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Medi-Cal and Cal MediConnect Quality Improvement Programs

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
    (does not apply to HSP)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

The Health Net Quality Improvement Department establishes programs to meet the regulatory requirements of the Centers for Medicare and MediCaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). These programs include clinical and service quality improvement activities, Healthcare Effectiveness Data and Information Set (HEDIS®) performance measures, member satisfaction and access surveys, Medi-Cal and Cal MediConnect facility site certification, and medical record audits, along with any necessary follow-up quality action plans. This department monitors the results of quality improvement (QI) activities to quantify baseline data, identify opportunities for improvement, develop strong interventions to improve performance, and conduct re-measurements to evaluate effectiveness. The department is also responsible for preparation and implementation of any identified corrective actions based on findings of the CMS, DHCS and DMHC audits and findings identified through quarterly CMS, DHCS and DMHC reviews.

The department is staffed by quality improvement specialists (QIS') who are responsible for ensuring compliance with DHCS standards for facility reviews, medical record audits and quality action plans. The QIS' are responsible for incorporating new accreditation and regulatory standards and implementing new programs to meet those standards. In addition, a QI program manager is responsible for ensuring compliance with all CMS, DHCS and DMHC access to care standards, monitoring processes and access to care action plans.

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Last Updated: 08/06/2021