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
Quality Program Review

Quality Improvement

Responsibilities of Blue Cross and Blue Shield of Oklahoma

Responsibilities of the Provider

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

Medicare Advantage Access Standards

Medicare Advantage Access Standards for Primary Care

Medicare Advantage Access Standards for Behavioral Health and Substance Abuse

Medicare Advantage Access Standards for Hours of Operation

Provider Standards of Care – Medical Record Documentation Standards

Physical Setting and Safety Standards

Quality Program Review