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
Thank you for being our member!
In 2017, we made changes to serve you better.
You can be confident our plan is approved by the experts. We’re accredited by the National Committee for Quality Assurance (NCQA), which means they’ve said we provide access to high quality health care.
We work hard to make sure you have access to great care. We do this by:
- Having programs and services to help improve the quality of health care you get
- Providing special programs and tools for specific populations including pregnant women and new moms
- Hosting learning events to answer your questions and concerns and help you make the most of your health care
- Helping members find local programs nearby to help them get needed care and services
- Following state and federal guidelines
- Looking at our quality results to find new ways to provide care
Every year, we look at how we’re doing and try to find ways to do it better. The Quality Management program sets goals each year. We’re working to improve in the following areas to achieve our goals:
- Better educate our members, staff and plan providers about Medicaid managed care
- Improve Consumer Assessment of Healthcare Providers and Systems (CAHPS) Composite Rating of Health Plan scores
- Improve quality outcomes through member and provider incentives
- Improve and promote member clinic days
- Continue provider and quality management physician opportunity visits
- Reduce wrong member contact information
To measure how we’re doing, we use tools from professional organizations, like the CAHPS survey. Based on your answers, here’s how you graded us in 2016:
CAHPS health plan ratings for 2016
- Getting care quickly - 86.45%
- Shared decision making - 80.43%
- How well doctors communicate - 94.47%
- Getting needed care - 86.45%
- Customer service - 89.64%
- Health care rating - 77.03%
- Personal doctor rating - 82.28%
- Specialist rating - 82.28%
- Health plan rating - 75.48%
Have questions about our Quality Improvement program, goals or CAHPS scores? Call Member Services toll free at
1-800-600-4441 (TTY 711).
Learn more about Quality Management
Have questions about the Quality Management program?
Call us or write to 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 1-800-600-4441 (TTY 711).
Care management: Helping you manage all the moving pieces
Health care can be overwhelming. Our care 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 care managers do.
As an Amerigroup member, we offer many different types of services. Your care manager works with you and your provider to set up a person-centered plan. You may already be working with a care manager and know how to contact them.
If you think you need care management services or need help contacting your care manager, call us at 1-800-600-4441 (TTY 711).
Our care managers may also call if:
- You or your provider thinks care 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 Amerigroup On Call 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 care manager can also help with:
- Setting up health care services
- Getting referrals and prior authorizations (approvals)
- Checking your person-centered plan
If we call you, a nurse or social worker will:
- Always identify themselves with their name, title and position with Amerigroup.
- 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 providers to withhold or give you fewer services limiting or denying care.
- Stop certain people from getting services.
- Reward providers for limiting or denying care.
Getting in touch with our Utilization Management staff
Some Amerigroup services and benefits need prior approval. This means your provider must ask Amerigroup 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 Amerigroup benefits
What should you do if Amerigroup 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 1-800-600-4441 (TTY 711). Our Utilization Review team or your Care Manager can help answer your questions.
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.
Clinical Practice Guidelines
Clinical Practice Guidelines are rules that give providers in our network ways to treat health problems. Our Corporate Medical Advisory Committee and our Medical Policy Committee, who are two groups of specialists and external providers, approve them.
If you would like a copy of our Clinical Practice Guidelines, either:
- Call Member Services at 1-800-600-4441 (TTY 711), Monday through Friday from 8 a.m. to 5 p.m. Central time, or
- Go to providers.amerigroup.com
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 Amerigroup 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 1-800-600-4441 (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.
- Care management: Partner with a care 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.
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 1-800-600-4441 (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 or behavioral health provider.
It’s important for you to get the right care from your providers. As an adult, you can choose to change from a provider who specializes in care for children or teens to a provider who focuses on treating adults. This includes providers for physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.
Start by asking your current primary care provider (PCP) or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It’s easy with our Find a Doctor tool. Or call Member Services at 1-800-600-4441 (TTY 711).