Member Services: 877-514-2442

QUALITY ASSURANCE

At CGHC, we strive to provide the best services possible, which makes quality improvement an important part of our mission. Listed below are the variety of measures we take to improve our services and provider partnerships.

If you would like a copy of this material or more information please contact Member Services at 877.514.2442.

CGHC Quality Program

Quality Improvement Program

The Quality Improvement (QI) Program is established to provide the structure and key processes that enable CGHC to carry out its commitment to ongoing improvement of care and service, and the health of its members. The QI Program provides a formal process by which CGHC and its participating providers and practitioners strive to continuously improve the level of care and service rendered to members and customers. The program addresses both medical and behavioral health care, and the degree to which they are coordinated. It defines the systematic approach used to identify, prioritize and pursue opportunities to improve services, and to resolve identified problems.

The QI Program is reviewed, updated and approved by CGHC’s Executive Quality Oversight Committee (EQOC) and forwarded to the Board of Directors at least annually. It is distributed to applicable regulatory bodies and other stakeholders, as requested.

QI Program Goals and Objectives

  • Design and maintain a quality improvement structure that is integrated throughout the
  • Company and provides ongoing monitoring of identified clinical and service processes that support continuous quality improvement; including measurement, trending analysis, intervention and re-measurement.
  • Continue to establish effective, long-term relationships with providers by securing provider input regarding quality initiative program design and operations, maintaining open lines of communication and providing feedback related to individual and product-wide performance.
  • Ensure that adequate and appropriate resources are available to maintain and enhance the ongoing QI Program.
  • Uphold established standards/guidelines to ensure appropriate and optimal availability, accessibility and continuity of care for members.
  • Use evidence-based guidelines as the basis for all clinical decision-making
  • Continuously monitor and enhance Behavioral Health strategies based upon the most current, evidence-based clinical practice guidelines from nationally recognized sources, which will be adopted by the Company and made available to network providers via postings on the Company’s website, and against which performance is measured.
  • Promote the delivery of preventive health services by network providers through physician and member education while encouraging the utilization of such services.
  • Promote the implementation of wellness programs for employer groups, members and employees based on Health Assessments results Monitor member and provider satisfaction to identify potential concerns and opportunities for improvement
  • Continue to work toward meeting our members’ culturally diverse and linguistic needs
  • Continue to serve members with complex health needs through adherence to interventions and programs available within the Case Management & Disease Management Program Descriptions
  • Continue to educate members on product benefit design, operational policies and procedures and improve upon the manner in which information is disseminated to members.
  • Encourage joint action with our network providers, acute care, ambulatory surgery facilities and pharmacies in addressing patient safety issues.
  • Continue to improve upon the core service functions of timely, accurate adjudication of claims and timely response to written correspondence, email and telephone calls.
  • Monitor and analyze member utilization of services to ensure the identification of areas where over and/or underutilization of services may be occurring so that appropriate action/interventions can be initiated
  • Leverage standards published by national accreditation bodies to continually enhance the QI Program.
  • Promote improvement through sound, nationally supported measurement activities and associated benchmarking.
  • Provide members and practitioners with readily available, easily accessed web-based information and tools to promote and enhance services and clinical care. Features include:

o Evidenced based guidelines for providers

o Provider Supply Request form to facilitate online requests of frequently used forms/supplies

o Interactive tools

o Provider and member newsletters posted to the Company’s websites

o Member ability to identify and select a provider online including information on Board Certification and language(s) spoken

o Member ability to e-mail concerns/complaints to Customer Service

o Ability to receive Explanation of Benefits (EOB) online versus via U.S. Mail Services.

o Evaluate the efficiency and effectiveness of the Quality Improvement Program on an annual basis with an emphasis on the structure, processes, outcomes, methodology, and results.

 

To learn more or to request a complete copy of CGHC’s QI Program, call Member Services at 877.514.2442 or click here.

New Technology

New medical technology is always emerging in the healthcare industry and with new technology comes new potential risks. CGHC has an assessment process that follows the HAYES Medical Technology Directory as a guideline to ensure the new techologies or new uses for existing technologies and medical interventions are effective and safe for our members.

Through evaluations we can determine whether the procedure, service or supply will be a covered benefit and whether coverage will be subject to prior authorization. Our Medical Management Committee (MMC) reviews the technology and makes decisions based on safety, efficacy, cost and availability of published information including clinical trials. Coverage decisions are then implemented by our Chief Medical Officer and Chief Operations Officer. If we’re covering it, we want to make absolutely sure the service is important and necessary for our members to have access to.

Care Management

Do you have a complex condition that requires special care? If so, did you know that you have access to our Care Management program designed to help you coordinate your care needs?

The Care Management program is designed to provide you with support in understanding your treatment plan, tips on how to make the most of your doctor appointments, help you set goals to better manage your condition and assist you obtaining the latest relevant medical information.

Below are examples of the conditions we work with:

  • Cancer
  • Multiple Sclerosis
  • Brain injury or stroke
  • Premature infants
  • Developmental delays
  • Organ transplant candidates
  • End stage renal disease or dialysis
  • Sepsis

Disease Management is an additional program offered to members who would like help managing chronic conditions and the different levels of care involved including preventive measures, self-care an outpatient services. You can join the program to take an active role in managing and improving your health if you have one of the following conditions:

  • Asthma
  • Coronary artery disease
  • Congestive heart failure
  • Chronic obstructive pulmonary disease (emphysema)
  • Diabetes

These services are free to you and are delivered primarily over the phone by a registered nurse who evaluates your health status working with you and your doctor. If you have any of the conditions above and have not already received information about these programs, please contact us at 877.779.7598. Click here for more information.

Online Resources

Our mission at Common Ground Healthcare Cooperative is to provide you, our member, with accessible and simple to understand details about your coverage. Below are some examples of the online resources available to you. Most are posted in easy to find, public areas of our website so you don’t have to log in to any portal except when it is important to protect your health information.

  • Current Individual and Small Group Certificates of Coverage describing CGHC’s covered services
  • Member Guide with helpful instructions about how to use your member resources such the Mobile ID Card app and the My Health Portal
  • Frequently Asked Questions
  • Prescription Coverage and Drug Formulary information with quarterly updates
  • Prior authorization details and current list of services requiring prior authorization
  • Find a Doctor through CGHC’s searchable Provider Directory
  • How to enroll in a case management or disease management program through the CGHC MemberCare Program
  • Preventive Care guidelines
  • Access to CGHC’s Wellness and Self-Management tools
  • Ability to check the status of your medical claims
  • Ability to order additional member identification cards
  • Instructions for downloading CGHC’s Mobile ID Card app for smartphones
  • Member Rights & Responsibilities
  • CGHC Policies, Procedures and Privacy Practices
Pediatric to Adult Care

It can be crucial to your health and wellness to establish a relationship with your primary care physician or PCP early. A PCP can be a great resource when you need medical attention, have health related questions or need a referral to see a specialist. Your PCP should be your first stop before for all non-emergent care.

All members who have reached 18 years of age who have been receiving pediatric care are encouraged to transition to an adult primary care physician such as a general family or internal medicine practitioner or ob/gyn who are better equipped to care for your needs during adulthood.

Click here to find a doctor in your network or you can call Member Services at 877.514.2442.

Emergency Care

If you have a medical emergency, please call 911 immediately or visit the nearest emergency room.

If you do not have a medical emergency, then it is best to avoid the emergency room and seek treatment with your primary care physician or urgent care facility if necessary. Emergency rooms are designed to treat life threatening conditions, and the most seriously ill or injured patients will be seen first.

The information below describes the differences between a medical emergency and medical situations that may not be an emergency.

An emergency medical condition is the sudden and unexpected onset of a medical condition of sufficient severity, including severe pain, when the absence of immediate medical attention could reasonably be expected to result in:

  • Serious jeopardy to the mental or physical health of the individual
  • Danger of serious impairment of the individual’s bodily functions
  • Serious dysfunction of any of the individual’s bodily organs or parts
  • In the case of a pregnant woman, jeopardy to the health of the fetus

These are examples of emergencies:

  • Breathing problems
  • Broken back or neck, or broken bones
  • Chest pain or other heart attack signs
  • Convulsions or seizures
  • Drug overdose
  • Heavy bleeding or severe pain
  • Loss of consciousness
  • Poisoning or severe burns
  • Sudden weakness on one side
  • Severe allergic reaction

These are examples of non-emergencies:

  • Colds, flu, earaches, sore throat
  • Non-life threatening cuts or burns
  • Bronchitis
  • Pink Eye
  • Headache
  • Sprains
  • Animal and bug bites
  • Rashes and other skin conditions
  • Other concerns that can wait for an appointment
After Hours Care

Your primary care doctor (PCP) is responsible for your care 24 hours a day. When their office is closed, your PCP will make information available regarding after hours and weekend coverage. The following are some of the methods your PCP may use:

  • Answering service
  • Pager
  • Answering machine

Because each PCP may have different procedures, be sure to check with your PCP on the best method for receiving care after business hours.