Complaint Investigation and Process

The Clinical Quality Improvement (CQI) team conducts analysis, investigates and facilitates resolution of quality‑of‑care complaints from members, providers, employer groups, brokers and internal sources. Quality‑of‑Care complaint outcomes are tracked to identify trends.

Investigation of these potential issues may involve:

• Obtaining medical record documentation related to the concern
• Leveraging the Provider Partnership team to contact the provider’s office directly to address service or access issues
• Soliciting additional information directly from the practitioner to supplement medical record findings.

Complaints related to the quality‑of‑care rendered to a member are reviewed by the Blue Cross and Blue Shield of Nebraska (BCBSNE) Chief Medical Officer or designee to determine if a quality‑of‑care issue exists and its severity. Significant quality‑of‑care issues are presented for peer review at the BCBSNE Quality Management Committee, which is comprised of practicing network physicians not employed by BCBSNE. Recommendations for further action, when appropriate, are determined by the committee. The CQI complaint process supports the tracking and trending of identified issues and serves as a valuable tool for maintaining high‑quality provider networks, improving care, decreasing harm and improving processes and services our members expect from their health plan.