Quality Program

The scope of the QI Program is comprehensive and addresses both the quality and safety of clinical care and quality of services provided to Oklahoma Complete Health's members including medical, behavioral health, dental and vision care. We incorporate all demographic groups, care settings, and services in QI activities, including preventive care, emergency care, primary care, specialty care, acute care, short-term care, long-term care (depending upon Oklahoma Complete Health's products), and ancillary services.

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

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

As a company dedicated to managing the healthcare of our beneficiaries, Oklahoma Complete Health is committed to establishing multicultural principles and practices throughout its organizational systems of services and programs. That mission is supported by facilitating the process by which Oklahoma Complete Health can respond to the health care needs of all individuals, including those with limited English proficiency (LEP) and diverse cultural and ethnic backgrounds, abilities, and regardless of gender identity, sexual orientation or religion. Oklahoma Complete Health maintains an adequate network of primary care and specialty practitioners, and regularly monitors how effectively the network meets the needs and preferences of our membership.

The Cultural Competency Plan is reviewed and updated annually, and ensures that we address the cultural needs of our members by:

• Identifying and utilizing the appropriate resources for interpreter services: Oklahoma Complete Health provides professional, independent interpreter and translation services to members within the service area. Through effective partnerships with interpreters, Oklahoma Complete Health completes requests for onsite sign language and LEP/oral interpreters.
• Evaluating provider access and availability: We have contracted with providers that speak the languages required by our member population, with the most common language continuing to be Spanish.
• Identifying organizations and advocates that could work with LEP communities and individuals in a culturally competent way;
• Recruiting and training culturally diverse staff, including Care Managers and Participating Providers that will be able to operate fluently and deliver culturally and linguistically appropriate care with all communities throughout the State, including Tribal communities. This is done through Cultural Sensitivity training for all Oklahoma Complete Health staff through our robust Cultural Sensitivity training.
• Developing a set of cultural competency standards designed to help all parts of the care management process deliver culturally sensitive care;
• Identifying and developing intervention strategies for high-risk health conditions found in certain cultural groups; including American Indian/Alaska Native cultural competency.

HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds Oklahoma Complete Health accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.

Use of HEDIS Scores                                

As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician specific scores are being used as evidence of preventive care from patient centered medical home office practices. These rates then serve as a basis for physician profiling and incentive programs.

Calculating HEDIS Rates

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, routine Pap test, appropriate treatment of pharyngitis, appropriate treatment of URI, appropriate treatment of asthma, antidepressant medication management, access to PCMH services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care, and well-child care.

HEDIS and HIPAA

As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.

Oklahoma Complete Health providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. They will also enable Oklahoma Complete Health to review the quality and appropriateness of the services rendered. Oklahoma Complete Health will conduct random medical record audits as part of its QI program to monitor compliance with the medical record documentation standards. For more detailed information about standards, please see the MRR section of the Oklahoma Complete Health Provider Manual.The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services also may be assessed during a medical record audit. Oklahoma Complete Health will provide written notice prior to conducting a medical record review.

Preventive and clinical practice guidelines are based on the health needs and opportunities for improvement identified as part of the Quality Assurance Program Improvement (QAPI) program. Whenever possible, Oklahoma Complete Health adopts preventive and clinical practice guidelines that are published by nationally recognized organizations or government institutions as well as state-wide collaborative and/or a consensus of healthcare professionals in the applicable field.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to report their satisfaction with their healthcare, including their experience with their providers and health plan. The CAHPS survey scores are made available to the public and can determine whether patients and members stay with their provider or health plan or look elsewhere for their care. Surveys are sent to our members from February through June.

You are essential to providing the highest-quality healthcare possible for our members, and your satisfaction is important to us, too. We assess your experience with the health plan through an annual Provider Satisfaction Survey. These survey results will be reviewed by Oklahoma Complete Health and will be key to helping us improve the provider experience, so please be sure to complete the survey if you receive one in the 4th quarter.

During the credentialing process, Oklahoma Complete Health obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling your health plan Provider Engagement Representative.

If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify Oklahoma Complete Health as soon as possible so we can update our Provider Directory. Having access to accurate provider information is vitally important to our members, and we want to work together to ensure continuity of care can be maintained for Oklahoma Complete Health members.

Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.

Oklahoma Complete Health does not reward providers, practitioners or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. Nationally recognized criteria (such as InterQual or MCG) are used if available for the specific service request, without additional criteria (e.g., clinical/medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.

Submitting complete clinical information with the initial request for a service or treatment will help us make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting the UM department at the health plan.

Providing quality care to our members includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult patient centered medical home or specialist, contact Oklahoma Complete Health or reference the information in the Provider Manual. We can assist in locating an in-network adult care provider or arranging care if needed.

The health plan formulary/Preferred Drug List (PDL) is provided by the State of Oklahoma as is the prior authorization criteria. 

Our Care Management team is available for members who may benefit from increased coordination of services. The team is available to assist and support providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.

The care management team helps members:

• Achieve optimum health, functional capability and quality of life through improved management of their disease or condition.
• Determine and access available benefits and resources.
• Develop goals and coordinate with family, providers and community organizations to achieve these goals.
• Facilitate timely receipt of appropriate services in the right setting.

Early intervention is essential to maximizing treatment options and minimizing potential complications associated with illnesses, injury or chronic conditions. Members can receive services through face-to-face visits, over the phone or in a provider's office. You can directly refer members to the Care Management program at any time by calling the health plan or initiating a referral on the Provider Portal.

Every year Oklahoma Complete Health assesses appointment availability for PCPs, specialists and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent/sick visits, etc.) and type of practitioner. Please review the Provider Manual for the expectations of how quickly our members should be able to get an appointment.

Providers are expected to follow member rights. Members are informed of their rights and responsibilities in their enrollee handbook.

Member rights include, but are not limited to:

• Receiving all services the health plan provides.
• Being treated with dignity and respect.
• Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies.
• Being able to see their medical records.
• Being able to receive information in a different format in compliance with the Americans with Disabilities Act.

Member responsibilities include:

• Understanding their health problems and telling their healthcare providers if they do not understand their treatment plan or what is expected of them.
• Keeping scheduled appointments and calling the physician's office whenever possible if there is a delay or cancellation.
• Showing their member ID card at appointments.
• Following the treatment plans and instructions for care that they have agreed on with their healthcare.

We encourage you to review the Provider Manual to review the full list of rights and responsibilities.

Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:

• Address historical and contemporary injustices
• Overcome economic, social, and other obstacles to health and health care; and
• Eliminate preventable health disparities

To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. For more information about Culturally and Linguistically Appropriate Services (CLAS) Standards, see https://thinkculturalhealth.hhs.gov/clas. This is an external link that will take you outside the Oklahoma Complete Health website.

Together, we must make language assistance services available to people with Limited English Proficiency (LEP) at all points of contact during all hours of operation and at no cost to our members. We are here to help get language assistance to Oklahoma Complete Health members and providers without unreasonable delay at all vital points of contact. You can schedule language services, including telephone and face-to-face interpretation for non-English languages and American Sign Language, by calling our Provider Customer Contact Center or by calling the toll-free number on the back of our member’s ID card. See also the Member Languages and Interpreters Section under Health Equity Resources.

The health plan encourages our providers to engage in Cultural Humility trainings and education to promote positive interaction with diverse cultures.

For more information about the Cultural and Linguistic Competency e-Learning Program from the Office of Minority Health (OMH), see https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6. This is an external link that will take you outside the Oklahoma Complete Health website.

This program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS as a way to improve quality of care.