Quality Improvement

Optima Health, through its commitment to excellence, has developed a comprehensive program directed toward improving the quality of care, safety, and appropriate utilization of services for our members. The Quality Improvement program is designed to implement, monitor, evaluate, and improve processes within the scope of our health plan on a continual basis in order to improve the health of our members every day.

Quality Improvement Highlights

Clinical Guidelines Update

The guidelines are based on published national guidelines, literature review, and the expert consensus of clinical practitioners. They reflect current recommendations for screening, diagnostic testing, and treatment. These guidelines are published by Sentara Health Plans, Inc. (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these guidelines. The SHP guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment. Copies of clinical guidelines are available via mail, email, fax, or online. Please contact Quality Improvement Department at 1-844-620-1015.

QI Program and HEDIS®1 Progress Report

Each year, Optima Health is required by the Centers for Medicare and Medicaid Services (CMS) 2, Department of Medical Assistance and Services (DMAS) 3 and the National Committee for Quality Assurance (NCQA) standards to make available an annual Quality Improvement (QI) Program Progress Report to our members and providers. Optima Health offers a comprehensive QI program that focuses on objectively and systematically improving the quality of medical and behavioral health care and services for our members. The Plan has received NCQA Accreditation for its commercial HMO/POS health plans, Medicaid HMO product4, and Marketplace plans. NCQA accredits and certifies the Health Plan by assessing, reporting, and improving the quality of care and how well the plan manages all parts of its delivery system and services (e.g. physicians, hospitals, other providers and administrative services)5. Optima Health uses epidemiology, demographics, and analysis of the previous year QI monitoring rates to annually update its QI program and monitors services that are high volume, high cost, high risk, high impact and/or problem prone.

Progress is continuously evolving as we look for opportunities of improvement in the quality of care and the services provided to our members.

Quality Improvement Program for 2017 includes:

  • Communication with members and physicians via oral, written, and electronic forms to provide education and reminders regarding recommended preventive screenings and care
  • Health risk assessment and welcome calling programs to identify specific chronic conditions in our membership, with appropriate follow-up activities
  • Self-Management Tools are available (in digital or print) to help members manage their health and reduce risk
  • Disease Management programs for members with diabetes and asthma
  • Partners in Pregnancy is a program to provide guidance, support, and education to our expectant moms
  • Monitoring service activities to assess and improve access to practitioners and transitions to other care
  • Evaluating satisfaction with the health plan and care received from our practitioners and providers
  • Evaluating complaints and occurrences to ensure that our members’ needs are met by the highest level of care and service
  • Investigating and developing policies and guidelines with new treatments and procedures in medical, surgical, behavioral health services, pharmaceutical technologies, and devices through comprehensive technology assessment reviews
  • Credentialing and re-credentialing Primary Care, Behavioral Healthcare and Specialty Care providers
  • Medical record audits to evaluate accepted standards for medical record documentation

For more information about Quality Improvement at Optima Health please contact the Quality Improvement Department at 757-252-8400 or toll-free 1-844-620-1015. NCQA’s website (www.ncqa.org) contains information to help consumers, employers and others make more informed healthcare choices6.


1 HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
2 Centers for Medicare and Medicaid Services (2017). Subpart E—Quality Measurement and Improvement. Electronic Code of Federal Regulations. §438; §422.152.
3 DMAS (2017) Medallion Contract 3.0. Section 8.5 and Section 7.9
4 NCQA Accreditation documentation
5 National Committee for Quality Assurance (NCQA) (2016). 2017 Standards and Guidelines for the Accreditation of Health Plans. QI 1 QI 2. pp.55-63.
6 NCQA (September 2013). General Guidelines for Marketing and Advertising Health Plan Accreditation