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Quality management

Quality Assessment and Performance Improvement (QAPI) program

Quality Assessment and Performance Improvement (QAPI) program

The goal of quality management is to promote members’ health status or maintain it when their condition isn’t likely to improve.


Our process, which involves quality assessment and performance improvement activities, enables us to:


  • Review current practices in both clinical and non-clinical areas 
  • Find opportunities for improvement 
  • Choose the most effective interventions 
  • Evaluate and measure the success of current interventions, refining them as needed

We develop QAPI objectives each year and outline them in our annual QAPI Program Description. This documents the scope, structure and function of the QAPI program. We also evaluate our success in achieving our annual QAPI goals each year and document the results in our Quality Assessment and Improvement Program Evaluation.  


Need a copy of our QAPI Program Description or Quality Assessment and Improvement Program Evaluation? Just call Provider Relations at 1-855-242-0802 (TTY: 711).

Quality Management Oversight Committee (QMOC)

Quality Management Oversight Committee (QMOC)

QMOC integrates quality management and performance improvement activities through the health plan and provider network. The committee oversees the QAPI program and offers recommendations to the board of directors. Their tasks include:


  • Confirming that quality activities are designed to improve the quality of care and services 
  • Reviewing and evaluating the results of quality improvement activities
  • Reviewing and approving studies, standards, clinical guidelines, trends in quality and utilization management indicators, and satisfaction surveys
  • Advising and making recommendations to improve the health plan
  • Reviewing and evaluating company-wide performance-monitoring activities, such as care management, customer service, claims, grievances and appeals, and more

Criteria availability

Criteria availability

We use guidelines to make treatment authorization decisions. Providers and members have the right to request a copy of those guidelines or specific criteria. Just keep this disclosure in mind: 


“The material provided to you are guidelines used by this plan to authorize, modify, or deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under your contract.” 


Need a copy of the criteria? Just go to UM criteria on our medical management page. Or for more info, you can call 1-855-242-0802 (TTY: 711).

No penalties

We don’t take any action to penalize or discourage members or providers with regard to appeals, disputes or other disagreements about utilization management of covered care. You’re free to advocate on behalf of members within the utilization management process.

Value-based programs

Our value-based provider partnership program seeks to create a collaborative relationship that achieves improved clinical, quality and financial outcomes, and enhances the life of every member we touch. We help our providers succeed through a strategic and highly personalized approach that improves the health outcomes of our members — your patients.


Learn more about value-based programs


HEDIS stands for Healthcare Effectiveness Data and Information Set. Health plans use HEDIS scores to monitor performance in areas like quality of care, access to care and member satisfaction.


Learn more about HEDIS

Share your voice

Share your voice

Are you a network provider? We’d love to have your input and feedback. Just call 1-855-242-0802 (TTY: 711) for info about joining a committee. You can also get a written copy of the quality program description.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

Also of interest: