Quality Programs

  • The Quality Program supports Premera's mission: to provide peace of mind to members about their healthcare coverage. We do this by providing a framework for ongoing evaluation and communication designed to improve member health and the quality and safety of care and service experienced by our customers. Our Quality Program benefits Premera members across every plan and service. We work with you to monitor and improve the care you provide. The Quality Improvement Committee conducts a formal, system-wide quality assessment annually, which includes an annual program evaluation of the quality of its health services. View Quality Program Report Card.

    Visit our Quality & Coding Tools page for quality measure tip sheets, documentation and coding guides, web-based training, and more.

    Quality components

    Preventive health guidelines

    Premera maintains up-to-date guidelines for Preventive Services, adopting content from the:

    • United States Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services
    • Centers for Disease Control and Prevention (CDC)
    • Advisory Committee on Immunization Practices (ACIP) vaccination schedule, and
    • Institute for Clinical Systems Improvement (ICSI) guideline as the source of recommendations for child preventive services that providers and care systems should deliver.

    Premera's guidelines are a quick reference, describing recommended prevention and early detection interventions. All preventive service recommendations included in the guidelines have received USPSTF “A” or “B” grades based on strength of evidence and magnitude of benefit unless otherwise noted.

    Premera distributes the Preventive Health guidelines to members and practitioners by placing them on company web sites. Specific statements made within the Preventive Health Guidelines do not guarantee benefit coverage for services and are not intended as a recommended service for a specific patient.

    Benefit information can be obtained by calling Customer Service using the phone number printed on the back of the member's identification card.

    View Guide to Clinical Preventive Services (Adult) and Guide to Clinical Preventive Services (Children/Adolescents).

    Clinical practice guidelines

    Premera maintains clinical practice guidelines for medical conditions relevant to its member population. The guidelines are designed to help guide practitioner and member decisions about appropriate healthcare for specific clinical circumstances.

    When possible, Premera adopts nationally recognized clinical practice guidelines. When a suitable guideline is not available, Premera collaborates with subject matter experts to develop a clinical practice guideline.

    Guidelines supporting Premera's disease management program are maintained by the disease management department. Premera's adoption of a national guideline or any statement made within a clinical practice guideline does not guarantee benefit coverage for services and is not intended as a recommendation for services to a specific patient. Benefit information can be obtained by calling Customer Service using the telephone number printed on the back of the member's identification card.

    View the clinical practice guidelines used in our Disease Management Program.

    Physician collaboration

    The Quality Program provides opportunities for physician collaboration with Premera practicing physicians who are members of the Clinical Quality Improvement Committee, Pharmacy and Therapeutics Committee and Credentialing Committee. These committees seek practitioners' clinical guidance, expertise and perspective on Premera Quality Improvement, Behavioral Health, Care Management, Disease Management, Pharmacy and other health improvement programs and projects.

    Involvement in these forums assists the company in improving member health and the quality and safety of care and service experienced by our customers. Physicians interested in serving on one of the Quality Program committees should contact the Premera Medical Director.

    Quality of care complaint review

    If a member, practitioner or Premera associate expresses concern about the quality of care received by one of our members, we take the following steps:

    • Document and investigate their concern
    • Conduct an investigation observing strict confidentiality
    • Request pertinent information and/or medical record documentation as needed
    • Seek review by Premera senior medical directors, peers or Board-certified specialists as needed

    Patient safety

    Premera promotes awareness and provides educational information aligned with the national focus on patient safety. We provide access to information that equips members to take an active role in their healthcare. In addition, Premera provides access to information, standards of care and national resources designed to help physicians and other providers improve the effectiveness and safety of care delivery.

    Premera has selected a patient fact sheet titled, “Five Steps to Safer Healthcare” to educate members about steps they can take to have a more active role in promoting safe care for themselves. It encourages patients to communicate directly with their physicians or providers. The fact sheet was developed by federal agencies in the Quality Interagency Coordination (QuIC) Task Force working with other healthcare purchasers, physicians and providers.

    For more information, see Five Steps to Safer Healthcare fact sheet.