Best Practices, Clinical Resources and National Quality Standards

Online and downloadable to help support your care efforts

August 10, 2015 -

We're up-to-date on our quality standards -- make sure you are, too. Our Quality Improvement Program and council reviews national standards and best practices to make sure you have the best resources available to help support you in treating chronic disease, providing preventive care and maintaining office operations.

Click on the links and icons in the chart below for details on topics that can help you supplement the care you provide to your patients in your practice.

To request a paper copy of any of the PDFs listed, please call (800) 842-5975.

Quality Standards and Best Practices

General Guidelines and Survey Results

Topic	Condensed URL	PDF
CareFirst’s Quality Improvement Program Includes processes, goals and outcomes.	www.carefirst.com/qualityimprovement
Clinical Practice Guidelines Includes evidence-based clinical practice guidelines for medical and behavioral conditions.	www.carefirst.com/clinicalresources
Preventive Health Guidelines Includes evidence-based preventive health guidelines for perinatal care, children, adolescents and adults.	www.carefirst.com/clinicalresources
Access to Appointments Includes standards for routine care appointments, urgent care appointments and after-hours care.	www.carefirst.com/clinicalresources
Member Survey Results Includes survey to measure members’ satisfaction with their experience with their practitioner offices, health care and health plan.	www.carefirst.com/bluelink > 2015

Care Coordination Programs

Topic	Condensed URL	PDF
Access to Case Management Includes instructions for making referrals; or call 888-264-8648.	www.carefirst.com/providermanualsandguides
Practitioner Referrals for Disease Management Includes information to use the services, how a member becomes eligible and how to opt in or opt out.	www.carefirst.com/clinicalresources

Pharmaceutical Management

Topic	Condensed URL	PDF
Pharmaceutical Management Includes, the formulary, restrictions/preferences, guidelines/policies & procedures.	www.carefirst.com/rx

Utilization Procedures

Topic	Condensed URL	PDF
Utilization Management Criteria. Includes how to obtain UM criteria.	www.carefirst.com/bluelink > 2015
Physician Reviewer. Includes instructions to obtain a physician reviewer to discuss utilization management decisions.	www.carefirst.com/bluelink > 2015
Decisions about Medical and Mental Health Includes the affirmative statement for anyone making decisions regarding utilization management.	www.carefirst.com/bluelink > 2015

Member Related Resources

Topic	Condensed URL	PDF
Quality of Care Complaints Includes policies and procedures for complaints involving medical issues or services given by a provider in our network.	www.carefirst.com/qoc
How to File an Appeal Includes the policies and procedures for members to request an appeal of a claim payment decision.	www.carefirst.com/appeals
Member’s Privacy Policy Includes a description of our privacy policy and how we protect your health information.	www.carefirst.com/privacy
Member’s Rights and Responsibilities Statement Outlines responsibilities to our members.	www.carefirst.com/myrights