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Quality

The Quality Improvement (QI) Program monitors and evaluates the quality, appropriateness, accessibility and availability of health care services.

HEDIS®

HEDIS® is a tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service. The tool is comprised of 80 measures across five domains of care, including:

  • Effectiveness of care
  • Access and availability of care
  • Experience of care
  • Utilization and Relative Resource Use
  • Health Plan Descriptive Information

HEDIS® is a mandatory process that occurs annually. We've developed this toolkit to help identify required preventive services.


New: HEDIS Measurement Year 2020 Toolkit

HEDIS®

Coordination of Care requires proactively identifying the patient’s needs, organizing care and communicating vital information at the right time to the right people.

HEDIS® Adult Pocket Guide

When billing for an Evaluation and Management (E/M) service in addition to a preventive service, remember these guidelines from the Preventive Medicine Services section in the CPT book

HEDIS®

Preventive Health Counseling and Education for Children and Adolescents Ages 3–17 Years

HEDIS®

HEDIS®

This guide alerts you to important women's preventive care and services.

Other Resources


Helpful Information

View Clinical Guidelines

Clinical Coverage Guidelines
Evidence-based guidelines detailing the medical necessity of procedures or technologies.

NJ FamilyCare Dental Services Clinical Criteria

Clinical Practice Guidelines
CPGs outline medical standards of care and best practices.

Additional Resources

Dental Providers can access the additional resources for dental care including the NJFamilyCare Dental Services Clinical Criteria Policy by visiting the Liberty Dental Plan website.

Medical Records

QI may conduct annual medical record audits in physician offices. Patient records are reviewed for evidence that care and screenings have been documented. 

Provider Participation

Network providers are contractually required to cooperate with quality improvement activities. Providers are also invited to volunteer for the QI Program. Please contact us if you’re interested in volunteering.
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Last Updated On: 12/29/2020
Wellcare Medicare and PDP is getting a new look! Be on the lookout for changes in the coming months and know you can still count on the great coverage you’ve come to expect. Meet the New Wellcare. ×