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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.

Learn more about Quality Management

Have questions about the Quality Management program?

Call 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 1-866-231-0847 (TTY 711).

You have the right to ask for an appeal if you don’t agree with our decision to deny or reduce a service. An appeal is when you ask us to look again at the care we denied to make sure we made the right decision.

Learn more about your appeal rights:

Health care can be overwhelming. 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.

As a Highmark Blue Cross Blue Shield of Western New York member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.

If you think you need case management services or need help contacting your case manager, call us at 1-866-231-0847 (TTY 711).

Our case managers may also call if:

  • You or your doctor 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.
  • You have serious physical problems and need more help.
  • You have behavioral health problems and need more help working with all of your providers.

Your case manager can also help with:

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

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

  • Always identify themselves with their name, title and position with Highmark Blue Cross Blue Shield of Western New York.
  • Tell you about what we offer.
  • Talk to you about your health and how you’re handling different parts of your life.

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 doctors to withhold or give you fewer services limiting or denying care.
  • Stop certain people from getting services.
  • Reward doctors for limiting or denying care.

Some Highmark Blue Cross Blue Shield of Western New York services and benefits need prior approval. This means your provider must ask Highmark Blue Cross Blue Shield of Western New York to approve the services they want you to have. Services that don’t need approval are:

  • Emergency care.
  • Follow-up doctor visits after a hospital stay.
  • Urgent care.
  • Family planning services.
  • Primary care services.
  • Women’s health care services.
  • Children’s screening services.
  • Services provided at local health departments.
  • Some behavioral health and substance use disorder services.

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 Highmark Blue Cross Blue Shield of Western New York benefits.

What should you do if Highmark Blue Cross Blue Shield of Western New York 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 1-866-231-0847 (TTY 711). Our Utilization Review team or your case 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.

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.
  • Medicines.
  • Equipment.

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.

As a Highmark Blue Cross Blue Shield of Western New York 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 1-866-231-0847 (TTY 711).

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.
  • 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 correct levels of care and service.
  • Advance directives: Learn more about your right to use an advance directive (living will), and 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.
View your member handbook

Sometimes, dealing with all of the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can also lead to marriage, family and/or parenting problems. Stress can also lead to alcohol and drug use.

If you or a family member is having these kinds of problems, you can get help. Call Highmark Blue Cross Blue Shield of Western New York Member Services at 1-866-231-0847 (TTY 711). You can also get the name of a behavioral health specialist who will see you if you need one.

Your benefits include many medically needed services, such as:

  • Inpatient behavioral health services.
  • Outpatient behavioral health services.
  • Partial hospitalization.
  • Substance use treatment.
  • Crisis services.

You don’t need a referral from your primary care provider (PCP) to get these services or to see a behavioral health specialist in your plan.

If you think a behavioral health specialist does not meet your needs, talk to your PCP. They can help you find a different kind of specialist.

There are some treatments and services your PCP or behavioral health specialist must ask Highmark Blue Cross Blue Shield of Western New York to approve before you can get them. Your doctor will be able to tell you what they are.

If you have questions about referrals and when you need one, contact Member Services at 1-866-231-0847 (TTY 711).

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). View the Notice of Privacy Practices or find it in your member handbook. Call Member Services at 1-866-231-0847 (TTY 711) if you want a copy of the Notice of Privacy Practices mailed to you.

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 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 Change Your PCP tool. Or call Member Services at 1-866-231-0847 (TTY 711).

Annual Highlights

Our Quality Management program keeps track of Member Services and satisfaction.