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Keystone First's Quality Improvement program

The Quality Improvement (QI) program at Keystone First monitors and assesses the health care services used by our members to ensure that these services:

  • Meet quality guidelines.
  • Are appropriate.
  • Are efficient.
  • Are effective.

The Quality Assessment and Performance Improvement Committee (QAPI) oversees the QI program and coordinates efforts to measure, manage, and improve the quality of care and services for members. The committee is made up of local health care providers, along with clinical and nonclinical associates.

Each year, the QI program sets goals to improve members’ health outcomes by using data and conducting activities to meet those goals. Keystone First evaluates the QI program at the beginning of each year and determines the successes and new activities to focus on. The QI program supports the organization’s mission to help people get care, stay well, and build healthy communities.

Keystone First has adopted clinical practice guidelines for treating members, with the goal of reducing unnecessary variations in care. The clinical practice guidelines represent current professional standards, supported by scientific evidence and research. These guidelines are intended to inform, not replace, the practitioner’s clinical judgment. The practitioner remains responsible for ultimately determining the applicable treatment for each individual patient.
Clinical practice guidelines are also available by request by calling the Provider Services department at 1-800-521-6007. Keystone First will provide the utilization management (UM) criteria to network providers upon request. To obtain a copy of the UM criteria:
  • Call the UM department at 1-800-521-6622.
  • Identify the specific criteria you are requesting.
  • Provide a fax number or mailing address.

You will receive a faxed copy of the requested criteria within 24 hours or written copy by mail within five business days of your request. Please remember that Keystone First has medical directors and physician advisors who are available to address UM issues or answer your questions regarding decisions relating to prior authorization, durable medical equipment (DME), home health care, and concurrent review. Call the Medical Director Hotline at 1-877-693-8480.

Additionally, Keystone First would like to remind providers of our affirmation statement regarding incentives:
  • UM decision-making is based only on appropriateness of care and the service being provided.
  • Keystone First does not reward providers or other individuals for issuing denials of coverage or services.
  • Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.