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Our Quality Assurance and Performance Improvement program

We are committed to the provision of our well-designed and well-implemented Quality Assurance and Performance Improvement (QAPI) program. Our culture, systems and processes are structured around the mission to improve the health of all enrolled members.

Goals and objectives

Our primary quality assurance goal is to improve members’ health status through a variety of meaningful quality assurance activities implemented across all care settings and aimed at improving the quality of care and services delivered.

¿Tiene alguna pregunta?

Just call Provider Relations at 1-866-638-1232 (TTY: 711). You can call Monday through Friday, 8 AM to 5 PM.

Scope

Scope

The scope of the QAPI program is comprehensive and addresses both the quality and safety of clinical care and quality of services provided to Aetna Better Health® Kids members, including:
 

  • Atención de salud del comportamiento.
  • Atención dental.
  • Medical care
  • Vision care

We incorporate all demographic groups, care settings and services in QAPI activities.

  • Acute care
  • Ancillary services
  • Atención de emergencia.
  • Preventive care
  • Primary care
  • Short-term care (this is dependent upon the member’s Aetna Better Health coverage)
  • Specialty care

Quality Practice Liaison program

Through this program, we aim to improve our communication with you and your satisfaction with our health plan. Our Quality Practice Liaisons (QPLs) will be working to help health care practices increase Healthcare Effectiveness Data and Information Set (HEDIS®) and performance measure rates, decrease gaps in care and talk about specific quality matters.
 

To learn more about this program and to connect with your local QPL, just email our Quality Management Department. QPLs are available to meet with PA provider practices to discuss the program in detail.

You can contact your QPL for questions about quality or to set up a meeting. To find your liaison by region, just use the QPL map.
 

QPL Map (PDF)
 

More about HEDIS

Credentialing standards

For consideration to participate in the Aetna Better Health network, all licensed physicians and other licensed health care professionals who have an independent relationship with us must complete an application for participation and submit copies of applicable supporting documentation.

Cultural competency plan

Cultural competency plan

We are committed to establishing multicultural principles and practices throughout our organizational systems of services and programs. That commitment is supported by facilitating our response process to the health care needs of all individuals, regardless of their ethnicity, culture, religious beliefs or primary language. Our cultural competency plan is reviewed and updated annually.
 

More about cultural competency

 

Participation in QAPI

Aetna Better Health requires providers and practitioners to cooperate with all quality assurance activities, as well as allow the use of provider and/or practitioner performance data, to ensure the success of the QAPI program.
 

Interested in learning more about our QAPI program? Just call 1-866-638-1232 (TTY: 711) and ask to speak with the Quality Management Department. You can call Monday through Friday, 8 AM to 5 PM.

More resources and materials

Bright Futures services are services intended to provide preventive health care to children and young adults at periodic intervals. These services are based on the recommendations of:
 

  • Academia Americana de Pediatría
  • Asociación Dental Americana
  • Academia Americana de Odontología Pediátrica

 

All PCPs who provide services to recipients under age 21 should provide comprehensive health care, screening, preventive services and immunizations. Your provider manual (PDF) contains information about:
 

  • Identificación de obstáculos para la atención.
  • Diagnóstico y tratamiento.
  • Rastreo.
  • Seguimiento y asistencia.
  • Educating patients about Bright Futures

You can find more information about Bright Futures on our HEDIS page.
 

Or check out these resources:

Bright Futures reference guide (PDF)

Bright Futures wall chart (PDF)
 

Bright Futures periodicity schedule and coding matrix (PDF)
 

Valid development delay and autism spectrum disorders screening tools (PDF)

 

You can find more information on our pharmacy benefits page.
 

Pharmacy benefits flyer (PDF)

Our QAPI Program uses an integrated and collaborative approach by inviting providers to serve on our committees. Call us at 1-866-632-1232 (TTY: 711), then choose option 3 and then 5 if you’re interested in participating in the Quality Management and Utilization Management Committee (QM/UM) or the Pharmacy & Therapeutics Committee (P&T).  

We have requirements for documenting services and maintaining medical records. This is to ensure that the medical record includes full documentation of all services rendered to our members. We review these standards with you during your plan orientation. You can also find them in your provider manual (PDF).
 

Questions? Just call us at 1-866-638-1232 (TTY: 711), then choose options 3 and then 5.

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

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

The comprehensive toolkit offers a wealth of SDOH information, including:
 

  • Definición de los SDOH
  • Información sobre la importancia de los SDOH
  • Uso de los códigos aplicables del ICD-10 de los SDOH

SDOH toolkit (PDF)

Learn more about the care and services we offer to help keep our members healthy. The services they can receive depend on the child’s age and program. 

Children’s health and wellness

You can find information about billing and coding guides on our HEDIS page.

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

Also of interest: