Quality Standards | Virginia Medicaid

Your health is important to us.

We work hard to make sure you can get great care when you need it. We do this by:

Having programs and services to make sure you get quality healthcare.
Supporting pregnant members and new parents with tools and information.
Finding local programs in your community to help you get the services you need.
Hosting events to help you learn how to get the most out of your plan.
Following state and federal rules.
Looking at our quality reports to find new ways to offer better care.

Learn more about Quality Management

Have questions about our Quality Managementprogram? Call us. We can talk to you about:

What quality management is.
How we are doing and what our goals are.
How we are working to make things better for you.

We can also send you information on our Quality Management program. Call 800-901-0020 (TTY 711)

Care management: Helping you manage all the moving pieces

As a HealthKeepers member, we offer many different types of services. Your care manager works with you and your provider to set up a plan of care. You may already be working with a care manager and know how to contact them.

If you think you need care management services or need help contacting your care manager, call us at 800-901-0020 (TTY 711).

Our care managers may also call if:

You or your doctor thinks care management might help you.
You’ve just gotten out of the hospital and need help with follow-up visits to other providers.
You’re going to the emergency room (ER) often for nonurgent care that could be handled by your provider.
You call our 24-hour Nurse HelpLine and need more follow-up for ongoing care.
You have serious physical problems and need more help.
You have behavioral health problems and need more help working with your providers.

Your care manager can also help with:

Setting up healthcare services.
Getting referrals and prior authorizations (approvals).
Checking your plan of care.

If we call you, a nurse or social worker will:

Always identify themselves with their name, title, and position with your Anthem HealthKeepers Plus plan.
Tell you about what we offer.
Talk to you about your health and how you’re handling different parts of your life.

New technology in medicine and care

To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:

Medical treatment and services
Behavioral health treatment and services
Medicines
Equipment

They also look at the most up-to-date medical and scientific writings. With all this data, they consider:

If the changes are safe and helpful.
If these changes offer the same or better results than what is used today.

This work is done to help us decide if a new treatment or care should be added to your benefits.

You have rights and responsibilities

As an Anthem HealthKeepers Plus member, you have rights and responsibilities. They are listed in your member handbook. Do you need a printed copy of your member handbook? Call Member Services at 1-800-901-0020 (Medallion Medicaid and FAMIS) or 1-855-323-4687 (CCC Plus); TTY 711.

Your benefits and how to get medical care

Are you looking to learn more about our services and benefits? Grab your member handbook! You can read about:

Preventive health care: Find out how to help prevent many health issues and how to live a healthier life.
Preventive health care for women: Learn how to get access to women’s health specialists for regular and preventive health care services.
Benefits and access to care: Find out more about your benefits and how to get medical care.
Language help: Learn how to get our information in the language you use at home.
Pharmacy: Find out about your benefits and how to get the medicines you need.
Case management: Partner with a case manager to learn more about ways to get care for your health issues.
Member rights and responsibilities: Read about your rights and responsibilities.
Notice of Privacy Practices: Learn more about how we keep your private information safe.
Medical necessity: Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.
Advance directives: Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.

Find your member handbook

Have questions about an approval or a denial?

Call Member Services at 800-901-0020 (TTY 711). Our Utilization Review team or your care manager can help answer your questions.

Behavioral health services

Sometimes stress can lead to depression and anxiety. It can cause problems in our relationships and even lead to alcohol and drug use.

If you or a family member need some assistance, call Anthem HealthKeepers Plus Member Services at 800-901-0020 (TTY 711).

You can ask one of our member specialists for the name of a behavioral health specialist.

Your benefits also include many medically needed services, such as:

Inpatient behavioral health services
Outpatient behavioral health services
Partial hospitalization
Treatment and rehabilitative services

Lastly, while you don’t need a referral from your primary care provider (PCP) to see a behavioral health specialist in your plan, there are some treatments and services that require preauthorization.

See your member handbook, to learn more.

Clinical Practice Guidelines

Clinical Practice Guidelines are rules that give providers in our network ways to treat health problems. Our Corporate Medical Advisory Committee and our Medical Policy Committee, who are two groups of specialists and external providers, approve them.

If you’d like a copy of our Clinical Practice Guidelines, either:

Call Member Services at 800-901-0020 (TTY 711) Monday through Friday, 8 a.m. to 8 p.m. Eastern time; or
Go to the Virginia provider website.

You have rights and responsibilities

As an Anthem HealthKeepers Plus member, you have rights and responsibilities. They are listed in your member handbook.

Not a kid anymore? It may be time for a new PCP or behavioral health provider.

It’s important for you to get the right care from your providers. As an adult, you can choose to change from a provider who specializes in care for children or teens to a provider who focuses on treating adults. This includes providers for physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.

Start by asking your current primary care provider (PCP) or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It’s easy with our Find a Doctor tool. Or call Member Services at 800-901-0020 (TTY 711).

Our Notice of Privacy Practices

The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your member handbook as well as online. Live chat with a representative and let them know if you want a copy of the Notice of Privacy Practices mailed to you.