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Quality Management

SummaCare provides a high-quality, low-cost comprehensive, community-focused health plan that maximizes service with our integrated health system and choice to our providers, members and employers. We are committed to a thorough and effective Quality Management Program that follows the principles of Continuous Quality Improvement to improve the care and services members receive.

Major goals and objectives of the program include:

  • Promoting and building quality into the structure and processes of our organization
  • Monitoring and working to improve outcomes
  • Enhancing the customer experience
  • Promoting preventive health and wellness through targeted interventions
  • Promptly identifying opportunities for improvement with actions for resolution

Performance Measures

The healthcare industry's Healthcare Effectiveness and Data Information Set (HEDIS) provides standardized performance measures and comparisons against national benchmarks. Using HEDIS results, SummaCare monitors its quality improvement program performance and initiates efforts to improve performance when indicated.

HEDIS results measured in 2018 for 2019 performance identified SummaCare’s strengths and opportunities for improvement as follows:

For Medicare, SummaCare performed above the national average on the following Star Rating measures:

  • Getting Needed Care
  • Getting Appointments and Care quickly
  • Rating of Healthcare quality
  • Care Coordination
  • Annual Flu Vaccine
  • Getting Needed Prescription Drugs

We did not perform below the national average on any Star Rating measures.

For Commercial PPO, measures that were in or above the 75th percentile were:
  • Rating of Personal Doctor
  • Getting Needed Care
  • Rating of Specialist

Coordination of Care was identified as the greatest performance improvement opportunity for us. SummaCare has many initiatives in place, geared towards improving this performance metric; including interdepartmental communication and collaboration, and multidisciplinary team approach to care provision. These improvements are in place to enhance member experience and health plan satisfaction.

If you would like a summary of the annual program evaluation, call 330.996.8857.

Behavioral Health

SummaCare participates in behavioral healthcare clinical studies as part of NCQA requirements. The requirements' intent is to look at the coordination of care between medical and behavioral healthcare practitioners in order to improve health outcomes. Learn more about how SummaCare assesses areas of collaboration between medical and behavioral healthcare.

Quality Management – NCQA and HEDIS

Review the HEDIS MY 2020 & 2021 Technical Specifications and Measure Changes.

Member Mailings

SummaCare reminds and encourages members to get their preventive screenings by mailing annual preventive health letters. For members with chronic conditions such as diabetes and heart disease, care opportunity letters are also sent, which provide important information about screening and care for specific conditions. These letters help identify recommended services for you and your family. The care opportunity letter is only sent to members if we have not received claims by mid-year for the recommended cancer screenings, blood pressure checks and other tests or services. The letters are followed by a reminder phone call later in the year for members with continued care opportunities. SummaCare continues to evaluate and improve our outreach to members and providers to determine additional effective ways to help members get the care they need.

Credentialing Doctors

SummaCare’s goal is to offer the highest quality healthcare to our members. This is accomplished, in part, by building a provider network of physician and practitioner professionals who meet SummaCare’s standards.

Through the process of "credentialing," all new physicians and practitioners in the network are reviewed to assure their professional status is in compliance with our standards. After a physician or practitioner has been credentialed, his or her professional status is re-verified every three years in a process called "recredentialing."

SummaCare also credentials health delivery organizations such as hospitals, skilled nursing facilities and free-standing surgery centers.

Online Healthcare Quality Resources

Questions?  We are here to help.

Provider Support Services

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Provider Engagement Specialists

If you have not met with your assigned Provider Engagement Specialist or would like to schedule an in-office training or meeting to address any questions regarding the authorization process, claims issues, appeals, SummaCare products/benefits or Plan Central training, please contact the assigned Provider Engagement Specialist for your office.

Plan Central

View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.