Quality Improvement Program
The goal of the Horizon NJ Health Quality Improvement Program is to help you live a healthier life. We focus on your health and the kind of care you get when you see your doctor. We want to make sure you are happy with the care and services you get.
The goals of the program are to make sure that:
- You have doctors available to you and that you get the best care.
- You are happy with Horizon NJ Health and your doctors.
- We are making it easy for you to get good health care.
- We are obeying the laws and standards set for Horizon NJ Health by the state of New Jersey and accrediting groups.
To view the progress we are making toward our goals, please review our Quality Improvement Program Description.
For more information about Horizon NJ Health’s Quality Improvement Program, please call 1-800-682-9094 (TTY: 1-800-654-5505) and ask for the Quality department.
Performance Results
Each year, Horizon NJ Health takes part in a HEDIS program review. HEDIS, which stands for Healthcare Effectiveness Data & Information Set, is a tool that health plans throughout the country use to measure how well they provide service and care to their members. To find out how Horizon NJ Health ranks, visit the NCQA Health Insurance Plan Ratings 2018-2019-Summary Report Medicaid.
You can also visit NCQA.org for more information and a summary of HEDIS results by health plan.
Horizon Healthcare Services, Inc.
Horizon Blue Cross Blue Shield of
New Jersey
Government Programs
2021 Quality Improvement
Program Description
2021 QI Program Description
Page 2 of 41 Proprietary and Confidential
1. Purpose of the Quality Improvement (QI) Program ............................................................................................................... 4
2. Program Scope ...................................................................................................................................................................... 4
3. QI Program Objectives/Goals ................................................................................................................................................ 7
3.1 Program Evaluation ................................................................................................................................................. 7
4. Structure of the QI Program ............................................................................................................................................. 8
4.1 Governing Body ....................................................................................................................................................... 8
4.2 Committees ............................................................................................................................................................. 9
4.3 Inclusion of Participating Providers in the QI Program ............................................................................................12
4.4 GP Organizational Chart ..........................................................................................................................................13
4.5 QI Program?s Resources ..........................................................................................................................................13
4.6 External Quality Review ..........................................................................................................................................18
4.6.1 Department of Medical Assistance and Health Services (DMAHS)/Island Peer Review Organization (IPRO) ........ 18
4.6.2 Centers for Medicare & Medicaid Services (CMS) ..................................................... Error! Bookmark not defined.
4.7. Behavioral Health ...................................................................................................................................................19
5. QI Program?s Function .....................................................................................................................................................20
5.1 Member Safety .......................................................................................................................................................20
5.2 Disparities in Health ................................................................................................................................................21
5.2.1 Complex Health Needs ........................................................................................................................................... 21
5.3 Quality Assurance ...................................................................................................................................................22
5.3.1 Grievances and Appeals ......................................................................................................................................... 22
5.3.1.1 Medicaid Grievances ................................................................................................................................. 22
5.3.1.2 Medicare Grievances ................................................................................................................................. 23
5.3.2 Quality of Care and Service .................................................................................................................................... 24
5.3.2.1 Quality of Care and Service ....................................................................................................................... 26
5.3.2.1.1 Mortality Data ................................................................................................................................ 26
5.3.3 Programs for the Elderly and Disabled .................................................................................................................. 26
5.3.4 Population Health .................................................................................................................................................. 27
5.3.5 Audits and Reports ................................................................................................................................................. 27
5.3.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - Lead Screening .............................................. 28
5.4 Policy Management ................................................................................................................................................29
5.5 Delegation Oversight ..............................................................................................................................................30
5.6 Compliance with State and Federal Regulatory and NJ Medicaid Managed Care Contract Requirements ...............31
5.7 Accreditation ..........................................................................................................................................................33
2021 QI Program Description
Page 3 of 41 Proprietary and Confidential
5.8 Credentialing and Re-credentialing .........................................................................................................................33
5.9 Clinical Practice Guidelines (CPGs) ..........................................................................................................................33
5.10 Cultural Competency and Health Literacy ...............................................................................................................34
5.11 Fraud, Waste, and Abuse ........................................................................................................................................35
5.12 Program Performance .............................................................................................................................................35
5.12.1 QI Program Work Plan ................................................................................................................................. 36
5.12.2 Performance Improvement Projects (PIPs) ................................................................................................. 36
5.12.2.1 Medicaid PIPs (State PIPs) ....................................................................................................................... 36
5.12.2.2 Medicare PIPs (CMS PIPs/CCIPs) ............................................................................................................. 37
5.12.3 Healthcare Effectiveness Data and Information Set (HEDIS) ....................................................................... 37
5.12.4 Stars ............................................................................................................................................................. 38
5.12.5 Consumer Assessment of Healthcare Providers and Systems (CAHPS) ....................................................... 38
5.12.6 Health Outcomes Survey (HOS) ................................................................................................................... 38
5.13 New Initiatives ........................................................................................................................................................39
5.14 Opportunities for Continued Improvement .............................................................................................................40
Attachments to Program Description
Attachment 1 ? 2020-2021 Medicaid Managed Long Term Services & Supports (MLTSS) Program Description
Attachment 2 ? 2021 FIDE-SNP Care Management and Quality Management Program Description
Attachment 3 ? 2021 GP Committee Organizational Chart
Attachment 4 - GP Executive Organizational Chart
Attachment 5 - Quality Management Organizational Chart
2021 QI Program Description
Page 4 of 41 Proprietary and Confidential
1. Purpose of the Quality Improvement (QI) Program
The purpose of Horizon?s QI Program is to systematically monitor, assess, track, trend and
continuously improve the quality of care, service, health status and safety of its members. The QI Program is
designed to be comprehensive, with the necessary resources, infrastructure, and authority to meet the
program?s goals and objectives. The program also monitors quality assurance activities including the
development of clinical standards, medical care evaluations and member experience surveys. The QI Program
oversees quality-related activities for Medicaid, Medicare, Managed Long Term Services & Supports (MLTSS)
and FIDE-SNP.
2. Program Scope
The QI Program applies to all of Horizon?s Government Programs (GP) lines of business.1 The
membership served by the QI Program includes: Horizon NJ Health (Medicaid & MLTSS), Horizon NJ TotalCare
(HMO D-SNP), Medicare Supplement and Medicare Advantage HMO and PPO plans.
The scope of the QI Program encompasses the clinical and service aspects of the care that members
receive. The Program oversees Horizon?s efforts to monitor and improve preventive, acute, chronic,
behavioral and rehabilitative aspects of care. The Program also reviews the Plan?s initiatives and outcomes
related to member and provider satisfaction and education, access and availability of care, disparities in
health care, continuity and coordination of care, member appeals/grievances, quality-of-care concerns,
clinical and service quality metrics and the credentialing of providers. The Program effects changes to
improve Horizon?s performance on Healthcare Effectiveness Data and Information Set (HEDIS), Stars,
Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS).
1 As a result of incongruent State and Federal requirements and timelines, Horizon BCBSNJ?s Government Programs QI Program
description acts as an overarching guide while allowing individual lines of business to meet their specific contractual and regulatory
requirements through the creation of line of business specific QI programs when necessary. These line-of-business-specific program
descriptions are reviewed and approved by the QIC. This structure allows individual lines of business (MLTSS for example) to meet their
varied filing submission dates while ensuring each line of business? QI Program information is captured within the overall Horizon
Government Programs QI Program description. See Attachment 1 for the MLTSS Program Description. See Attachment 2 for the FIDE-
SNP Care Management and Quality Management Program Description.
2021 QI Program Description
Page 5 of 41 Proprietary and Confidential
Accreditation efforts and audits completed by the Quality Management Department and other departments
are also reviewed by the Program. The following Quality Assurance activities are developed and monitored on
an ongoing basis:
? Guidelines for the management of selected diagnoses and basic health maintenance, and
distribution of all standards, protocols, and guidelines to all providers and to enrollees and
potential enrollees upon request.
? Treatment protocols allowing for adjustments based on the enrollee?s medical condition, level of
functioning, and contributing family and social factors.
? Procedures for monitoring the quality and adequacy of medical and behavioral health care
including assessing the use of the distributed guidelines, assessing possible over-treatment/over-
utilization of services and assessing possible under-treatment/under-utilization of services.
? Evaluation of procedures for focused medical care evaluations that will be employed when
indicators suggest that quality may need to be studied, including procedures for conducting
problem-oriented clinical studies of individual care.
? Evaluation of timeliness of decision making and notification of Utilization Management decisions
and appeals.
? Procedures for prompt follow-up of reported problems and grievances involving quality of care
issues. Timeframes for prompt follow-up and resolution which meet the standard described in
Article 5.15B.
? Hospital Acquired Conditions and Provider-Preventable Conditions, including the implementation
of a no payment policy and a quality monitoring program consistent with guidance from the
Centers for Medicare and Medicaid Services (CMS) that addresses Hospital Acquired Conditions
and Provider-Preventable Conditions according to federal regulations.
? Data Collection Procedures for gathering and trending data, including outcome data.
? Mortality rates review of inpatient hospital mortality rates of its enrollees.
2021 QI Program Description
Page 6 of 41 Proprietary and Confidential
? Corrective action procedures to inform subcontractors and providers of identified deficiencies or
areas of improvement, conducting ongoing monitoring of corrective actions, and taking
appropriate follow-up actions, such as instituting progressive sanctions and appeal processes.
? Discharge planning procedures to ensure adequate and appropriate discharge planning, including
coordination of services for enrollees with special needs.
? Ethical issues monitoring of providers for compliance with state and federal laws and regulations
concerning ethical issues, including but not limited to; advance directives, family planning
services for minors and other issues as identified. Reports are submitted annually or within thirty
(30) days to DMAHS with changes or updates to the policies.
? Emergency care methods to track emergency care utilization and to take follow-up action,
including individual counseling, to improve appropriate use of urgent and emergency care
settings.
? New medical technology policies and procedures for evidence-based criteria for the evaluation of
the appropriate use of new medical technologies or new applications of established technologies,
including medical procedures, drugs, devices, assistive technology devices and durable medical
equipment.
? Informed consent, which requires that all participating providers comply with the informed
consent forms and procedures for hysterectomy and sterilization as specified in 42 C.F.R. Part
441, Sub-part F, and shall include the annual audit for such compliance in its quality assurance
reviews of participating providers.
? Continuity of care system, which includes a mechanism for tracking issues over time with an
emphasis on improving health outcomes, as well as preventive services and maintenance of
function for enrollees with special needs
? Collecting data and acting on opportunities to improve collaborative care between behavioral
health and medical health care for all members receiving case management services.
2021 QI Program Description
Page 7 of 41 Proprietary and Confidential
3. QI Program Objectives/Goals
The QI Program is designed to produce prospective, concurrent, and retrospective analyses of the
Plan?s activities in order to improve the quality of care and service members receive. The specific goals of the
Program are to ensure that Horizon:
? Provides health care that is medically necessary with an emphasis on the promotion of
health in a safe, effective and efficient manner
? Assesses the appropriateness and timeliness of the care and services being provided
? Promotes members? ability to maintain themselves in the least restrictive, most integrated
setting of their choice
? Optimizes care delivery for members with special and/or complex care needs
? Identifies members? needs and coordinates care to address the needs of the member
? Focuses on the quality of medical and behavioral health care and services provided to all
members
? Works to identify and reduce health care disparities within its membership
? Strives to improve member and provider satisfaction
? Maintains oversight of delegated entities
? Maintains oversight of the credentialing and re-credentialing of providers
? Meets current National Committee for Quality Assurance (NCQA) Health Plan
Accreditation requirements
? Works to improve plan performance on HEDIS, Stars, CAHPS, HOS and Performance
Improvement Projects (PIPs)
? Works to ensure compliance with State-mandated contract requirements
3.1 Program Evaluation
The QI Program is evaluated annually by the Quality Management Department with input
from all business areas represented on the Quality Improvement Committee (QIC). The format of the
QI Program Evaluation parallels the QI Program?s Work Plan and includes:
? A description of completed and ongoing QI activities that address quality of clinical care
and quality of service
? Evaluation and assessment of patient safety activities
? Tracking and trending of data to assess program performance in measures of quality of
care and quality of service
? An analysis of improvements in quality of care and service to members
? A critical assessment of barriers to achieving goals and root cause analysis
? An evaluation of the overall effectiveness of the QI Program
2021 QI Program Description
Page 8 of 41 Proprietary and Confidential
The QI Program Evaluation is presented annually to the QIC for review, comments,
and approval. The (VP/CMO), or a designee, annually presents the QI Program Evaluation
to the Horizon Healthcare of New Jersey Board of Directors.
4. Structure of the QI Program
4.1 Governing Body
Horizon Healthcare Services Inc.?s (the ?Parent?) subsidiary companies report to the Parent
organization. The Parent and its subsidiary companies have administrative service agreements with
each other, wherein the subsidiaries utilize staff, policies, procedures and other items from the
Parent. The subsidiary companies that comprise the Government Programs division include Horizon
Healthcare of New Jersey, Inc. and Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue
Shield of New Jersey. Horizon Healthcare Services is the contracting entity for the Medicare
Supplemental, Medicare Advantage HMO, MA PPO and Part D product lines. Horizon Healthcare of
New Jersey is the contracting entity for the FIDE-SNP HMO and Medicaid HMO product lines.
The Parent?s Board of Directors (the ?Board?) is the governing body of the Horizon BCBSNJ
enterprise, and holds the final authority and accountability for the Quality Improvement Program (the
?Program?). The Board has delegated oversight of the Program to the Quality Committee of the
Board. The Committee has further delegated the oversight of the Program to the Government
Program?s Quality Improvement Committee (QIC). The QIC reviews and approves the QI Program
Description, Work Plan and Program Evaluation Annually. The Board has assigned responsibility for
the Program to the Vice President and Chief Medical Officer (VP/CMO). The VP/CMO has the
authority over and responsibility for the development and implementation of the Program. The
director of quality improvement, who reports to the VP/CMO, has direct oversight of the
development and implementation of the Program. The VP/CMO has delegated the chairmanship of
the QIC to the medical director assigned to support the Quality Management Department. The QIC is
responsible for the day-to-day approval, monitoring and evaluation of the Program.
2021 QI Program Description
Page 9 of 41 Proprietary and Confidential
4.2 Committees
The organizational structure of the committees supports the implementation of the Program.
Each committee has a charter that outlines the purpose, scope, meeting frequency, and composition.
Below are descriptions of the committees and subcommittees/workgroups that report to the QIC.
Quality Improvement Committee (QIC)
The QIC?s purpose is to oversee all QI activities. The QIC is a multidisciplinary committee that
meets at least 6 times per year. This frequency is sufficient for the committee to follow up on all
findings and required actions. The role, structure, and function of the committee are specified in its
charter. Annually, the charter is revised as needed and approved by the committee. Recorded
meeting minutes document the committee's activities, findings, recommendations and actions.
The QIC is accountable to the Board. Quarterly, QIC reports their activities, findings,
recommendations and actions to the Board?s Quality Committee. Additionally, there is active
participation on the QIC from network providers. At least one participating provider attends all QIC
meetings.
? Healthcare Disparities Workgroup
The Healthcare Disparities Workgroup meets at least 6 times per year. The purpose of
this workgroup is to reduce health care disparities within its membership. The
workgroup brings together a cross-functional team that reviews data, develops and
implements interventions, conducts barrier analysis and measures the impact of
interventions put in place to decrease health care disparities.
? Physician Advisory Committee (PAC)
The PAC meets quarterly. The purpose of this committee is to identify issues of
concern to the physician community and identify opportunities to optimize patient
care. The PAC meetings are combined with the Utilization Management/Case
Management Committee.
? Dental Committee (Special Needs and Oral Advisory)
This committee advises on and reviews issues pertinent to the delivery of oral health
care services to special needs members. This committee advises GP of changes and
advances in the treatment of oral health care issues that are unique or prevalent with
this population. The committee advises and reviews benefits and services GP provides
2021 QI Program Description
Page 10 of 41 Proprietary and Confidential
to its special needs members as well as new or existing policies. This may or may not
involve quality of care issues. This committee meets quarterly.
? Delegated Vendor Oversight Committee (DVOC)
The DVOC is an interdisciplinary subcommittee that provides oversight of delegated
vendors performing services on GP?s behalf for both health care and non-health care
contracts. The committee meets at least eight times per year.
? Medicare Star Rating Subcommittee
The Medicare Star Rating Subcommittee is an interdisciplinary committee that meets
ten times per year and oversees efforts aimed to improve the quality and cost
effectiveness of the care and services provided to Medicare beneficiaries. The
committee coordinates efforts that focus on improving the plan?s Medicare Star Rating
and CAHPS scores.
? HEDIS Workgroup
The HEDIS Workgroup is an interdisciplinary team that provides oversight of efforts
aimed at improving the quality and cost effectiveness of the care and services
provided to all members. The workgroup coordinates efforts focused on improving the
plan?s Medicare and Medicaid HEDIS performance. This workgroup meets six times per
year.
? Utilization Management/Case Management Committee (UM/CM)
The purpose of the UM/CM committee is to ensure high-quality, cost-effective health
care for all members. The committee is responsible to review the management of
Medicare and Medicaid health services to support Horizon?s vision of improving
quality and enhancing the member experience. The UM/CM Committee reviews and
approves clinical criteria, monitors utilization data (including over and underutilization
of services), and reviews UM appeals data. The UM/CM Committee meets at least ten
times per year. The UM/CM Committee is inclusive of behavioral healthcare, and a
designated behavioral healthcare practitioner is actively involved in implementing and
evaluating the behavioral health aspects of the UM program.
? Managed Long Term Services & Supports Committee (MLTSS)
The purpose of the MLTSS committee is to provide oversight to the Horizon NJ Health
MLTSS Quality Program. The committee reviews the program?s progress toward its
goals to systematically monitor, assess, track, trend and improve the quality of care,
service, health status and safety of MLTSS members. The committee meets at least
quarterly.
? Fully Integrated Dual Eligible Special Needs Plan Committee (FIDE-SNP)
2021 QI Program Description
Page 11 of 41 Proprietary and Confidential
The purpose of the FIDE-SNP committee is to provide oversight to the Horizon NJ
TotalCare (HMO D-SNP) Quality Program. The committee reviews the program?s
progress towards its goals to systematically monitor, assess, track, trend and improve
the quality of care, service, health status and safety of the FIDE-SNP members and
ensure compliance with stated program activities according to the Centers for
Medicare & Medicaid Services? (CMS) FIDE-SNP Model of Care (MOC). The FIDE-SNP
Committee meets at least four times per year.
? MLTSS & FIDE-SNP Community Advisory Committee (MLTSS & FIDE-SNP CAC)
The MLTSS & FIDE-SNP CAC is comprised of MLTSS and FIDE-SNP leadership as well as
providers from the communities that serve MLTSS and FIDE-SNP membership. CAC
meetings allow Horizon to share information about the operations and performance of
the MLTSS and FIDE-SNP programs with community providers, while allowing them to
share their experiences related to the programs with the Plan. The MLTSS & FIDE-SNP
CAC meets at least four times per year.
? Administrative Policy Approval (APA) Subcommittee
The APA Subcommittee meets monthly, and the purpose of the committee is to review
and approve all Administrative Policies and Procedures.
? Quality Peer Review Committee (QPRC)
The goal of the QPRC is to ensure members receive quality health care and excellent service.
QPRC meets at least six times per year and on an ad hoc basis to review potential quality of care
and service issues involving GP members. QPRC reviews both medical and behavioral health
quality of care issues, and a behavioral health practitioner is actively involved in review of
behavioral healthcare issues.
? Member Services Satisfaction Committee (MSSC)
The MSSC is a multidisciplinary committee, focusing on issues related to member satisfaction in
order to create proactive action plans that address the identified barriers to providing members
with the highest quality experience. The MSSC reviews reports focused on call center
performance, member grievances, and claims as well as appeals associated with these issues. The
MSSC reviews CAHPS results and other member satisfaction survey results so that the committee
can coordinate interventions aimed at improving member experience. The committee also
determines areas of service with the greatest effect on member satisfaction, and identifies areas
of opportunity to increase quality of care through quality initiatives. This committee meets at
least four times per year.
? Community Health Advisory Committee (CHAC)
2021 QI Program Description
Page 12 of 41 Proprietary and Confidential
The purpose of the CHAC is to provide a vehicle for community review and advice on matters
related to health care education, outreach and promotion affecting members. Meetings are held
in both English and Spanish. The CHAC meets quarterly.
? Provider Service Satisfaction Committee (PSSC)
The purpose of the PSSC is to oversee and ensure provider satisfaction with the Plan. The PSSC
committee reviews grievance and appeal data and specific issues related to provider satisfaction.
The committee meets on a quarterly basis.
? Credentials Committee
The Credentials Committee reports to the QIC and was established to implement and oversee
credentialing, re-credentialing, certification, and/or re-certification of physicians, health care
professionals, facilities and ancillary providers. The Credentials Committee is empowered by
Horizon Healthcare Services, Board of Directors and the Horizon Healthcare of New Jersey Board
of Directors, the management of GP and the QIC with decision-making authority on matters
pertaining to provider credentialing and re-credentialing. This committee meets at least 10 times
per year.
? Pharmacy and Therapeutics (P&T) Committee (Medicaid)
The Medicaid P&T Committee is responsible for clinical support of the Medicaid Pharmacy
Program. The P&T Committee is comprised of primary care and specialty physicians, pharmacists
and other health care professionals. The Medicaid P&T Committee provides input on
pharmaceutical management procedures and on developing, managing, updating and
administering the Drug Formulary System. The Medicaid P&T Committee meets at least quarterly.
? Pharmacy and Therapeutics (P&T) Committee (Medicare)
The Medicare P&T Committee is responsible for clinical support of the Medicare Pharmacy
Program, including FIDE-SNP. The P&T Committee is comprised of primary care and specialty
physicians, pharmacists and other health care professionals. The Medicare P&T Committee
provides input on pharmaceutical management procedures and on developing, managing,
updating and administering the Medicare Formulary. The Medicare Formulary development and
maintenance is delegated to the Pharmacy Benefit Manager, Prime Therapeutics, and is overseen
by the Prime P&T Committee with active participation by the Horizon?s Medicare Pharmacy
Program. The Medicare P&T Committee meets at least quarterly.
4.3 Inclusion of Participating Providers in the QI Program
Horizon medical and behavioral health providers are included as voting members of the QIC.
Participating providers are also voting members of Utilization Management/Case Management
2021 QI Program Description
Page 13 of 41 Proprietary and Confidential
Committee, Physician Advisory Committee, Pharmacy and Therapeutics Committees, Dental Advisory
Committee and Quality Peer Review Committee. Participating physicians and other providers are kept
informed about the written QI Program Description available in provider newsletters and on the
plan?s website at horizonNJhealth.com/for-providers. Providers can also access information in the
Provider Administrative Manual about how they can be included in the design, implementation,
review and follow up of QI activities.
4.4 GP Organizational Chart
See Attachment 3 2020 GP Committee Organization Chart, Attachment 4 for the GP Executive
Organizational Chart and Attachment 5 for the Quality Management Department?s Organizational
Chart. Due to the size of the Quality Management Department, the Quality Management Clinical
Operations Organizational Chart, the Quality Management Performance Improvement and Reporting
and the Quality Management and Administration Organizational Chart are reported separately. These
teams collaborate to share best practices and also leverage resources that will yield positive
outcomes for Horizon members.
4.5 QI Program?s Resources
Horizon?s executive leadership and all departments within the division contribute to the
success of the QI Program through their focus on quality in their daily activities and their participation
in the QIC. With the expansion and reorganization of the Quality Management Department in 2020,
and the existing health services structure, the Program has sufficient material resources and staff
with the necessary education, experience and/or training to effectively carry out the Program?s
activities. In addition, the Quality Management Department has access to consultants who provide
activities such as statistical analysis, business process improvement recommendations, quality-
related education and accreditation preparation support. To maintain and improve quality
performance, Horizon monitors all current and planned initiatives to assess current and future
staffing needs. This opportunity ensures that the appropriate staff is in place to adequately address
the needs of the quality improvement efforts. Below are descriptions of the key roles within GP that
support the QI Program.
QI Programs Staffing:
Vice President and Chief Medical Officer (VP/CMO)
2021 QI Program Description
Page 14 of 41 Proprietary and Confidential
The VP & Chief Medical Officer VP/CMO of Horizon is a board-certified New Jersey licensed
physician, experienced in health insurance, health care consulting, NCQA accreditation and
pharmaceutics. The VP/CMO is responsible for the design and implementation of the QI Program.
The VP/CMO provides quarterly reports to the Quality Subcommittee of the Horizon Healthcare of
New Jersey Board of Directors, which details the quality-related activities of Horizon and the QIC. This
reporting may be delegated to the medical director of the Quality Management Department.
Executive Medical Directors
The executive medical directors provide senior level leadership and direction, and contribute
to Quality Management initiatives, including accreditation and CMS Star programs, as well as
furnishing strategic and UM oversight. The executive medical directors establish and implement
utilization standards, provide overall medical expertise to ensure continuous quality improvement,
work to ensure that cost-effective services are provided to members, maintain effective provider
relations and develop clinical innovations.
Senior Medical Directors/Medical Directors/Dental Director/Director of Behavioral Health
The Senior Medical Directors, Medical Directors, Director of Behavioral Health and Dental
Director provide support to the QI Program and the Quality Management Department. They are
involved in the evaluation of the clinical and service functions including, but not limited to, clinical
practice guidelines, grievances, and quality of care referrals, HEDIS/Stars/CAHPS/HOS initiatives and
corrective action plans (CAP).
Quality Management Coordinator
The Quality Management Coordinator is a board-certified New Jersey licensed physician who
has experience in UM, Quality Management, managed care operations, MLTSS, Medicare and Fully
Integrated Dual Eligible Special Needs Programs. The QM coordinator is responsible for the creation
and execution of the QI Program Description, work plan, and annual evaluation, as well as all the
functions carried out by the Quality Management Department. The QM Coordinator or designee
chairs the QIC and is a voting member of select QIC subcommittees. The QM Coordinator?s
representation and voting rights on QIC subcommittees may be delegated to medical directors within
Horizon or a director within the Quality Management Department.
2021 QI Program Description
Page 15 of 41 Proprietary and Confidential
Director, Quality Management Performance Improvement and Reporting
The Director of the Quality Management Department reports to the VP/CMO. The Director
has experience leading HEDIS and Star Rating initiatives for large health plans as well as coordinating
quality transformation efforts within institutions and provider groups. The Director is responsible for
assisting in the planning and direction of the QI Program and Quality Management Department
functions. The Director is also responsible for the oversight and function of the business areas within
the Quality Management Department including Star Rating/HEDIS/CAHPS/HOS, pay for performance
and population health. The Director develops departmental reports and presents these reports, along
with the medical director, to the leadership team directly and through the committee reporting
structure. The Director represents the Quality Management Department on committees and may
serve as the Quality Management Medical Director?s designee when the Medical Director is not
present.
Director Quality Management Clinical Operations
The Director of Quality Management Clinical Operations reports to the Medical Director of
the Quality Management Department. The Director is a licensed professional registered nurse and
has experience in health plan management for UM, CM and appeals. The Director is responsible for
assisting in the planning and direction of the QI Program and Quality Department functions specific to
clinical operations. The Director is also responsible for the oversight and function of the business
areas within the Quality Management Department, including medical UM appeals audits, and quality
of care referrals and quality of care. The Director develops departmental reports and presents these
reports, along with the Medical Director, to the leadership team directly and through the committee
reporting structure. The Director represents the Quality Management Department on committees
and may serve as the Quality Management medical director?s designee when the medical director is
not present.
Director Quality Management Improvement Operations
The Director of the Quality Management Improvement Operations Department reports to
the VP & Chief Medical Officer. The Director has experience in Continuous Quality Improvement
(CQI) methodology, state contractual requirements, and NCQA, DMAHS and CMS quality standards.
The Director has a master?s degree in business administration, with concentrations in management
2021 QI Program Description
Page 16 of 41 Proprietary and Confidential
information systems and risk management. The Director is responsible for design, development, and
implementation of on-going improvement and maintenance of quality improvement initiatives
necessary for attaining NCQA accreditation, and meeting CMS and DMAHS contractual
requirements. The Director provides leadership for implementing, monitoring and evaluating the
Quality Improvement Program. The Director also leads and directs processes and overall quality
improvement activities that produce better patient care and more efficient operations. They also
develop programs to review and evaluate patient care and outcomes. The Director represents the
Quality Management Department on GP committees and may serve as the Quality Management
Medical Director?s co-chair.
Director of Clinical Behavioral Health Services
The Director of Clinical Behavioral Health Services reports directly to the Vice President of
Behavioral Health. The Director has a doctoral degree in social work and is a licensed clinical social
worker. The Director monitors the effectiveness of behavioral health care services including
utilization management, Medicare Case Management and all Quality Management activities related
to behavioral health. Internal management of behavioral health services allows Horizon to be in a
stronger position to work directly with providers and health systems to improve integration of
physical and behavioral health care for our members.
Quality Management Department Managers
Quality Management Department managers report to the Directors within the Quality
Management Department. GP Quality managers are nurses, social workers and non-clinicians with
backgrounds in quality assurance, compliance, analytics and State Health Department operations.
Managers are responsible for routine operations within their scope of accountability. Managers have
specific business areas within the Quality Management Department that they oversee including
member and provider grievances and appeals, quality peer reviews, audits, HEDIS/Star Rating
performance, quality policy revisions, accreditation, quality assurance and quality-related
compliance.
Quality Management Department Supervisors
Supervisors within the Quality Management Department report to managers or directors.
Quality Management Department supervisors include both clinicians (RNs and LPNs) and non-
2021 QI Program Description
Page 17 of 41 Proprietary and Confidential
clinicians. The supervisors are responsible for ensuring that the Quality Management Department?s
staff completes daily operations as outlined within policies and procedures.
Quality Management Department Subject Matter Experts
Accreditation Specialists
The accreditation specialists support the Quality Management Department?s goal of
improving the quality of health care for its members through ongoing monitoring of compliance with
accreditation standards and regulatory requirements. The specialists work with all business areas, as
well as with delegated vendors, to ensure that their work and reporting supports all applicable NCQA
Health Plan Accreditation Standards.
PIP Specialists
There is a dedicated team responsible for assisting in the design, implementation, execution,
analysis, and reporting of State and CMS required PIPs. They lead the Quality Management
Department, as well as other departments and external collaborators, in the work required to
successfully achieve the goals of each of QI project.
Health Data Analysts
Health data analysts perform research, analysis, programming, implementation and
coordination to ensure accurate and timely reporting for the Quality Management Department. The
responsibilities include, but are not limited to, analysis reporting, development of databases and
reports that are responsive to department needs, review and coordination of all data requests to
ensure data consistency and accuracy, and utilization of various software packages to extract and
analyze data. They provide support and education to all Health Services departments on data
requirements and needs for quality activities.
Quality Outreach Specialists
Quality Outreach Specialists are responsible for the coordination, implementation and
monitoring of all Medicaid and Medicare (Star Rating) HEDIS member and provider outreach,
engagement and intervention. This position is also responsible for assisting the manager of Outreach
& Interventions in operationalizing all initiatives to improve HEDIS performance by working with
internal and external stakeholders.
2021 QI Program Description
Page 18 of 41 Proprietary and Confidential
Additionally, the QI program pursues an integrated approach to achieving ongoing
improvements in the quality of care and service delivered to members. Staff in the Quality
Department work closely with the following departments:
Provider Contracting & Strategy (PC&S) works with Quality Management to ensure that the
tools to assess the access and availability of practitioners and providers are adequate, that
practitioners/providers comply with the QI program, that clinical materials distributed to
practitioners are understandable and useful, and that practitioners understand members? rights and
responsibilities and treat enrolled members accordingly.
Clinical Services Operations includes Care, Case and Disease Management and UM. Care,
Case Disease Management staff identifies and refers potential quality issues to the Quality
Management Department for investigation, recommends benefit enhancement, approves clinical
practice guidelines and participates in the QIC.
Delegate Vendor Oversight (DVO) and Quality Management staff work collaboratively in the
review of Quality Management initiatives with delegates and ensure compliance with the NCQA
standards. In addition, DVO provides oversight of the activities and responsibilities of delegated
vendors to ensure quality health care is provided to members.
4.6 External Quality Review
4.6.1 Department of Medical Assistance and Health Services (DMAHS)
and the Island Peer Review Organization (IPRO)
On behalf of the New Jersey DMAHS, IPRO conducts oversight activities of Horizon NJ
Health and Horizon TotalCare (HMO D-SNP). Annually, IPRO conducts an assessment of
Horizon operations to determine if the Plan has implemented and operationalized State-
mandated contractual requirements. The Quality Management Department is responsible for
preparation, the submission of documentation and the coordination of the onsite
assessment. After the annual assessment is completed and Horizon BCBSNJ receives feedback
from DMAHS/IPRO, corrective action plans are created and executed to address the
opportunities for improvement that were highlighted in IPRO?s report. These corrective
actions are monitored by the QIC through their completion.
2021 QI Program Description
Page 19 of 41 Proprietary and Confidential
Additionally, as a follow up to the annual assessment, the plan receives a Quality
Technical Report (QTR) each year from IPRO that aggregates and analyzes relevant data to
draw conclusions on quality, timeliness and access to Medicaid managed care services. IPRO
is required to make improvement recommendations as a part of its external quality review
activities and then discuss how the managed care organization addressed those
recommendations in the next annual QTR.
DMAHS/IPRO also has oversight of additional activities including focused studies,
audits to evaluate the quality of care received by the publicly insured enrolled in managed
care, HEDIS performance, CAHPS performance and evaluation of Horizon?s Performance
Improvement Projects (PIPS).
In addition to the external quality reviews performed by the State, Horizon
undergoes quality reviews/audits performed by CMS and NCQA. Horizon ensures required
QIPs and CIPS are approved by CMS. Horizon maintains compliance with NCQA Health Plan
Accreditation standards and the plan?s Medicaid and Medicare lines of business are assessed
by NCQA as part of the health plan accreditation process.
4.7. Behavioral Health
The Behavioral Health Program is committed to providing quality services to help members
manage all aspects of their health. Behavioral Health Case Management services are available to
Medicare and Medicaid members. The outpatient behavioral health benefits provided through
Medicaid are limited to the enrollees in the Division of Developmental Disabilities (DDD), MLTSS and
FIDE-SNP programs. Acute inpatient services are covered for the entire Medicaid membership. Case
managers assess, develop and implement individualized plans of care; and offer coordination of
medical and behavioral health care services for members and their families. The Behavioral Health
Program utilizes the Care Radius medical management system to support delivery and
documentation of the case management process.
The Director of Behavioral Health Services reports into QIC and a behavioral health
practitioner participates on the QIC, UM/CM, P&T and FIDE-SNP Committees to provide information
and guidance on mental health/substance use disorder topics and related quality initiatives and
activities. Additionally, the Provider Contracting & Strategy and Network Operations Departments
2021 QI Program Description
Page 20 of 41 Proprietary and Confidential
review geographical access reports that address the adequacy of the behavioral health provider
network and member experience accessing the network. Grievances and requests for out of network
services are also analyzed. Deficiencies are addressed to reduce barriers to access and ensure
continuity of care for members.
5. QI Program?s Function
The function of the QI Program is to coordinate, oversee, guide, and assess GP efforts to ensure
continuous quality improvement throughout the organization. The following sections highlight the
functions of the QI Program. The Program also has the ability, through the QIC, to add focus areas when
indicated.
Each year the QI Program Description is reviewed and revised as necessary. Annually, a QI Work
Plan is developed and implemented to guide the execution of the QI Program. At the conclusion of each
year, a QI Program Evaluation is completed to assess the success of the QI Program and guide the
creation of the following year?s QI Program Description and Work Plan. The Program Evaluation identifies
areas where goals were not met and will continue to be monitored into the next calendar year. The work
plan is used as a tool to monitor, review and track quality improvement activities on a quarterly basis, and
new initiatives are added as needed.
5.1 Member Safety
Promoting safety for its members is a key focus for Horizon BCBSNJ and involves a wide range
of activities. The QI Program, as well as the Quality Management Department, are central
contributors and coordinators of member safety initiatives performed throughout the organization.
To promote safety for hospitalized members in accordance with CMS guidelines, state law,
and the State Medicaid Managed Care Contract, Horizon has policies to address quality of care and
service, hospital acquired conditions and serious adverse events. The Quality Management
Department reviews the State Medicaid Managed Care contract, CMS regulations, applicable state
laws, national clinical practice and other guidelines at least annually. Policies are reviewed and
approved every year, including the list of selected hospital-acquired conditions and serious adverse
events.
2021 QI Program Description
Page 21 of 41 Proprietary and Confidential
Additional activities occurring within the Quality Management Department and QIC that
focus on enhancing member safety include: assisting in the reporting of quality indicators to the
provider network, monitoring and follow up on corrective action plans required from delegated
vendors and/or network providers who identified care and/or service deficiencies, conducting quality
of care reviews focused on member safety issues, designing quality improvement projects targeted to
at-risk populations, researching grievances related to member safety issues, coordinating responses
to potential urgent/immediate member safety threats when appropriate.
5.2 Disparities in Health
Disparities in health reduce the overall quality of care provided within the health care system
while adding to costs. In 2021, 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 2021 and will be included in the 2021 QI Work Plan. Current topics under review include breast
cancer screening (BCS), cervical cancer screening (CCS), depression in the elderly FIDE-SNP population,
colorectal cancer screening (COL), prostate cancer screening, social determinants of health and the
Maternal Health Learning Collaborative. Horizon BCBSNJ?s ongoing efforts to reduce disparities will be
coordinated and monitored through the QIC.
The goal of this program is to implement interventions and community health events, which
reduce disparities between differing member populations. The Maternal Learning Collaborative was a
new project in 2020 and the interventions and strategy will be implemented in 2021. Ongoing
interventions from 2020 for depression in the elderly FIDE-SNP population, social determinants of
health, BCS, CCS, COL and prostate cancer screening will continue through 2021.
5.2.1 Complex Health Needs
The QI program is dedicated to addressing the needs of members with complex
health issues. The Complex Case Management Program resides within the Medicaid Case
Management and Medicare Advantage (MA) Care Management teams (product line specific)
2021 QI Program Description
Page 22 of 41 Proprietary and Confidential
and integrates all components of case management and coordination to support access to
care for members with complex diseases including acute physical, behavioral and chronic
conditions.
Members are identified and referred for Complex Case Management using a variety
of methods, such as data provided from utilization/concurrent review, predictive modeling
tools and physician and/or member referrals. The assigned case manager coordinates care
with members, their families, and providers as appropriate to assist in assessment,
development and implementation of individualized plans of care to meet the identified needs
of the member across multiple settings. Medicaid Case Management and Medicare
Advantage Care Management utilize the Care Radius medical management system to support
both the delivery and documentation of the case management process.
Additionally, the Provider Contracting & Strategy and Network Operations
Departments review geographical access reports to address the adequacy of the provider
network. Reporting indicates sufficiency of PCP, obstetrics and gynecology, high volume and
high impact specialties required to treat the membership. Deficiencies in the network are
acted upon to reduce barriers to care and to ensure continuity of care for members.
5.3 Quality Assurance
5.3.1 Grievances and Appeals
5.3.1.1 Medicaid Grievances
Horizon is committed to improving the efficiency and quality of how the Plan
manages appeals and grievances. In 2020, all grievance analysts were provided with
additional training to ensure grievances were handled timely and efficiently, and will
continue to be monitored in 2021 to initiate additional training where needed. The
training included reviewing the process for identifying quality of care issues and
making outbound calls to providers. In addition, 100 percent of all grievances receive
a quality review prior to closure. This added step ensures that member and provider
grievances are addressed appropriately.
2021 QI Program Description
Page 23 of 41 Proprietary and Confidential
The grievance resolution teams address member and provider grievances
within the mandated timeframes required by the NJ State Medicaid Contract, CMS
Health Maintenance Organization (HMO) regulations, and in accordance with
standards set forth by NCQA. The staff receives grievances through incoming
telephone calls to the member/provider services areas, State referrals, CMS referrals,
internal and external direct calls, written correspondence, the website and the
electronic internal complaint forms. The internal processes provide the opportunity
for all employees within the organization to document any grievance that was
received during an interaction with a member and/or provider. The grievance staff is
the liaison between the member/provider, Horizon, and the delegate or vendor for
grievances related to any delegate or vendor. The team participates in monthly
meetings as necessary with delegates and vendors to ensure grievances are
processed within compliance contractual agreements and service level agreements
and also discuss any issues that may arise.
Grievance data is analyzed monthly and submitted to the appropriate
committees for review and discussion. At least quarterly, member, provider and
delegated vendor grievance data is presented to the QIC by line of business. Trends
in the elderly and disabled population are closely monitored for areas of opportunity.
After presentation at the QIC, the information is presented to the Quality Committee
of the Horizon Healthcare of New Jersey Board for review and discussion. As required
by the NJ State Medicaid Managed Care Contract and CMS regulations, grievance
reports are prepared and submitted to the state and CMS.
The Horizon NJ Health appeals staff handles all member and provider
Utilization Management appeals in accordance with the NJ State Medicaid Managed
Care contract requirements, applicable CMS regulations, and accreditation standards.
Please note that grievances may also be called complaints.
5.3.1.2 Medicare Grievances
CMS provides stringent guidelines related to the intake and resolution of
grievances received by Medicare enrollees. In order to meet the requirements, a
dedicated grievances team exists within the organization to resolve grievances. The
2021 QI Program Description
Page 24 of 41 Proprietary and Confidential
focus of the team is to review and resolve grievances regardless of where they
originate within the organization. The grievances staff receives referrals by telephone
calls, written correspondence, internal referrals or legislative referrals. Grievances
received by 1-800-Medicare are also handled within the grievances team.
All grievances are reviewed in detail to identify the root cause of the issue.
There is continuous collaboration within various departments of the organization to
review and resolve grievances. All grievances are handled within the CMS designated
timeframe and follow all CMS guidelines as outlined in the Managed Care Manual
Chapter 13; Medicare Managed Care Beneficiary Grievances, Organization
Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans,
and Health Care Prepayment Plans (HCPPs), collectively referred to as Medicare
Health Plans. The staff member serves as a liaison between the member/provider,
delegated vendors, and regulatory bodies, and follows the grievance until
completion. Grievance inventory is monitored on a daily basis in order to ensure
grievances are acknowledged and resolved in a timely manner. The overall outcomes
are reviewed on a monthly basis in order to identify trends and any corrective action
is identified on a case-by-case basis. Quarterly grievance reports are presented to the
appropriate committees for review. Please note that grievances may also be called
complaints.
5.3.2 Quality of Care and Service
Within the Quality Management Department is a team that focuses on quality of care
issues. This team provides ongoing education to personnel regarding potential quality of care
concerns and serious adverse events. This education includes the definitions/categories for
quality of care referrals with direction on how staff can refer potential issues to the Quality
Management Department for investigation, and to the medical director for review. All
instances where a quality of care issue and/or serious adverse event, hospital acquired, or
provider preventable event may exist are presented to the Quality Peer Review Committee
(QPRC) for discussion, determination of departure from quality standards and guidelines, and
possible practitioner sanctioning.
2021 QI Program Description
Page 25 of 41 Proprietary and Confidential
QPRC sanction determinations are forwarded to the Credentialing Committee for
inclusion in the provider's credentialing file. Quality of care referrals and provider sanctions
are tracked and trended by the QPRC. Entities that receive sanctions may be monitored by
the PC&S team through telephonic and medical record audits, as well as onsite visits. When
the QPRC issues sanctions against providers, the QPRC may require the provider to create and
implement corrective action plans (CAPs). These CAPs are reviewed by the QPRC for
completeness. The QPRC reports quality of care concerns (QOC), hospital acquired conditions
(HAC) and serious adverse events (SAE) to the QIC.
The Quality Management Clinical Operations RN staff provides quarterly education
sessions regarding quality of care referral categories. These information sessions are
conducted in offices and via WebEx. In addition to structured reviews of the criteria, the
Quality Management staff provides support to all referring staff to ensure correct creation of
referrals and grievances.
Quality of Care referrals are captured by a Tableau dashboard ? a comprehensive
repository of quality of care referrals and grievances. This dashboard follows all lines of
business and is updated daily. Information obtained from Tableau is used for monthly
monitoring of total cases referred, closed, and outstanding.
Readmission monitoring for quality of care indicators is reviewed prior to proceeding
with the UM appeal process. Working with the medical directors, cases are reviewed and
quality of care indicators are validated. If no quality of care indicators are identified, the UM
appeal process will commence.
Monthly data is reviewed for trends and outliers. In the event that a quality of care
indicator persists, referrals are made to the Provider Contracting & Strategy (PC&S) team.
PC&S reports the results of its investigation to the Provider and Member Services Satisfaction
Committees, which report to the QIC.
The QI Program is designed to maintain and enhance high quality of care and service
in an era of high expectations from our members and providers.
2021 QI Program Description
Page 26 of 41 Proprietary and Confidential
5.3.2.1 Quality of Care and Service
The Clinical Quality Operations team has the ability to monitor and track quality of
care grievances and quality of care referrals for all lines of business including MLTSS
and FIDE-SNP. Data regarding these lines of business is reported to the QIC. In
addition, tracking of cases for members defined as aged, blind and disabled (ABD),
Division of Developmental Disabilities (DDD) and elderly is reported to the QPRC
committee. Potential quality of service issues identified for MLTSS, FIDE-SNP, ABD,
DDD, and elderly during the investigation of a quality of care issue will be referred to
the appropriate area for review and investigation.
5.3.2.1.1 Mortality Data
Another function of the Quality Management Department is the
tracking of mortality data for Medicaid, FIDE-SNP and MLTSS members. The
mortality data is also stratified by special populations as defined by the New
Jersey Medicaid HMO contract. These categories include aged, blind, disabled
(ABD), Division of Developmental Disabilities (DDD) and elderly members. On
an annual basis, the analysis is presented to the QPRC committee for review
and approval.
5.3.3 Programs for the Elderly and Disabled
Horizon continues to focus on the care of all members. In doing so, Horizon has
segmented the population to address the needs of the most critical members, which include
a focus on elderly members aged 65 years and older and members with disabilities. The
elderly and disabled population is managed by various programs including Care, Case and
Disease Management and Quality Management Programs. They are designed to outreach,
engage and educate both members and providers on the importance of preventive visits and
communication to providers on outcomes of care.
Horizon monitors, evaluates and reports on member outcomes for elderly and
disabled enrollees at least annually. Horizon tracks and reports on each population
separately. The program is comprised of functional standards to evaluate outcomes of care,
as well as measurement and distribution of outcome reports to providers. The program also
includes a process for communicating measurement standards to providers.
2021 QI Program Description
Page 27 of 41 Proprietary and Confidential
The results are incorporated into the QI Program Evaluation. Horizon includes quality
indicators of potential adverse outcomes and provides appropriate education, outreach, case
management and other activities as outlined in the Medicaid Contract.
5.3.4 Population Health
Horizon manages Medicaid and Medicare 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 to understand the target population?s needs and barriers so that their needs are
met. 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 Medicaid and
Medicare populations and selects subpopulations to ensure that adequate programs and staff
are available to meet the health care needs of our members. Those subpopulations are
children and adolescents, members with disabilities, pregnant women, and members with
severe and persistent mental illness. Findings are presented, reviewed, and approved
annually by the Quality Improvement Committee (QIC).
5.3.5 Audits and Reports
The Program has oversight of audits and reports completed by multiple business
areas. There are several reasons that audits and reports are performed. Audits and reports
are required by the State, necessary to meet accreditation requirements, and they provide
Horizon with insights as to how processes, providers and systems are performing. Here is a
selection of the audits and reports that are performed and then reviewed by the QIC:
2021 QI Program Description
Page 28 of 41 Proprietary and Confidential
? MLTSS Quarterly Audit
? FIDE-SNP Audits
? Geo Access Reports
? 24-hour Access Audit (Medical and Behavioral Health)
? Medical Record Review Audit (Medical and Behavioral Health)
? Appointment Availability Audit (Medical and Behavioral Health)
? Office Manager Satisfaction Survey (Medical and Behavioral Health)
? Behavioral Health Clinical and Quality Performance Measures
? EPSDT Audit
? Lead Report
? Vendor Oversight Audit
These audits are incorporated into the QI Program Work Plan. The QIC uses the work
plan to track the completion of these audits. The QIC reviews the results of these
audits/reports and provides each business area with recommendations about modifications
to improve usefulness.
5.3.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
- Lead Screening
Lead screening using blood lead level determination must be done for every Medicaid-
eligible and NJ FamilyCare child between nine (9) months and eighteen (18) months of age,
preferably at twelve (12) months of age and a second time between 18-26 months, preferably
at twenty-four (24) months of age. Testing should be done on any children between twenty-
seven (27) to seventy-two (72) months of age who have not been previously tested. Horizon
provides a screening program for the lead toxicity in children, consisting of two components: a
verbal risk assessment and blood lead testing. The verbal risk assessment is given to providers
to perform at every periodic visit between the ages of six (6) months and seventy-two (72)
months. Monthly data reports are reviewed for the 9-18 month and 18-26 month age groups.
Those between 27-72 months that have not previously been tested are also included on this
report. Those members that have been tested and have an abnormal rate above 5 ug/dl are
handled by the Case Management Department for management and follow up. Additionally,
there are various lead monitoring methods and interventions in place to increase screening
rates plan-wide. Primary and secondary prevention methodologies have been adopted to
ensure lead screening takes place earlier, rather than later, in the applicable age groups. These
2021 QI Program Description
Page 29 of 41 Proprietary and Confidential
interventions include, but are not limited to, member mailings, provider mailings, call
campaigns, provider onsite education, provider webinars, member gap-detail analysis and
community events.
In 2021, Horizon will continue to monitor initiatives to increase lead screening
awareness and lead testing. In addition to our interventions targeted towards all of our
members and providers, we have interventions specific to our hard-to-reach members who
appear on the annual member work plan. There are also specific interventions in place and
developed each year specific to providers falling under 80% lead testing compliance for two-
consecutive, six month periods. Those providers who are on this ?under compliance? list are
monitored throughout the year and reported to the Quality Peer Review Committee in the
case that they are unable to increase their rate to 80% or higher. Providers that are placed on
a CAP are notified in April following the measurement year (i.e. letters are sent out in April
2021 for providers under 80% for two consecutive, six month periods in 2020) via letter and
fax. They are advised that they have been placed on a CAP and their lead screening
performance will be monitored throughout the year (i.e. 2021 for 2020 non-compliance). In
August of the following year (August 2021 for 2020 non-compliance), providers who are still
under 80% compliance are notified via fax as a reminder that they have until year-end to
increase their lead screening rates. If their lead screening compliance is still below 80% by
year-end, they are referred to QPRC to determine further corrective action.
While provider compliance is key and monitored closely, there are a number of
interventions underway that support providers to increase their lead testing rates. These
efforts are proactive and ongoing throughout the year to maintain compliant rates and also to
improve low rates.
5.4 Policy Management
Annual policy review is conducted and presented by the responsible department to the QIC or
the applicable subcommittee or workgroup of the QIC. All policies are reviewed to comply with the
Corporate Policy and Procedure Development Policy and include the original effective date, current
effective date, most recent revision, most recent review dates, recertification date and revision
history. In addition, policies are reviewed for applicable regulatory and accreditation content.
2021 QI Program Description
Page 30 of 41 Proprietary and Confidential
All policies are maintained on a policy repository portal. This allows all Horizon staff read-only
access to all current and archived policies. Monitoring of state compliance requirements is coordinated
with the Regulatory Affairs Department. Any policies requiring state (DMAHS or MFD) approval are
submitted to the GP Regulatory Affairs Department for submission to the state. Such policies which
require state/DMAHS review and approval require a DMAHS acceptance stamp on the policy and are
required to be submitted for State review 90 days prior to their recertification date or the change
effective date.
5.5 Delegation Oversight
Delegated managed care entities that administer health care services and/or provide covered
services under GP?s benefit plans are subject to review and oversight under the QI Program. These
services include, but are not limited to, activities/functions relating to utilization review/management,
case management, quality improvement, credentialing/re-credentialing, utilization management
appeals, HEDIS gap closures, radiology services, pharmaceutical services, laboratory services, vision
services, dental services, telemedicine, post-acute skilled nursing facility (SNF) and rehab care services,
durable medical equipment, grievances, customer service and claims processing.
Contracted delegates/vendors are obligated to provide and administer services in accordance
with contractual terms and conditions and applicable state and federal laws and statutes, including but
not limited to regulations set forth by the New Jersey Department of Banking and Insurance (DOBI),
New Jersey DMAHS Managed Care Contract provisions, the Health Claims Authorization, Processing
and Payment (HCAPP) Act, CMS regulations, Horizon policies and procedures, and current-year NCQA
standards and guidelines. Horizon remains accountable for the quality, integrity and appropriateness
of delegated functions and services provided by subcontractors for the Plan?s MLTSS, FIDE-SNP and
Medicare Advantage members.
It is Horizon?s responsibility to ensure monitoring and oversight activities are performed to
ensure delegate/vendor compliance and promote delivery of and access to quality and cost-effective
health care and services to members. The Delegate Vendor Oversight Committee is responsible for the
following: assessing ongoing monitoring and evaluation activities performed collaboratively and
independently by business units; evaluation of delegate/vendor performance results to ensure
business goals and outcomes are achieved to further the delivery of quality health goals and outcomes
2021 QI Program Description
Page 31 of 41 Proprietary and Confidential
for our members and; ensuring subcontractor compliance with contractual provisions, regulatory
requirements and applicable accreditation guidelines.
A quarterly subcommittee report summarizing items and issues reviewed and discussed at
DVOC meetings must be submitted and presented to the QIC and the Horizon Quality Committee
Board (HQCB). A summarized overview on delegate/vendor oversight activities must also be submitted
to the Compliance and Ethics (C&E) Committee. Committee reports must include, but not be limited
to, delegate/vendor performance statistics, the status of delegate/vendor CAP (when applicable),
oversight monitoring reports and must highlight matters of importance and/or those that require the
attention of the QIC, HQCB or C&E Committee.
5.6 Compliance with State and Federal Regulatory and NJ Medicaid
Managed Care Contract Requirements
Government Programs places the utmost importance on compliance with regulatory and
contract requirements. This is particularly important as it relates to member safety, the handling of
private health information and the integrity with which the Plan cares for its members.
? Confidentiality
GP processes ensure confidentiality of protected health information about members and
physicians. Documents that are created and reviewed as part of the process are confidential and
privileged. Information is maintained in compliance with appropriate federal and state regulations,
the Health Insurance Portability and Accountability Act (HIPAA) and all applicable accreditation
standards. All employees, participating physicians, vendors and consultants must maintain the
Horizon standards of ethics and confidentiality regarding both member information and proprietary
information. All employees and non-employees are required to sign a confidentiality statement, as
well as any consultant or business associate that may need to access confidential member
information. In addition, certain business associates perform certain business functions on behalf of
Horizon involving the use, disclosure or receipt of private health information. These third parties are
business associates of Horizon and sign a Business Associate Agreement to protect the privacy and
safeguard the security of such private information when assisting with administrative functions or
providing services for or on behalf of the Plan.
2021 QI Program Description
Page 32 of 41 Proprietary and Confidential
? Member Rights, Responsibilities and Patient Engagement
Horizon is committed to maintaining a mutually respectful relationship with its members that
promotes effective health care. Horizon makes clear its expectation for the rights and responsibilities
of members and sets a structure for cooperation among members, practitioners and the health plan.
Horizon recognizes that members must establish a dynamic partnership in the management of their
care, which includes the members' family and their health care practitioner.
Horizon complies with all applicable Federal 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.
When care does not meet the member's expectations, Horizon assures members of their
right to voice grievances (complaints) and to appeal any decisions with which they do not agree.
? Regulatory Compliance
The QI Program through the QIC:
o Monitors regulatory requirements for quality management and compliance;
o Ensures that the appropriate actions are taken when areas of quality management non-
compliance are identified; and
o Ensures that the quality management reporting system provides adequate information for
meeting the regulatory external review and accreditation requirements of mandatory and
voluntary review bodies.
? Ethics
The program functions as a key component in the promotion of integrity and values in the
care and services provided to members. As outlined in the Horizon Corporate Code of Business
Conduct and Ethics, Horizon is committed to maintaining the highest legal and ethical standards in
the conduct of its businesses. In maintaining these standards, Horizon places heavy reliance on
individual good judgment, honesty and character. This commitment applies without exception to all
activities.
2021 QI Program Description
Page 33 of 41 Proprietary and Confidential
5.7 Accreditation
Medicare and Medicaid 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 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. Horizon will notify DMAHS of any change to its accrediting body.
5.8 Credentialing and Re-credentialing
Horizon?s credentialing and re-credentialing activities are managed by the Credentialing
Department in a process that determines whether physicians, other health care professionals, and
organizational providers of services meet all applicable state licensing standards, participation and
credentialing criteria, and are qualified to provide the care or services for which they have been
contracted. Horizon maintains oversight of the credentialing and re-credentialing activities through
the QIC. In addition, the QPRC provides reports to the Credentialing Committee on quality of care and
service sanctions that are issued by the QPRC. This information is taken into account when providers
are evaluated for re-credentialing.
5.9 Clinical Practice Guidelines (CPGs)
CPGs are evidenced-based practice standards promoted by Horizon. They are used to assist
staff in making appropriate recommendations and to inform members and providers about making
educated health care decisions. Topics addressed by CPGs include, but are not limited to, preventive
health, asthma, diabetes, maternity, EPSDT, behavioral health and geriatric care. The CPGs are based
on nationally recognized medical association standards and medical references. The guidelines are
reviewed and updated at a minimum of every two years, or as needed, and they are presented to the
UM/CM Committee for approval. Information about Horizon?s CPGs is made available to providers
through the Provider Administrative Manual, provider newsletters and the Horizon website.
Guidelines are available to members through the website, member newsletters and can be requested
by calling the Member Services Department.
2021 QI Program Description
Page 34 of 41 Proprietary and Confidential
5.10 Cultural Competency and Health Literacy
Horizon BCBSNJ 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. Staff and participating providers
receive education to enhance the provision of culturally competent and linguistically appropriate
care. Language assistance services, including bilingual staff and interpreter services, are offered and
provided to members at no cost. Horizon produces easily understood member-related materials in
languages that meet member needs.
The objective of cultural competency and health literacy efforts is to improve member
experience and communications by:
? Increasing the cultural competency of employees and providers
? Gaining a better understanding of the needs of our members through solicitation of
member feedback
? Optimizing members? experience with the health plan
? Enhancing the provision of quality care to members with diverse values, beliefs and
behaviors
? Encouraging the development of more effective strategies for communication with
members
? Identifying and overcoming barriers to the advancement of health care for diverse
groups
In evaluating cultural and linguistic needs, Horizon:
? Identifies linguistic needs and cultural backgrounds of members by using U.S. Census
data, enrollment data, language line utilization, analysis of grievances and member
feedback from surveys
? Identifies languages of practitioners in provider networks to assess whether they meet
members' linguistic needs and preferences
The data from these reports is analyzed and used by Horizon to adjust the practitioner
network if the current network does not meet members' language needs and preferences. Where
there is a deficiency, efforts are made to recruit providers and practitioners to meet the needs of the
underserved groups.
2021 QI Program Description
Page 35 of 41 Proprietary and Confidential
Additionally, case managers identify member cultural, physical, auditory, vision and
linguistic barriers to care as a part of the Complex Needs Assessment process. Member needs are
assessed and barriers are addressed throughout the continuum of care.
5.11 Fraud, Waste, and Abuse
The Fraud, Waste and Abuse Prevention Plan documents the organization's comprehensive
approach to prevent, detect, investigate, recover and report cases of fraud, waste and abuse in the
Medicare Advantage, Medicare Advantage Part D, Medicaid, NJ FamilyCare, Horizon NJ Total Care,
Managed Long Term Services and Supports, Supplemental Social Security Income, Division of Child
Protection & Permanency and clients of the Division of Developmental Disabilities. The plan
supplements all Horizon policies and workflows on fraud, waste and abuse prevention, and provides a
framework for monitoring compliance with the following fraud waste and abuse-related
requirements including:
? NJ Medicaid Managed Care Contract
? Federal Program Fraud Civil Remedies Act, New Jersey False Claims Act
? New Jersey Anti-Fraud Prevention and Detection Plan Protocol, (N.J.A.C.
11:16-6.7)
Horizon routinely discovers issues that require intervention and analysis. The various
methods employed to aid in monitoring and identifying fraud, waste and abuse include daily queries,
the SAS analytical software package, referrals from internal departments, external referrals (i.e. State
Medicaid Fraud Unit, pharmacy audit vendors and fraud hotline) and media publications. Horizon?s
Medicaid and Medicare Special Investigations Unit (SIU) coordinates fraud waste and abuse activities
with all state and federal agencies. If a potential issue is identified, the information is reported to
Horizon?s Medicaid and Medicare SIU for evaluation and further action.
5.12 Program Performance
Horizon dedicates resources across the organization and within the Quality Management
Department to focus on quality performance. This work is guided by the QI program and included in
the QI program Work Plan. The QIC oversees this work, including the planning, monitoring and
evaluation of the outcomes of these efforts.
2021 QI Program Description
Page 36 of 41 Proprietary and Confidential
5.12.1 QI Program Work Plan
Annually, the Quality Management Department creates the QI program Work Plan.
The work plan is presented to the QIC in the first quarter of the year. The QIC provides
recommendations for revisions and the committee approves the work plan. The QI program
Work Plan is designed to be inclusive of all aspects of the QI program?s responsibilities. The
work plan is updated as needed during the year to incorporate recommendations identified
through the completion of the QI Program Evaluation and/or by recommendations made by
the QIC. The QIC reviews the work plan at least quarterly to ensure that the activities outlined
are being addressed by the appropriate business owners, and to ensure progress is being
made toward the stated goals. If the QIC determines that progress is not being made toward
goals, the committee is tasked with providing recommendations to assist the business area in
identifying barriers and developing interventions to overcome the barriers. The 2021 QI Work
Plan will identify items applicable to Medicaid, Medicare, MLTSS and FIDE SNP.
5.12.2 Performance Improvement Projects (PIPs)
A performance improvement project (PIP) is a concentrated effort on a specific
problem within the health plan. Information is systematically collected for the clarification of
issues or problems, which are then the focus of improvement. Improvements are made via
the development of interventions. The Plan develops and conducts PIPs to examine and
improve care or services in areas that have been determined to contain deficiencies via the
analysis of data against a specific standard.
The Quality Improvement Operations team is responsible for assisting in the design,
implementation, execution, analysis and reporting of state- and CMS-required PIPs and
Chronic Care Improvement Projects (CCIPs). Plan Do Study/Check Act cycle in addition to Lean
Six Sigma methodologies are used to develop and ensure continuous quality improvement
throughout the entirety of each PIP.
5.12.2.1 Medicaid PIPs (State PIPs)
Horizon conducts four performance improvement projects (PIPs) specific to
its State/Medicaid membership. The topics for these PIPs are determined by DMAHS.
The current topics include: (1) MLTSS reducing admissions, readmissions and gaps in
2021 QI Program Description
Page 37 of 41 Proprietary and Confidential
service for members with congestive heart failure in the Horizon MLTSS Medicaid
population; (2) Increasing Developmental Screening and Early Intervention; (3) FIDE-
SNP reducing admissions, readmissions and Emergency Room (ER) visits in members
with asthma; (4) MCO Adolescent Risk Behavior and Depression Collaborative. Twice
per year, Horizon submits reports to the State detailing its efforts and outcomes
related to each PIP. This takes place in April and August. In addition to semi-annual
submissions, Horizon monitors intervention implementation timeliness and
effectiveness along with all other PIP-related activities to ensure positive results.
5.12.2.2 Medicare PIPs (CMS PIPs/CCIPs)
Horizon participates in ongoing quality improvement programs for each
contract. The purpose of the QI program is to ensure that Horizon has the necessary
framework and infrastructure to coordinate care, promote quality, performance, and
efficiency on an ongoing basis. The guidelines followed and incorporated into the QI
programs are based on the 42 CFR? 422.152 regulation. Each Chronic Care
Improvement Project (CCIP) applies to the three MA contracts in place. Currently,
there are three CCIPs in place for each contract with a focus on promoting effective
management of chronic disease. The CCIPs in place have a three-year project cycle.
Horizon is no longer required to submit updates for its Medicare CCIPs to CMS, but
rather monitors CCIPs internally and submits an attestation that confirms the projects
are in place.
5.12.3 Healthcare Effectiveness Data and Information Set (HEDIS)
Medicare, FIDE-SNP and Medicaid HEDIS measures are evaluated and analyzed
monthly. Initiatives are developed, changed, and/or enhanced based on measure
performance. Initiatives and outreach activities are discussed with stakeholders in the HEDIS
workgroup meetings. HEDIS performance results are reported annually to the State, QIC,
NCQA and at the Quality Committee board meeting through review of the QI Program
Evaluation.
Annually, Horizon creates a new work plan to address State HEDIS measures that fall
below 50th percentile with the exception to the Lead Screening Measure, which is added if it
falls below the 75th percentile. This work plan is provided to DMAHS on or before August 15.
2021 QI Program Description
Page 38 of 41 Proprietary and Confidential
Existing initiatives and outreach areas are evaluated for their impact and, if needed, are
enhanced to improve measure performance. The results and outcomes of initiatives and
outreach are monitored monthly and shared in HEDIS workgroup meetings held four times
per year.
5.12.4 Star Ratings
Medicare Star Rating measures are monitored monthly. Star Rating measures are
assigned to business owners who develop strategies, initiatives and outreach activities to
maintain and/or improve performance. Star Rating progress is reported to the QIC on a
quarterly basis and to executive leadership on a monthly basis. Star Rating measure
performance results are reported annually to the State (FIDE-SNP product only), to the QIC,
NCQA and at the Quality Committee board meeting through review of the QI Program
Evaluation.
5.12.5 Consumer Assessment of Healthcare Providers and Systems
(CAHPS)
The CAHPS survey captures accurate and complete information about member-
reported experiences and how well the Plan and providers are meeting members?
expectations and goals. The Quality Management Department coordinates Government
Programs? efforts to improve CAHPS scores for Medicare, Medicaid and FIDE-SNP for adults
and children. The planning, work and results of these efforts are reported to QIC directly.
Specific CAHPS work plans are created to manage each line of business. Horizon has
determined that in 2021, opportunity exists to continue efforts to improve on several key
measures. These measures focus on member experience and satisfaction, and they impact
the Plan?s overall ratings. The QI Program Work Plan will incorporate the QIC?s oversight of
CAHPS improvement efforts. All CAHPS scores are reported to DMAHS. If Horizon conducts an
additional non-CAHPS member satisfaction survey, it will send the results of the survey to
DMAHS.
5.12.6 Health Outcomes Survey (HOS)
The Health Outcomes Survey (HOS) provides an assessment of how Horizon members
describe changes in their health status over time. Horizon?s Customer Experience team
2021 QI Program Description
Page 39 of 41 Proprietary and Confidential
analyzes the results of the HOS survey and this analysis is presented to the QIC for discussion
and recommendations for interventions that can be put in place to improve survey results.
Review of the HOS survey results is included in QI Program Work Plan.
5.13 New Initiatives
In 2021, Horizon will be embarking on multiple new initiatives. While all of Horizon?s new
initiatives have the potential to impact the quality of care and service provided to members, the
following specific initiatives require direct monitoring by the QI program because of their scope and
impact on members and providers.
? In an effort to improve member experience, Medicaid members are no longer required to
obtain a referral from their PCP to visit an in-network specialist. This change occurred in
2020, however additional efforts will be taken in 2021 to ensure that members are aware of
this change.
? Horizon has engaged providers on clinical best practice including coordination of care. In
parallel, Horizon has performed member outreach to provide reminders and education for
gaps in care. The Quality Performance Improvement team developed a new intervention
aimed at partnering Horizon?s outreach coordinators with a selected (piloted) subset of
provider groups to improve coordination of care and throughput among their member panel.
Selected providers with volumes will be confirmed in the 4th quarter of 2020. The outreach
coordinators will work with provider representatives to confirm gaps in care, identify open
orders and scripts and facilitate appointments. By working together, outreach coordinators
will be better informed before initializing the call with the member. This will improve the
member?s experience and perspective on their healthcare. The partnership will also support
members in addressing open healthcare concerns by connecting them to the targeted care
they need.
? The Horizon Quality Improvement Operations team developed two new Performance
Improvement Projects that will be initiated in 2021:
o Increasing PCP Access and Availability for members with low-acuity ED visits ?
Horizon NJ Total Care (FIDE-SNP) Membership
2021 QI Program Description
Page 40 of 41 Proprietary and Confidential
? Aim: By the end of each measurement year, Horizon NJ Total Care aims to
improve access and availability to primary care for continuously enrolled FIDE
SNP members greater than 6 years of age within designated practices with
high emergency department (ED) utilization for low acuity, non-emergent
(LANE) only diagnoses. Detailed performance increases will be specified and
included once participating practice groups have been confirmed and
baseline data for the practice groups has been finalized.
o Increasing PCP Access and Availability for members with low acuity, non-emergent ED
visits ? Core Medicaid Membership
? By the end of each measurement year, Horizon NJ Health aims to improve
access and availability to primary care for continuously enrolled core
Medicaid members greater than 6 years of age within designated practices
with high emergency department (ED) utilization for low acuity, non-
emergent (LANE) only diagnoses. Detailed performance increases will be
specified and included once participating practice groups have been
confirmed and baseline data for the practice groups has been finalized.
5.14 Opportunities for Continued Improvement
Opportunities for improvement that are identified in the QI Program Evaluation are
incorporated into the following year?s QI Program activities for implementation and monitoring by
the QIC including but not limited to:
? Improving collaboration with the Grievance Dept. to ensure timeliness of referrals to
Quality of Care team
? Star Rating?focused implementation of improvement initiatives
? Improving lead screening rates across all counties
? Reducing the volume of providers whose lead testing rates are under 80% for YE 2020.
? Improving the rates of preventive vaccines in the DDD population
? Reducing admissions, readmissions and gaps in services for members with congestive
heart failure in the Horizon NJ Health MLTSS Medicaid population
? Eliminating dental provider network deficiencies in Atlantic County
? Eliminating MLTSS provider network deficiencies in Gloucester and Salem counties
? Improving timeliness of grievance processing
? Continuing focus on CAHPS - to ensure that member satisfaction is achieved.
2021 QI Program Description
Page 41 of 41 Proprietary and Confidential
? Improving Medicaid HEDIS performance to reduce the number of items on the State
work plan and achieve 3.5 stars in NCQA accreditation
? Addressing gaps and opportunities for improvement with underperforming delegates.
? Improving CAHPS performance for both the Medicaid Adult and Child Population
Horizon will pursue these opportunities for improvement in 2021 and include updates to
activities in the QI Work Plan to monitor, track and trend progress toward goals.