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36 11/2005
Continuity and Coordination of Care
The BCBSGa/BCBSHP Quality Management program features a number of monitors
and improvement activities designed to ensure the continuity and coordination of care
across physician, hospital, facility, or other health care professional sites. Hospitals
are reminded of contractual obligation to provide a discharge summary and
Emergency Services record to the PCP, as noted on the member’s insurance card.
Hospitals may be requested to provide medical records in conjunction with the
following activities:
• Complaint and/or Adverse Occurrence Investigation Member complaints
regarding quality of care, service, access, privacy or continuity are investigated
using records of those parties named in the complaint. In addition to records,
each party is provided an opportunity to comment on the complaint made.
Specifics of the determination by BCBSGa/BCBSHP are not shared with the
member/complainant. Upon notification of a possible adverse occurrence, an
investigation, using medical records and solicited input begins. Determinations
are made by peer physicians.
• Clinical studies to determine care provided for specific diagnoses or procedures
(e.g. Community acquired pneumonia, diabetes etc.) BCBSGa/BCBSHP designs
and participates in studies to determine current community practice or level of
care provided by network hospitals for the specified diagnosis or procedure.
Information is not shared outside the organization that can be linked to a
specific facility, practitioner or patient/member.
• HEDIS Measures, including:
o Maternal Measures
o Use of Beta Blocker Medication After an Acute Myocardial Infarction
• Follow-up After Hospitalization for Mental Illness
Confidentiality and Health Insurance Portability & Accountability Act (HIPAA)
BCBSGa/BCBSHP is HIPAA compliant and any request for information or records from a
hospital is made within the boundaries of HIPAA regulations.