complex Case Management Program which includes specialty care management services, Horizon Care Navigator Program, Case Management Plus, Primary Nurse Stop Loss Program, Behavioral Health Services, eviCore, CareCentrix, Magellan RX, Pharmacy assistance, and referrals to Horizon par external vendors. To integrate member’s services with all those providing care through ongoing collaboration in treatment planning, discharge planning, transition of care in such venues as Interdisciplinary Community Based Care Model meetings, hospital and post-acute facility discharge planning meetings, Case Rounds, and individual outreaches to providers and vendors.
  • To achieve optimum cost efficiency while assuring delivery of quality of care.
  • To improve population health through population health management strategies.
  • To identify and address social determinants of health.
  • To promote and manage safe transitions in care.

Medical Management

The Medical Management (MM) Program evaluates clinical necessity, access, appropriateness, and efficiency of services. This includes, but is not limited to the following programmatic components: prior authorization, concurrent review, discharge planning, retrospective review, care management, and chronic care management. The MM Program also generally seeks to coordinate, when possible, emergent, urgent and elective health care services. The MM Program evaluates overall utilization such as ER, admission and readmission rates, coordination of services, over and underutilization, and evaluation of new technology. In addition, oversees all Medical Managed delegated functions. Refer to Medical Management (MM) Program Description for more detailed information.

Pharmacy Management

The purpose of the Pharmacy Utilization Management Program is to identify different patterns of medication utilization and identify variables in treatment patterns for different disease states. The goal of this program is to improve patient outcomes and to utilize various interventions, including physician and member education, to ensure medically appropriate cost-effective prescription drug therapy in accordance with all applicable state and federal laws and regulations. Goals of the Pharmacy Utilization Management Program are as follows:

  • To assure that adequate and appropriate resources are available to provide accessible health care services.
  • To design interventions that improve clinical outcomes, optimize patient compliance, and maximize safety.
  • To provide pertinent education to members, physicians and healthcare professionals.
  • To identify medication utilization issues.
  • To identify patterns of inappropriate prescribing based on recommended prescribing guidelines.
  • To evaluate the impact of interventions.
  • To augment the drug selection process for formulary inclusion.
  • To further integrate Pharmacy Utilization Management activities with Medical Utilization Management, BH and Quality Improvement processes.
  • To audit retail pharmacies and the pharmacy benefit manager to ensure appropriate utilization and reporting.
  • To differentiate drugs based on physical/ (BH) versus pharmacy.
  • To review quarterly utilization reports to monitor drug use patterns.
  • To perform outcomes research based on pharmacy, physical/ (BH) and laboratory data.

Credentialing & Recredentialing

A significant part of Horizon’s Quality Improvement Program is the appropriate and regular credentialing of providers. The Credentials Committee establishes standards for identifying competent physicians and other providers in accordance with regulatory requirements and accreditation standards. The Committee uses the standards to determine eligibility for participation in one or more of Horizon’s networks. The goal is to develop a network of participating physicians and providers that demonstrates Horizon’s commitment to continuously improve the quality of health care delivered to its members.

All physicians and providers participating with the health plan must submit their qualifications for review and approval by the Credentials Committee. Qualifications for physicians include, but may not be limited to, current licensure(s), education and training, work history, board certification, hospital/facility privileges, and malpractice history.

Re-credentialing is performed on every network physician (excluding those to whom credentialing is not applicable per the Credentialing and Re-credentialing policy) and provider every three years.

To ensure the quality and safety of care between credentialing cycles, the program performs continuous monitoring for sanctions, limitations on licensure, potential quality of care issues including member complaints and compliance with Horizon’s performance standards, such issues are brought to the Credentials Committee, which takes action as warranted.


Network Management focuses on exploring and implementing opportunities to improve member access to care and services. Data is continuously gathered and analyzed throughout the Horizon organization to ensure that our Network(s) meet these needs and is able to deliver quality healthcare to our members.

Some examples of analysis include but are not limited to the following: Our quarterly geo-access reporting that identifies any potential network deficiencies within provider specialties that we would need to recruit into our network(s). We also conduct an appointment availability analysis to ensure that members have access to needed providers and that they are getting desired appointments within the required timeframes. Additionally, we conduct several annual in-service education seminars for our network providers to inform them of updates to our various programs, services, products and requirements. We use the provider feedback from these seminars to plan future programs.

Customer Service

Horizon Member Services seeks to establish and maintain effective communication with members and providers in order to deliver the highest level of service. Member and Provider satisfaction are evaluated from data which includes phone performance, member/provider complaint handling, and member/provider satisfaction surveys (CAHPS and other internally developed surveys). Survey data is reviewed quarterly, and continuous process improvements are developed to optimize service levels in areas such as first call resolution, Average Speed of Answer, information accuracy and content of written materials (health literacy).

Member/Provider satisfaction reports and complaint and appeal information are used to identify opportunities for improvement, review root cause / “end to end” processes and develop action plans as warranted.

Delegate Vendor Oversight

The Delegate and Vendor Oversight Department (DVOD) performs the formal process by which Horizon monitors, directs, and evaluates a set of activities by contractors who are responsible for the performance. Horizon maintains oversight responsibility of delegated activities and retains the right to modify or withdraw the nature of the contractual relationship, including the termination of the contract and/or the delegation of activities as specified in the relevant contract or delegation agreement.

The Delegate and Vendor Oversight Committee (DVOC) also seeks to ensure that the vendor or delegate’s activities adhere to Horizon’s policies and procedures, regulatory and accreditation standards and meet performance standards as required in the relevant contract or delegation agreement. In the event a delegate and/or vendor is not meeting performance expectations, the committee requires improvement and requests a corrective action plan, which is monitored until the issue(s) is remediated.

Behavioral Health (BH) Care Management Programs

The mission of the Horizon Blue Cross Blue Shield of New Jersey Care Management Program is to promote the well-being of our members by empowering them with the tools they need to better manage their disease and lead a better quality of life. The BH Integrated Care Management Program provides members with education and support utilizing a collaborative management approach with the Physical Health Care team to help manage behavioral health conditions such as but not limited to depression, anxiety, alcohol, and other substance abuse or dependence, eating disorders, schizophrenia, and bipolar disorder. The program encourages the member to actively participate and empower the member to be able to manage their own health conditions. Through the provision of education, support and motivation, we encourage member adherence to provider recommended treatment regimens, thereby improving member quality of life and preventing unnecessary complications. Horizon Blue Cross Blue Shield of New Jersey supports and partners with the interdisciplinary health team and employers to ensure access to high quality, cost effective behavioral health management programs.

The BH Integrated Care Management Programs include the following goals:

  • Providing Behavioral Health support to members that are identified as at risk or with a diagnosis of depression, anxiety, bipolar, schizophrenia, autism disorders, alcohol or other substance abuse and eating disorders. Also identifying members with comorbid behavioral health and chronic Physical Health conditions with symptoms that complicate adherence to prescribed treatment plan and self-management of their conditions.
  • Assisting members with behavioral health referrals by linking them to network providers.
  • Support the transition of members who are in physical inpatient units to behavioral health services as appropriate.
  • Assisting members with primary or secondary diagnosis of substance abuse or dependence with appointments within 14 days of diagnosis, establishing initiation of treatment and two (2) subsequent appointments (HEDIS Substance Abuse Treatment Initiation and Engagement).
  • Improving community tenure, functioning and treatment compliance for members with behavioral health issue through complex case management (CCM).
  • Prevent use of the ER for behavioral health reasons through proactive identification and providing assistance with referrals to specialty programs, appropriate authorizations and community resources.
  • Improving communications between primary care providers and behavioral health providers.
  • Performing diagnostic assessment of symptoms to determine the severity of the conditions (Patient Health Questionnaire).
  • Providing all enrolled members with education about behavioral health conditions.
  • Assisting members with depression and other behavioral health conditions to overcome barriers to treatment.
  • Focus on behavioral health conditions as barrier to adherence with self-management.
  • Monitoring the member’s condition through assessment of treatment response.
  • Collaborating, with the member’s consent, routinely with behavioral health providers and physical health providers, as needed.
  • Identifying and promoting an optimal, realistic level of an individual’s wellness and functionality.
  • Improving overall member and provider satisfaction with Horizon Blue Cross Blue Shield of New Jersey.
  • Identifying needs following an acute care episode and assisting with interventions for long term behavioral health needs.
  • Providing follow up after hospitalization support.
  • Provide support via consultation to Horizon PCPs and pediatricians to improve the identification, evaluation and treatment of behavioral health conditions such as depression, anxiety and bipolar disorders. PCPs are afforded access to telephonic consultations with a behavioral health medical director (psychiatrist) to consult on psychotropic medication management and appropriateness of their Horizon member’s current behavioral treatment plan.
  • Post-partum support for member with comorbid Behavioral health symptoms and or diagnosis to assist in navigation for provider needs as well as community resources.

Education and Training

A team of clinical and non-clinical training professionals from the Clinical Operations Training team will create and deliver education and training materials. Trainings are provided in either a classroom setting, by WebEx, or via Horizon University to employees across the Enterprise. All courses are reviewed annually to ensure information is current. Education includes but is not limited to:

  • Medical Management
  • Health literacy
  • Cultural competency
  • Ethics
  • Regulatory and key industry guidelines
  • Accreditation
  • Safety
  • Quality reporting

Training modules are provided to Clinical Operations staff and include a knowledge check or attestation to assess completion. General orientation training is conducted for new employees. Focused/specialized ad hoc training, including system upgrades, and trainings identified by departmental leadership are created and offered. Areas receiving education include:

  • Utilization Management
  • Case/Care Management
  • Quality Management
  • Appeals
  • Medical Directors
  • Other Departments as requested

Regulatory Compliance

The QI Program through the QIC:

  • Monitors regulatory requirements for quality management and compliance;
  • Ensures that the appropriate actions are taken when areas of quality management non-compliance are identified; and
  • Ensures quality management reporting system provides adequate information for meeting the regulatory external review and accreditation requirements of mandatory and voluntary review bodies.


Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal and State civil rights laws and does not discriminate against nor does it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. For further information, see the Notice of Nondiscrimination and Information in Other Languages sections of the Horizon Blue Cross Blue Shield of New Jersey website.

New Jersey is a diverse state and so is the membership at Horizon. Horizon collaborates with numerous institutions, community centers, hospitals and practitioners implementing programs to decrease health care disparities, training providers and staff on cultural competency and developing programs on health literacy. The Horizon Foundation, through the yearly award of grants, helps to demonstrate our compassion, social responsibility and commitment to New Jersey.

Value Based Programs

Value-Based Programs are administered by the Healthcare Management and Transformation division of Horizon with the following goals based on the Triple Aim:

  • To improve the health of the population.
  • To achieve a sustainable trajectory in health care spending.
  • To improve the patient experience.

To achieve these goals, Horizon works to establish collaborative provider relationships and looks to streamline processes to reduce clinician burnout, with clinician experience often called the Quadruple Aim. To reach these goals, Value-Based Programs has focused on:

  • Redefining care delivery to emphasize population health management and delivery system alignment.
  • Creating accountable consumers and purchasers.
  • Enhancing data exchange.
  • Enforcing clinical quality standards.

Providing coaching and insights to identify care barriers and fragmentation.


Commercial lines of business are accredited by the NCQA. The Quality Management Department, through the QI program, continuously monitors all applicable business areas to ensure their compliance with the most current NCQA Health Plan Accreditation standards and guidelines. The QI Accreditation Team provides education, assessment and feedback to business areas for continual readiness in between reaccreditation cycles. The Accreditation Team monitors compliance with standards on an ongoing basis and reports the status of accreditation activities at least quarterly to the QIC.