Quality Improvement

The Quality Improvement Program implements mechanisms to identify, monitor, evaluate, and resolve issues that impact the accessibility, availability, continuity, and quality of care and service provided to our members. Key objectives include the following:

  • Monitor access and availability to medical and behavioral health care, as well as services and implement corrective action for improvement as identified
  • Provide communication with members, physicians, and providers on issues of quality medical care to promote improvements in the health status of members
  • Develop and distribute information that improves knowledge regarding clinical safety, general wellness and disease prevention as it relates to self care
  • Monitor and evaluate quality of care, quality of service, member satisfaction and provider satisfaction and implement interventions as needed
  • Maintain mechanisms to ensure that cost containment activities do not adversely affect the quality of care provided to members

  • Responsibilities of Blue Cross and Blue Shield of Oklahoma
    • Qualified staff is properly trained for the Quality Assurance/Quality Improvement (QA/QI) program with oversight by a licensed physician.
    • Health care practices are monitored and evaluated for the sole purpose of improving the quality of care and quality of services rendered by participating providers.
    • All information obtained by the QA/QI staff is used solely for the purpose of improving member care through quality management. Such information is confidentially maintained and protected.
    • A variety of evaluation methods are used, such as surveys, access studies, medical record reviews, clinical studies and utilization studies.
    • The written Quality Improvement program is updated at least annually. Information is available to providers regarding activities of the QA/QI program. We appreciate your willingness to work with and would be glad to share our annual report with you. A copy may be obtained by making a request to:

      Medical Director, Healthcare Quality
      Blue Cross and Blue Shield of Oklahoma
      1400 South Boston
      Tulsa, OK 74119-3612

  • Responsibilities of the Provider
    • Supply complete and detailed clinical information to allow Blue Cross and Blue Shield of Oklahoma to make an informed decision
    • Participate in Quality Assurance/Quality Improvement activities, including provider surveys and on-site visits.
    • Cooperate with QA/QI staff to provide medical records or other appropriate medical information upon request and in a timely manner.

  • Patient Access to Care – Blue Cross Blue Shield of Oklahoma Access Standards

  • Medicare Advantage Access Standards

    Medicare Advantage Access Standards for Primary Care

    Routine and Preventative Care:

    • Appointment available within 30 business days


    Services that are not urgent or emergency, but requires medical attention

    • Appointment available within 7 business days


    Urgent or Emergency Services (acute symptoms of sufficient severity):

    • Immediately care


    Emergency medical conditions: CMS defines emergency medical condition as:

    A medical condition, mental or physical, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of immediate medical attention to result in:

    • Serious jeopardy to the health of the individual or, in case of a pregnant woman, the health of the women or her unborn child;
    • Serious impairment to bodily function; or
    • Serious dysfunction of any bodily organ or part.

                 

    Medicare Advantage Access Standards for Behavioral Health and Substance Abuse

    Urgent or Emergency Services (acute symptoms of sufficient severity):

    • Immediate care


    Services that are not urgent or emergency, but requires medical attention

    • Appointment available within 7 business days


    Routine and Preventative Care:

    • Appointment available within 30 business days


    Emergency medical conditions: CMS defines emergency medical condition as:

    A medical condition, mental or physical, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of immediate medical attention to result in:

    • Serious jeopardy to the health of the individual or, in case of a pregnant woman, the health of the women or her unborn child;
    • Serious impairment to bodily function; or
    • Serious dysfunction of any bodily organ or part.

     

    Medicare Advantage Access Standards for Hours of Operation

    • Hours of operation of providers are convenient to the population served and do not discriminate against Medicare member
    • Services are available to members 24 hours a day, seven days per week, when medically necessary

  • Provider Standards of Care – Medical Record Documentation Standards

  • Physical Setting and Safety Standards