Quality Assurance Policies and Procedures

The evaluation and monitoring process used to evaluate and ensure all individual and facility providers meet federal, state, and Cigna CarePlan requirements are described in the following policies and procedures: Credentials Protocols, Practitioner Office Site Reviews, Initial Credentialing, Credentialing Rush Requests, Re-credentialing, Ongoing Sanction Monitoring, Delegation of Credentialing, and Delegated Oversight of Credentialing.

The Quality Improvement Program provides a framework for developing and implementing a comprehensive quality improvement program for members that provides a systematic mechanism for monitoring, evaluating, and improving the quality of care and services and ensures patient safety. The Program includes a Work Plan, which insures integration and coordination of all quality improvement activities and provides the structure and framework for day-to-day operation of the Quality Improvement Program and serves as the basis for the annual Program Evaluation.

Some of the policies and procedures which support the Quality Improvement Program include: Quality Improvement Program, Establishment of Quality Improvement Committees and Subcommittees, Technology Assessment, Policy Development, Quality and Safety of Care/Service Concern: Identifying, Investigating, Resolving, and Reporting, Exceptional Case Review, Health Information System, Delegation Oversight of Health Information System and Encounter Data, Hierarchical Condition Category (HCC) Data Validation, Quality Improvement Committee, Quality Improvement Projects, Developing the QI Program Description, Board of Directors, Compliance with State and Federal Regulations, and Medical Record Standards and Review.

Quality Improvement at Cigna

Summary of Quality Improvement Program Focus Areas