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Provider Manual

Quality Improvement/Utilization Management Program Overview

Last Updated on July 05, 2022

The goal of the Quality Improvement/Utilization Management (QI/UM) program  is to support Security Health Plan in providing accessible, high-quality, cost-effective patient care using appropriate resources. QI/UM program initiatives assess the quality of clinical care provided by affiliated providers and customer service provided by Security Health Plan. QI/UM initiatives focus on interventions as needed to continually improve the quality of care and service delivered to members.

The Security Health Plan QI/UM program objectives are to:

  • Monitor and evaluate the quality and appropriateness of health care provided to Security Health Plan members.
  • Monitor and evaluate the performance of affiliated providers on an ongoing basis.
  • Promote patient safety through QI/UM activities such as education materials, health management systems, credentialing and pharmacy management.
  • Define expectations for each indicator through the use of acceptable standards of care, routinely evaluate opportunities to improve the delivery of care and services, and organize data for trend analysis and pattern assessment.
  • Pursue opportunities to improve care provided to members by monitoring member satisfaction, ensuring access, availability and service delivery against standards and implementing corrective actions as needed.
  • Promote and monitor continuity and coordination of care among medical and behavioral health providers participating in member care.
  • Maintain Security Health Plan network provider involvement in and awareness of QI/UM and credentialing activities.
  • Conduct ad hoc primary care physician and behavioral health site visits and medical record reviews to ensure provider compliance with Security Health Plan standards.
  • Conduct ongoing evaluation, monitoring and documentation of the effectiveness of interventions and recommendations of QI/UM activities.
  • Promote and enhance education aimed at members and providers to facilitate high-quality care; provide a systematic complaint procedure to ensure all complaints are reviewed and resolved in a consistent and timely manner.
  • Provide a systematic grievance/appeals process to ensure all grievances/appeals are reviewed and resolved in a consistent and timely manner.
  • Promote health education and use of preventive health care services; annually monitor results through HEDIS®.
  • Protect the confidentiality of data, medical records and other member, provider, vendor and/or employer sensitive information.
  • Monitor timeliness standards on a quarterly basis; assess provider satisfaction with the UM process on an annual basis.
  • Regularly communicate to members, providers and staff the findings of the QI program to ensure its effectiveness and support.
  • Orient new staff to the QI/UM program.
  • Evaluate, no less than annually, the effectiveness of the QI/UM program and recommended areas for improvement.

To see the annual QI evaluation, please visit online or call Security Health Plan Customer Service to request a paper copy.

HEDIS is registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).