Our Quality Standards
Our quality standards: Striving to do better, every day
Your health is important to us. We work hard to make sure you can get great care when you need it. We do this by:
- Having programs and services to help make sure the quality of health care you get is even better
- Supporting pregnant members and new moms with tools and information
- Finding local programs in your community to help you get the services you need
- Hosting events to help you learn about your plan and get the most out of it
- Following state and federal rules
- Looking at our quality reports to find new ways to offer better care
Learn more about Quality Management
Have questions about the Quality Management program?
Call us. We can talk to you about:
- What quality management is
- How we are doing and what our goals are
- How we are working to make things better for you
We can also send you information on our Quality Management program. Call 1-800-300-8181 (TTY 711).
Case management: Helping you manage all the moving pieces
Health care can be overwhelming. Our case managers can help make it easier. Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. That’s what our case managers do.
As an Empire BlueCross BlueShield HealthPlus member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.
If you think you need case management services or need help contacting your case manager, call us at 1-800-300-8181 (TTY 711).
Our case managers may also call if:
- You or your doctor thinks case management might help you
- You’ve just gotten out of the hospital and need help with follow-up visits to other providers
- You’re going to the emergency room (ER) often for nonurgent care that could be handled by your provider
- You call our 24/7 NurseLine and need more follow-up for ongoing care
- Serious physical problems and need more help
- Behavioral health problems and need more help working with all of your providers
Your case manager can also help with:
- Setting up health care services
- Getting referrals and prior authorizations (approvals)
- Checking your plan of care
If we call you, a nurse or social worker will:
- Always identify themselves with their name, title and position with Empire
- Tell you about what we offer
- Talk to you about your health and how you’re handling different parts of your life
Utilization management: How we make choices on care and services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
- Looks at what, when and how much of our services are medically needed
- Always strives for the best possible health outcomes for our members
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care
- Stop certain people from getting services
- Reward doctors for limiting or denying care
Getting in touch with our Utilization Management staff
Some Empire services and benefits need prior approval. This means your provider must ask Empire to approve the services he or she wants you to have. Services that don’t need approval are:
- Emergency care
- Care needed after a hospital stay
Our Utilization Review team looks at approval requests. The team decides if:
- The service is medically needed
- The service is one that is included in your Empire benefits
What should you do if Empire won’t approve care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:
- Are not approved
- Have been limited in the amount or length of time from what was requested
Do you have questions about an approval or a denial you got? Call Member Services at 1-800-300-8181 (TTY 711). Our Utilization Review team or your Case Manager can help answer your questions.
You have the right to ask for an appeal if you don’t agree with our decision to deny or reduce a service. An appeal is when you ask us to look again at the care we denied to make sure we made the right decision. Learn more about your appeal rights:
- Medicaid appeal process
- Health and Recovery Plan appeal process
- Managed Long-Term Care appeal process
- Child Health Plus appeal process
- Essential Plan appeal process
Your opinion matters!
Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Help us make your plan better.
New technology in medicine and care
To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:
- Medical treatment and services
- Behavioral health treatment and services
They also look at the most up-to-date medical and scientific writings. With all this data, they consider:
- If the changes are safe and helpful
- If these changes offer the same or better results than what is used today
This work is done to help us decide if a new treatment or care should be added to your benefits.
You have rights and responsibilities
As an Empire member, you have rights and responsibilities. They are listed in your member handbook. Do you need a printed copy of your member handbook? Call Member Services at 1-800-300-8181 (TTY 711).
Your benefits and how to get medical care
Are you looking to learn more about our services and benefits? Grab your member handbook! You can read about:
- Preventive health care: Find out how to help prevent many health issues and how to live a healthier life.
- Preventive health care for women: Learn how to get access to women’s health specialists for regular and preventive health care services.
- Benefits and access to care: Find out more about your benefits and how to get medical care.
- Language help: Learn how to get our information in the language you use at home.
- Pharmacy: Find out about your benefits and how to get the medicines you need.
- Case management: Partner with a case manager to learn more about ways to get care for your health issues.
- Member rights and responsibilities: Read about your rights and responsibilities.
- Notice of Privacy Practices: Learn more about how we keep your private information safe.
- Medical necessity: Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.
- Advance directives: Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.
Behavioral health (mental health and substance use disorder services)
Sometimes, dealing with all of the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can lead to marriage, family, and/or parenting problems. Stress can also lead to alcohol and drug abuse.
If you or a family member are having these kinds of problems, you can get help. Call Empire Member Services at 1-800-300-8181 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. and on Saturday from 9 a.m. to 5 p.m. Eastern time. You can get the name of a behavioral health specialist who will see you if you need one. You can also find a provider with our Find a Doctor tool or by viewing the provider directory.
Your benefits include many medically needed services, such as:
- Inpatient behavioral health services.
- Outpatient behavioral health services.
- Partial hospitalization.
- Treatment and rehabilitative services.
See your member handbook to learn more about your benefits.
You don’t need a referral from your primary care provider (PCP) to see a behavioral health specialist in your plan.
There are some treatments and services your behavioral health specialist must ask Empire to approve before you can get them. For information about services that need preapproval, please see your member handbook.
If you have questions about referrals and when you need one, contact Member Services at 1-800-300-8181 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. and on Saturday from 9 a.m. to 5 p.m. Eastern time.
Our Notice of Privacy Practices
The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your member handbook as well as online. Call Member Services at 1-800-300-8181 (TTY 711) if you want a copy of the Notice of Privacy Practices mailed to you.
Not a kid anymore? It may be time for a new PCP.
As you become an adult, your health care needs start to change. If you’re seeing a pediatrician, you may want to find a primary care provider who treats adults.
Adult PCP offices include:
- Family practice
- General practice
- Internal Medicine
Start by asking your current PCP for a recommendation for a new adult PCP. We’re here to help, too. You can change your PCP at any time. It’s easy with our Change Your PCP tool. Or call Member Services at 1-800-300-8181 (TTY 711).