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Quality Management

Striving to do better, every day

Your health is important to us. We work very 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 healthcare 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

Your benefits and how to get medical care

Looking to learn more about our services and benefits? Grab your member handbook! You can read about:

  • Preventive healthcare: Find out how to help prevent many health issues and how to live a healthier life.
  • Preventive healthcare for women: Learn how to get access to women’s health specialists for regular and preventive healthcare 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 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.
Find your member handbook

What is case management?

Sometimes knowing how to care for your health can be hard. 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.

When you become a Healthy Blue member, we’ll give you a welcome call. This call is a great chance to talk about what case management handles and if it could help you. You’d be surprised how many different services we have. If we find one that might help you, we’ll connect you to a case manager. Your case manager will work with you and your provider to set up a plan of care. Do you think you need case management services? Please call Member Services at 1-844-521-6941 (TTY 711).

Our case managers may also call if:

  • Your provider 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

Your case manager can also help with:

  • Setting up healthcare services
  • Getting referrals and prior authorizations (approvals)
  • Checking your plan of care

We use data to find out if our Complex Case Management program could help you. We may call you about this program if you have:

  • Serious physical problems and need more help
  • Mental health problems and need more help working with all of your providers

If we call you, a nurse or social worker will:

  • Ask if you’d like to join our case management program
  • Tell you about what we offer
  • Talk to you about your health and how you’re handling different parts of your life

Not a kid anymore? It may be time for a new PCP

As your child reaches adulthood his or her healthcare needs start to change. By age 18, your young adult may want to find a primary care provider who treats adults.

Adult PCP offices include:

  • Family practice
  • Internal Medicine
  • Gynecology

Start by asking your child’s current PCP for a recommendation for a new adult PCP. Healthy Blue is here to help, too. You can change your teen’s PCP at any time. It’s easy with our Find a Doctor tool.

Find a Doctor

You have rights and responsibilities

As a Healthy Blue member, you have rights and responsibilities. They are listed in your member handbook. Do you want a printed version of your handbook? Call Member Services at 1-844-521-6941 (TTY 711).

How we make choices on care and services

Sometimes, Healthy Blue needs to make choices about how we pay for care and services. This is called Utilization Management (UM). Our UM process uses rules from the National Committee for Quality Assurance (NCQA) and our state contract. All UM choices are made from medical needs and current benefits we offer. We do this so you can be as healthy as possible. We don’t tell or ask providers not to use certain services. And we don’t try to make getting healthcare hard for you. Providers don’t get any rewards for limiting or denying care. And when we hire, promote or fire providers or staff, we don’t do it because they might, or we think they might, deny or would be likely to deny benefits.

Getting in touch with our Utilization Management staff

Some Healthy Blue services and benefits need prior approval. This means your provider must ask Healthy Blue to approve the services he or she wants you to have. Services that don’t need approval are:

  • Emergency care
  • Post-stabilization care
  • Urgent care

It’s our Utilization Review team that looks at approval requests. The team decides if:

  • You need the service
  • The service is one that Healthy Blue should pay for

What should you do if Healthy Blue won’t pay for care you think you need? You or your provider can ask us to take another look at that care. 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 changed and are now less in the amount or length of time than what you asked for

Do you have questions about an approval or a denial you got? Call Member Services at 1-844-521-6941 (TTY 711). Our Utilization Review team can help answer your questions.

New technology in medicine and care

The world is changing so fast! To make sure we are always using the very latest to help you feel your best, we have help, too. Our medical director and providers take a look at all the latest medical changes. They look at:

  • Medical steps
  • Behavioral health steps
  • Medicines
  • Equipment

They also look at scientific writings. With all this data, they think about:

  • Whether the government thinks these changes are safe and helpful.
  • If these changes offer the same or better results than what is used.

This work is done to help us decide if a new treatment or care should be added to your benefits.

How to contact Quality Management

Do you want to know more about our Quality Management program? How does Quality Management work? How are we doing? How are we meeting our goals? How are we making things better for you? Talk with us, or get a free copy of our Quality Management brochure:

Call Healthy Blue Quality Management at 1-844-521-6941 (TTY 711).

Or write to us at:
Quality Management Department
Healthy Blue
3850 N. Causeway Blvd., Ste. 600
Metairie, LA 70002

Our Notice of Privacy Practices

This notice tells you about how Healthy Blue 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. Do you want a copy mailed to you? Call Member Services at 1-844-521-6941 (TTY 711).