Quality improvement

Quality is in all we do at Aetna Better Health

Our Quality Assurance and Performance Improvement (QAPI) program is a continuous quality improvement process that includes comprehensive quality assessment and performance improvement activities. We continuously and proactively review our clinical and operational programs and processes to identify opportunities for continued improvement. Our continuous Quality Management/Quality Improvement (QM/QI) process enables us to:

  • Assess current practices in both clinical and non-clinical areas
  • Identify opportunities for improvement
  • Select the most effective interventions
  • Evaluate and measure on an ongoing basis the success of implemented interventions, refining the interventions as necessary.

The use of encounter data, ad-hoc internal reports, HEDIS®, External Quality Review (EQR), and CAHPS in the monitoring, measurement and evaluation of quality and appropriateness of care and services is an integral component of Aetna Better Health’s quality improvement process. Check our Provider Manual (LINK) to learn more about our QM Program.

Learn more about our quality improvement programs by reading the Quality Management Program Evaluation.

The Department of Health Services (DHS) requires us to produce HEDIS® rates for all Medicaid reporting measures, with the exception of behavioral health measures. HEDIS® is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) designed to reliably compare health plan performance. HEDIS® performance measures are divided into eight domains of care:

  • Effectiveness of care
  • Access/availability of care
  • Satisfaction with the experience of care (Adult and Child CAHPS)
  • Health plan stability
  • Use of services
  • Informed health care choices
  • Cost of care
  • Health plan descriptive information.

We work with you to assure that all DPW requirements concerning HEDIS® performance measures are met on an ongoing basis, by: 

  • Producing rates for all Medicaid reporting measures, with the exclusion of behavioral health measures
  • Following NCQA specifications as outlined in the HEDIS® Technical Specifications, clearly identifying the numerator and denominator for each measure.
  • Validating HEDIS® results by using an NCQA-licensed vendor

Consumer Assessment of Healthcare Providers and Systems (CAHPS) are a set of standardized surveys that assess patient satisfaction with the experience of care. CAHPS surveys (Adult and Child) are subsets of HEDIS® reporting required by the Department of Public Welfare. We contract with an NCQA-certified vendor to administer the survey according to HEDIS® survey protocols. The survey is based on randomly selected recipients and summarizes satisfaction with the health care experience.

In addition to the Adult survey, HEDIS® incorporates a CAHPS survey of parental experiences with their children’s care. The separate survey is necessary because children’s health care frequently requires different provider networks and addresses different consumer concerns (e.g. child growth and development). We contract with a certified vendor to complete both Adult and Child CAHPS surveys and submit recipient level data files to the NCQA for calculation of HEDIS® CAHPS survey results.

Measures in the HEDIS ECDS domain are specified for the Electronic Method of data collection.

Organizations may use several data sources to provide complete information about the quality of health services delivered to its members. Data systems that may be eligible for HEDIS ECDS reporting include, but are not limited to, member eligibility files, EHRs, clinical registries, HIEs, administrative claims systems, electronic laboratory reports (ELR), electronic pharmacy systems, immunization information systems (IIS) and disease/case management registries.

Data sources are categorized using the following criteria:

  • (EHR)- Electronic health record. This data category includes information obtained directly from a patient as well as clinical findings generated as a result of samples collected from a patient (i.e., pathology and laboratory reports generated from entities not directly connected to the patient’s EHR).
  • HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives.
    • HIEs used for ECDS reporting must use standard protocols to ensure security, privacy, data integrity, sender and receiver authentication and confirmation of delivery.
  • Case management system - A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. These systems include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
  • Administrative - Includes data from administrative claim processing systems for all services incurred as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.


Each digital measure includes both the human readable technical documentation and the machine-readable files necessary for implementation. Each HEDIS ECDS digital measure includes the following files:

  • Measure-specific Human Readable file: Description of the measure specifications and requirements – to be used as a reference
  • Expression Logical Model (ELM) files: These files are in a standard format and naming convention that should not be altered by either the MCO or healthcare provider. It is recommended that all files within a measure package are housed in the same place and naming conventions preserved, as the computer readable files will reference the library files by name.


HEDIS ECDS measures reference single codes and value sets that must be used for HEDIS ECDS reporting. To administratively close gaps for ECDS measures, it is recommended you use the NCQA codes provided in the HEDIS specifications for each of the ECDS measures. The appropriate code for the measure you are reporting will be submitted as a “Data Criteria” (Element Level)

Aetna Better Health is dedicated to improving health outcomes for our members with type 2 diabetes. Referrals of people living with type 2 diabetes to diabetes self-management education (DSME) programs throughout Pennsylvania is one way to accomplish this goal.

DSME programs are a critical component of diabetes care. These programs offer structure, expertise, medical knowledge, and evidence-driven education that diabetics need which is not offered through less formal types of diabetes education and support groups.

The Medicaid MCO Provider Education Materials Resource Toolkit was developed through a partnership with the Health Promotion Council, Pennsylvania Department of Health, and managed care organizations in the state, as part of the Pennsylvania Community-Clinical Integration Initiative (PA CCI).

This comprehensive toolkit offers a wealth of diabetes self-management education and support including:

Click here for the full toolkit with helpful links and resources. You can find specific doctor and patient communications tips, talking points and resources on pages 12-15.

Early Periodic Screening, Diagnosis, and Treatment (EPSDT)/Bright Futures services are federally-mandated services intended to provide preventive health care to children and young adults (under the age of 21 years) at periodic intervals. These services are based on the recommendations of:

  • American Academy of Pediatrics (AAP)
  • American Dental Association (ADA)
  • American Academy of Pediatric Dentistry (AAPD)

All PCPs who provide services to recipients under age 21 must provide comprehensive health care, screening, preventive services and immunizations as outlined in the provider manual. You can also read the provider manual to learn more about:

  • Identifying barriers to care
  • Diagnosing and treating
  • Tracking
  • Following up and outreaching
  • Educating patients about EPSDT/Bright Futures

Check out the most up-to-date immunization schedule. You can also review a list of EPSDT/Bright Futures guidelines on our website.

Finally, it’s also important that you bill us appropriately for the services rendered.  Call your Provider Relations representative at 1-866-638-1232 option 3, option 5 if you have questions on EPSDT/Bright Futures billing.

Learn how you can earn more compensation by reading about our pay-for-performance (P4Q) guidelines and measures and 2021 coding guide.

We recognize the value of giving incentives to promote improvements in the delivery of effective health care services.  P4Q initiatives include those with financial rewards and those that develop partnerships with physician groups with the sole objective of improving health care outcomes. We participate in the HealthChoices P4Q as funded and allowed by contract.


Our QAPI Program uses an integrated and collaborative approach by inviting providers to serve on our committees. Call us at 1-866-632-1232 option 3 and then 5 if you’re interested in participating in the Quality Management and Utilization Management Committee (QM/UM) or the Pharmacy & Therapeutics Committee (P&T).  

There are requirements for documenting services and maintaining medical records. This is to ensure that the medical record includes full documentation of all services rendered to our members. We review these standards with you during your plan orientation. You can also find them in the provider manual. If you have questions, call your Provider Relations Representative at 1-866-638-1232 option 3 and then 5.

We want to help our members reach their health goals.  Through the Aetna Better Health Member Rewards Program, our members can earn gift cards to use for themselves and their family. To learn more about this program available to our members and how they can earn rewards, click the link below.

Member Rewards Program

Aetna Better Health is dedicated to improving health outcomes for our members.  Identifying and addressing Social Determinants of Health (SDOH) among those we serve throughout Pennsylvania is one way we are working to accomplish this goal. 

By using SDOH codes, you’ll be helping us identify areas of opportunity for our members. As a result, we can integrate appropriate Chronic Care management with preventive health while connecting members with needed community services.

This comprehensive toolkit offers a wealth of SDOH information including:

  • Definition of SDOH
  • Information regarding the importance of SDOH
  • Using applicable SDOH ICD-10 Codes

Click here for the full SDOH toolkit.