Quality improvement

Quality is in all we do at Aetna Better Health

Our Quality Assurance and Performance Improvement (QAPI) program is a continuous quality improvement process that includes comprehensive quality assessment and performance improvement activities. We continuously and proactively review our clinical and operational programs and processes to identify opportunities for continued improvement. Our continuous Quality Management/Quality Improvement (QM/QI) process enables us to:

  • Assess current practices in both clinical and non-clinical areas
  • Identify opportunities for improvement
  • Select the most effective interventions
  • Evaluate and measure on an ongoing basis the success of implemented interventions, refining the interventions as necessary.

The use of encounter data, ad-hoc internal reports, HEDIS®, External Quality Review (EQR), and CAHPS in the monitoring, measurement and evaluation of quality and appropriateness of care and services is an integral component of Aetna Better Health’s quality improvement process. Check our Provider Manual (LINK) to learn more about our QM Program.

Learn more about our quality improvement programs by reading the Quality Management Program Evaluation.

The Department of Health Services (DHS) requires us to produce HEDIS® rates for all Medicaid reporting measures, with the exception of behavioral health measures. HEDIS® is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) designed to reliably compare health plan performance. HEDIS® performance measures are divided into eight domains of care:

  • Effectiveness of care
  • Access/availability of care
  • Satisfaction with the experience of care (Adult and Child CAHPS)
  • Health plan stability
  • Use of services
  • Informed health care choices
  • Cost of care
  • Health plan descriptive information.

We work with you to assure that all DPW requirements concerning HEDIS® performance measures are met on an ongoing basis, by: 

  • Producing rates for all Medicaid reporting measures, with the exclusion of behavioral health measures
  • Following NCQA specifications as outlined in the HEDIS® Technical Specifications, clearly identifying the numerator and denominator for each measure.
  • Validating HEDIS® results by using an NCQA-licensed vendor

Consumer Assessment of Healthcare Providers and Systems (CAHPS) are a set of standardized surveys that assess patient satisfaction with the experience of care. CAHPS surveys (Adult and Child) are subsets of HEDIS® reporting required by the Department of Public Welfare. We contract with an NCQA-certified vendor to administer the survey according to HEDIS® survey protocols. The survey is based on randomly selected recipients and summarizes satisfaction with the health care experience.

In addition to the Adult survey, HEDIS® incorporates a CAHPS survey of parental experiences with their children’s care. The separate survey is necessary because children’s health care frequently requires different provider networks and addresses different consumer concerns (e.g. child growth and development). We contract with a certified vendor to complete both Adult and Child CAHPS surveys and submit recipient level data files to the NCQA for calculation of HEDIS® CAHPS survey results.

Aetna Better Health is dedicated to improving health outcomes for our members with type 2 diabetes. Referrals of people living with type 2 diabetes to diabetes self-management education (DSME) programs throughout Pennsylvania is one way to accomplish this goal.

DSME programs are a critical component of diabetes care. These programs offer structure, expertise, medical knowledge, and evidence-driven education that diabetics need which is not offered through less formal types of diabetes education and support groups.

The Medicaid MCO Provider Education Materials Resource Toolkit was developed through a partnership with the Health Promotion Council, Pennsylvania Department of Health, and managed care organizations in the state, as part of the Pennsylvania Community-Clinical Integration Initiative (PA CCI).

This comprehensive toolkit offers a wealth of diabetes self-management education and support including:

Click here for the full toolkit with helpful links and resources. You can find specific doctor and patient communications tips, talking points and resources on pages 12-15.

Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services are federally-mandated services intended to provide preventive health care to children and young adults (under the age of 21 years) at periodic intervals. These services are based on the recommendations of:

  • American Academy of Pediatrics (AAP)
  • American Dental Association (ADA)
  • American Academy of Pediatric Dentistry (AAPD)

All PCPs who provide services to recipients under age 21 must provide comprehensive health care, screening, preventive services and immunizations as outlined in the provider manual. You can also read the provider manual to learn more about:

  • Identifying barriers to care
  • Diagnosing and treating
  • Tracking
  • Following up and outreaching
  • Educating patients about EPSDT

Check out the most up-to-date immunization schedule. You can also review a list of EPSDT guidelines on our website.

Finally, it’s also important that you bill us appropriately for the services rendered.  Call your Provider Relations representative at 1-866-638-1232 option 3, option 5 if you have questions on EPSDT billing.

Learn how you can earn more compensation by reading about our pay-for-performance (P4Q) guidelines and measures2019 coding guide and P4Q tip sheet.

We recognize the value of giving incentives to promote improvements in the delivery of effective health care services.  P4Q initiatives include those with financial rewards and those that develop partnerships with physician groups with the sole objective of improving health care outcomes. We participate in the HealthChoices P4Q as funded and allowed by contract.


Our QAPI Program uses an integrated and collaborative approach by inviting providers to serve on our committees. Call us at 1-866-632-1232 option 3 and then 5 if you’re interested in participating in the Quality Management and Utilization Management Committee (QM/UM) or the Pharmacy & Therapeutics Committee (P&T).  

There are requirements for documenting services and maintaining medical records. This is to ensure that the medical record includes full documentation of all services rendered to our members. We review these standards with you during your plan orientation. You can also find them in the provider manual. If you have questions, call your Provider Relations Representative at 1-866-638-1232 option 3 and then 5.

We want to help our members reach their health goals.  Through the Aetna Better Health Member Rewards Program, our members can earn gift cards to use for themselves and their family. To learn more about this program available to our members and how they can earn rewards, click the link below.

Member Rewards Program

Aetna Better Health is dedicated to improving health outcomes for our members.  Identifying and addressing Social Determinants of Health (SDOH) among those we serve throughout Pennsylvania is one way we are working to accomplish this goal. 

By using SDOH codes, you’ll be helping us identify areas of opportunity for our members. As a result, we can integrate appropriate Chronic Care management with preventive health while connecting members with needed community services.

This comprehensive toolkit offers a wealth of SDOH information including:

  • Definition of SDOH
  • Information regarding the importance of SDOH
  • Using applicable SDOH ICD-10 Codes

Click here for the full SDOH toolkit.