Quality Standards

Quality Improvement Program


At Healthy Blue, we always want to improve. Our quality improvement (QI) program helps us do this. 


The program: 


  • Assesses the health plan to help you find ways to improve it. 

  • Tracks how happy you are with your doctor. 

  • Tracks how happy you are with us. 

  • Uses the data we learn to make a plan to improve our services. 

  • Puts our plan into action to make your health care services better. 


You can get details about our QI program by calling Customer Service. We can send you more details on the program and a report on how we are doing to meet our improvement goals. 


Other Programs We Offer That Improve Our Quality Of Service


Care Management 


Our Care Management (CM) program helps you manage your complex and special health care issues. When you sign up for our CM program, a case manager will work with you and your family to: 


  • Create a care plan that fits your life. 

  • Set up health care services. 

  • Help with referrals and request for service. 

  • Send health records to your doctors when they need them. 


We also have complex care management for members with serious physical or mental health care needs. We may call you about this program if we think it could help you. 


If you think you need case management services or would like to learn more about the CM program, call our engagement team at 866-781-5094 (TTY 866-773-9634). A case manager will contact you to: 


  • Ask you about your health, support system and lifestyle needs. 

  • Explain how the program can help. 

  • Ask if you'd like to sign up. 


Learn More About Care Management 

Utilization Management 

Healthy Blue wants to make sure our members get the medical services they need to get or stay well. To do so, we have to decide which services we will cover. We call this process utilization management (UM).

We work with local doctors and other health providers to decide which services are needed and proper for us to provide full coverage for our members. Medically necessary services are the services covered by the state Medicaid program, including any treatment limits.

You and your primary care provider (PCP) always decide what is best for your health. If your doctor asks us to approve payment for certain health care services, we base our decision on two things:

  • If the care is medically necessary.

  • The health care benefits you have. 


You also should know Healthy Blue does not pay Medicaid doctors or other health care workers who make UM decisions to:

  • Deny you care. 

  • Say you do not have coverage. 

  • Approve less care than you need. 


Sometimes we ask other companies that are not part of Healthy Blue to help us decide if care is proper. Some examples are those who are experts in the use of X-rays and other imaging services. If you or your doctor has questions about our UM program, call us at 866-781-5094 (TTY: 866-773-9634).

Behavior Health Care

This care helps you with these kinds of problems:

  • Extreme stress, depression and anxiety

  • Marriage, family and parenting issues

  • Alcohol and drug misuse


If medically necessary, you may get: 

  • Inpatient mental health care. 

  • Outpatient mental health care and substance use treatment. 

  • Partial hospitalization for substance use treatment. 

  • Mental health rehabilitative treatment services 


We cover medically necessary services for all members who get care in a contracted hospital or Division of Alcohol and Other Drug Abuse Services (DAODAS) facility. Your doctor can send you to a certified psychiatric or substance use hospital that takes members your age, or you can choose one yourself. Your choice may require an approval if the specialist you choose is not part of our plan.


For outpatient services, these types of health care workers can provide covered outpatient mental health and substance use care:

  • Psychiatrists.

  • Outpatient mental health facilities.

  • Psychologists.

  • Licensed social workers, licensed psychiatric nurses and other licensed master-level providers.

  • DAODAS facilities and professionals who work there.

  • Department of Mental Health Community Mental Health facilities and the professionals who work there.

  • Department of Education facilities and the professionals who work there.

  • Department of Juvenile Justice facilities and professionals who work there.


Please call Customer Service for help finding care, such as the name of a behavioral health specialist. If you think a behavioral health specialist doesn’t meet your needs, talk to your PCP. Your PCP can help you find a different kind of specialist.

There are some treatments and services your PCP or behavioral health specialist must ask us to approve before you can get them. Your doctor will be able to tell you what they are. You can also call Customer Service if you have questions about referrals, approvals and when you need them.

You do not need a referral from your PCP to get these services or to see a behavioral health specialist in your network. If you are having a crisis or feeling overwhelmed, please dial 988 to call the Suicide and Crisis Hotline.


Want to learn more about the benefits we offer?