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Quality management

Quality Assessment and Performance Improvement (QAPI) program

Quality Assessment and Performance Improvement (QAPI) program

The goal of quality management is to promote members’ health status or maintain it when their condition isn’t likely to improve.


Our process, which involves quality assessment and performance improvement activities, enables us to:


  • Review current practices in both clinical and non-clinical areas.
  • Find opportunities for improvement.
  • Choose the most effective interventions.
  • Evaluate and measure the success of current interventions and refine them as needed.


We develop QAPI objectives each year and outline them in our annual QAPI Program Description. This documents the scope, structure and function of the QAPI program. We also evaluate our success in achieving our annual QAPI goals each year and document the results in our Quality Assessment and Improvement Program Evaluation.  


Need a copy of our QAPI Program Description or Quality Assessment and Improvement Program Evaluation? 


These documents will be updated throughout the year. Call Provider Relations at  1-833-711-0773 (TTY: 711) with questions. We’re here for you Monday through Friday, 7 a.m. to 8 p.m. ET.

Quality Management Oversight Committee (QMOC)

Quality Management Oversight Committee (QMOC)

Aetna Better Health of Ohio’s QMOC integrates quality management and performance improvement activities through the OhioRISE plan and provider network. The committee oversees the QAPI program and offers recommendations to the board of directors. Their tasks include:


  • Confirming that quality activities are designed to improve the quality of care and services. 
  • Reviewing and evaluating the results of quality improvement activities.
  • Reviewing and approving studies, standards, clinical guidelines, trends in quality and utilization management indicators, and satisfaction surveys.
  • Advising and making recommendations to improve the OhioRISE plan.
  • Reviewing and evaluating company-wide, performance-monitoring activities, such as care coordination, customer service, claims, grievance and appeals, and more.

Guidelines availability

Guidelines availability

We use clinical guidelines to make treatment authorization decisions. Providers and members have the right to request a copy of those guidelines or specific criteria. 


Note: The material provided to you are guidelines used by this plan to authorize, modify, or deny care for the person with similar illnesses or conditions. Care and treatment may vary depending on individual need and the benefits covered under your contract.  


Need a copy of the criteria? Just call Provider Relations at 1-833-711-0773 (TTY: 711).

Value-based programs

Our value-based provider partnership program seeks to create a collaborative relationship that achieves improved clinical, quality and financial outcomes, and enhances the life of every member.  


HEDIS stands for Healthcare Effectiveness Data and Information Set. Health plans use HEDIS scores to monitor performance in areas like quality of care, access to care, and member satisfaction.


Learn more about HEDIS

Share your voice

Share your voice

Are you a network provider? We’d love to have your input and feedback. Email, call or consider joining our provider committees and getting more involved.


Provider committees 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

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