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Optima Health, through its commitment to excellence, has developed a comprehensive program directed toward improving the quality of care, safety, and appropriate utilization of services for our members. The Quality Improvement program is designed to implement, monitor, evaluate, and improve processes within the scope of our health plan on a continual basis in order to improve the health of our members every day.

Quality Improvement Highlights

Clinical Guidelines Update

Optima Health has completed our bi-annual review and revision of the following clinical guidelines:

  • Pelvic Mass
  • Pharyngitis
  • OB/GYN: Referral & Management

The clinical practice guidelines are based on published national guidelines, literature review, and the expert consensus of clinical practitioners. They reflect current recommendations for screening, diagnostic testing, and treatment. These guidelines are published by Sentara Health Plans, Inc. (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these guidelines. The SHP guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.

The clinical guidelines are available on optimahealth.com/providers under Provider Resources. If you would like a printed copy of these guidelines, or have questions, comments, or suggestions about the guidelines, please contact 757-252-8400 or 1-866-425-5257.

QI Program and HEDIS®1 Progress Report

Optima Health offers a comprehensive quality improvement program that focuses on objectively and systematically improving the quality of medical and behavioral health care and services for our enrolled members. Optima Health Plan has received NCQA Accreditation for its commercial HMO/POS health plans, Medicaid HMO product2, and Marketplace plans. NCQA Health Plan Accreditation evaluates how well a health plan manages all parts of its delivery system—physicians, hospitals, other providers and administrative services—in order to continuously improve the quality of care and services provided to its members3. Annually, a review of the health plan epidemiology and demographics and analysis of the previous year quality improvement monitoring rates is completed and an updated program is developed to monitor services that are high volume, high cost, high risk and/or problem prone. Although significant progress has been made, this is an evolving process with many remaining opportunities to improve the care and service of our members.

Quality Improvement Program for 2016 includes:

  • Reminder cards and/or calls to members, and follow up communication with the physicians, regarding recommended prevention screenings and care
  • Health risk assessment and welcome calling programs to identify specific chronic conditions in our membership, with appropriate follow up activities
  • Disease Management programs for members with diabetes and asthma.
  • Programs focused on promoting healthy pregnancy
  • Service activities to assess and improve access to health care, as well as satisfaction with the health plan and with the care received from our practitioners and providers
  • Evaluating complaints and occurrences to ensure that our members’ needs are met by the highest level of care and service
  • Investigating new procedures and treatments through comprehensive technology assessment review.
  • Credentialing and re-credentialing Primary Care and Specialty Care providers
  • Medical record documentation review and provider education

For more information about Quality Improvement at Optima Health please contact the Quality Improvement Department at 757-252-8400 or toll free 1-866-425-5257. For more information regarding NCQA visit their web site at ncqa.org.

1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
2 NCQA Accreditation documentation
3 NCQA (September 2013). General Guidelines for Marketing and Advertising Health Plan Accreditation

2017 Quality Improvement Annual Notice
This annual notice serves as Optima Health’s commitment to providers and compliance with the National Committee for Quality Assurance (NCQA), state and federal regulations and mandates.

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