Committee Structure

The ASH QI System is supported by a committee structure designed to integrate clinical and service operations, include contracted peer provider participation, and permit focus on improving the quality, efficiency and effectiveness of ASH core processes. The following is a brief description of the primary committees that make up the quality improvement structure.

ASHA Board of Directors is accountable for the overall quality improvement system. ASHA Board of Directors consist of the President and CEO as well as senior executives over each of the key clinical and operational areas of the company. The Corporate Quality Oversight Committee, as directed by the Board of Directors, oversees the implementation of the quality improvement system.

The CQOC develops and oversees the quality improvement program, including adoption of policies, oversight of accreditation, delegation and regulatory compliance activities.

The CCC addresses and responds to new or revised expectations that routinely emanate from clients, legislative and regulatory agencies, accreditation organizations or the company to oversee corporate compliance in support of existing business, new business, product development or quality improvement initiatives. The CCC is responsible for developing and overseeing the QI Workplan.

The CPRC is primarily responsible for peer review for credentialing denial appeals and first level termination appeals, and clinical quality improvement activities. The CPRC reviews reports of ongoing clinical quality improvement and initiatives, including analyzing and evaluating the results of quality improvement activities.

The CQT primarily recommends topics for research review by TACCC; provides review and recommendation for new and existing clinical policies and clinical practice guidelines; recommends clinical quality improvement initiatives and studies; recommends practitioner educational information; and reviews quarterly and annual clinical performance management reports.

The PQCC is primarily responsible for providing peer review functions for credentialing, clinical services management, and clinical performance management case review. The PCQQ makes decisions regarding Clinical Services Alerts/Clinical Performance Alerts, initial credentialing and recredentialing, corrective action plans, terminations, and sanctions.

POC KPT serves to oversee the cross-functional integrity of critical business processes that produce the expected results to meet company, client, regulatory and accreditation organizations. The POC KPT is primarily responsible for processes related to the quality and timeliness of administrative services provided to members/insureds, as well as the quality and timeliness of administrative transactions to providers.

NKPT oversees the administrative management of the provider network to produce the expected results to meet company, client, regulatory and accreditation organizations. NKPT is primarily responsible for processes and policies related to maintenance of the administrative relationship with contracted providers.

The Education KPT principally serves to implement new or revised expectations that routinely emanate from clients, legislative and regulatory agencies, accreditation organizations or the company in support of existing business, new business, product development or quality improvement initiatives with respect to the Healthyroads Web site, product retailing, and the Healthyroads education programs.

The PPC principally services to permit Members and Employer Group Plans to make recommendations related to clinical and quality improvements to the Board of Directors of American Specialty Health Plans of California, Inc (ASH Plans).

The AFOC primarily monitors the activities, related to anti-fraud prevention and detection, of ASHA, the Special Investigations Unit (SIU), contracted practitioners, subscribers, enrollees, members, and employees to deter, identify or detect incidents involving suspected fraudulent activity with regard to health care services arranged by ASHA or other forms of fraudulent behavior.

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