Quality Improvement (QI) Program
AmeriHealth Caritas Ohio's Quality Assurance and Performance Improvement (QAPI) program monitors and evaluates the quality of care and service provided to members. Practitioners and providers agree to allow AmeriHealth Caritas Ohio to use their performance data as needed for the organization's QI activities to improve the quality of care and services, and the overall member experience.
About our QAPI program
The purpose of the QAPI program is to provide a formal process to systematically monitor and objectively evaluate the care and services our providers give to members, to ensure they are:
- Of high quality
The QAPI program also provides oversight and guidance by:
- Determining practice guidelines and standards that measure the program's success
- Complying with all applicable laws and regulatory requirements, including but not limited to applicable state and federal regulations and NCQA accreditation standards
- Providing oversight of all delegated services
- Ensuring that a qualified network of providers and practitioners is available to provide care and service to members through the credentialing/recredentialing process
- Conducting member and practitioner satisfaction surveys to identify opportunities for improvement
- Reducing health care disparities by measuring, analyzing, and redesigning services and programs to meet the health care needs of our diverse membership
We develop goals and strategies considering:
- Applicable state and federal laws and regulations and other regulatory requirements
- NCQA accreditation standards
- Evidence-based guidelines established by medical specialty boards and societies
- Public health goals
- National medical criteria
We also use performance measures such as HEDIS®, CAHPS®, consumer and provider surveys, and available results of the external quality review organization (EQRO) as part of QAPI program activities.
Help us in our quality-related efforts. Speak with your Provider Services Account Executive or call Provider Services at 1-833-644-6001 participate in one of our Quality Committees.
Our Pediatric Preventive Health Care Program is designed to improve the health of members from birth to under age 21 who are enrolled in Medicaid by increasing adherence to Early and Periodic Screening, Diagnosis and Treatment (EPSDT) guidelines through identification of growth and development needs and coordination of appropriate health care services.
All Plan, Ohio-licensed practitioners (including registered nurses, physicians, or physician’s assistants; or a person with a master’s degree in health services, public health, or health care administration or another related field, and/or who is a Certified Professional in Health Care Quality or CHCQM) are responsible to provide EPSDT/Healthchek services to AmeriHealth Caritas Ohio members from birth to under age 21 according to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule or upon request to evaluate the general physical and mental health, growth, development, and nutritional status of a member.
The most current periodicity schedules are available online https://brightfutures.aap.org/Pages/default.aspx.
EPSDT services include all mandatory and optional medically necessary services (including treatment) and items listed in 42 USC 1396d(a) to correct or ameliorate defects, and physical and mental illness and conditions discovered by a Healthchek screening. Such services and items, if approved through prior authorization, include those services and items listed at 42 USC 1396d(a), including services provided to members with a primary diagnosis of autism spectrum disorder, in excess of state Medicaid plan limits applicable to adults.
For the initial examination and assessment of a child, practitioners are required to perform the relevant EPSDT/Healthchek screenings and services, as well as any additional assessment, using the Ohio Department of Medicaid (ODM) developed, standardized, developmental screening tools to determine whether or not a child has special health care needs.
Periodic assessments must consist of the following components:
Routine physical examinations as recommended by the AAP and “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents.”
Comprehensive health and developmental history that assesses for both physical and mental health, as well as for Substance Use Disorders.
Screening for developmental delay at each visit through the fifth year using a validated screening tool.
Screening for Autism Spectrum Disorders per AAP guidelines.
Comprehensive, unclothed physical examination.
All appropriate immunizations in accordance with the schedule established by the Advisory Committee on Immunization Practices.
Vision and hearing screening.
Dental screening and education.
Nutrition assessment and education.
Laboratory tests including blood lead screening.
Health education and anticipatory guidance for both the child and caregiver.
Referral for further diagnostic and treatment services, if needed.
EPSDT/Healthchek providers (PCPs) are expected to provide written and verbal explanation of EPSDT services to AmeriHealth Caritas Ohio members including pregnant women, parent(s) and/or guardian(s), child custodians and sui juris (of one’s own right) teenagers. This explanation of EPSDT/Healthchek services should occur on the member’s first visit and quarterly thereafter, and must include distribution of appropriate EPSDT/Healthchek educational tools and materials.
Healthcheck screening services are covered at the following frequency:
For immunizations, in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to pediatric vaccines established by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, found at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For other screening services, at ages and intervals in accordance with the bright futures guidelines; and
For all screening services, at such other intervals indicated as medically necessary to determine the existence of physical or mental illnesses or conditions.
Plan practitioners are expected to assist members and parents/caregivers with accessing substance use disorder and mental health services, as needed. The Plan’s EPSDT Manager on theRapid Response and Outreach Team is also available to members and providers to support the care coordination of EPSDT services. Members and providers may request the EPSDT Manager’s support by calling 1-833-464-7768.