Quality Assurance

Quality Assurance

The Quality Assurance and Performance Enhancement Department is built on the well-known and well-regarded structure-process-outcome model of quality. This model employs the proactive Plan-Do-Check-Act (PDCA) cycle of continuous quality improvement which includes the following activities:

• Identification of processes which require improvement
• Organization of workgroups which understand the process which requires improvement. These workgroups include committees such as the Quality Improvement and Compliance Committee and a Medical Affair Committee
• Understanding sources of variation and error within the process
• Development of the optimal intervention to improve the process
• Implementation of the intervention
• Collection of data to evaluate the results of process improvement
• Continuing the quality improvement process as needed

In addition to its proactive quality improvement activities, continuous program monitoring and evaluation plays a critical role within the organization. As such, the plan participates in an annual HEDIS audit to ensure the highest standards of care and service are met. The plan also reviews the results of its Consumer Assessment of Health Plan Survey (CAHPS) data to ensure the highest degree of member satisfaction. When quality of care issues, quality of service issues, or member satisfaction issues are identified, they are subject to the scrutiny of the PDCA quality improvement cycle outlined above. The result of these ongoing and proactive activities is improved quality of care, better health outcomes for our members, and greater levels of member satisfaction. If you have questions pertaining to plan quality assurance processes call (713) 558-4618.

Lastly, the plan has quality assurance policies and procedures in place for drug utilization review, medication therapy management, and pharmacy-related appeals and grievances. Questions relating to the Medicare Part D Drug program should be directed to Member Services.

TexanPlus (all plans): 800.958.2707

TTY/TDD (all plans): 866.338.4681

Hours of Operation: 8:00 AM – 5:00 PM CST, Monday – Friday.