March 18, 2024
Potential Quality of Care (PQoC)
Blue Cross and Blue Shield of Texas (BCBSTX) Quality Improvement investigates potential quality of care (PQoC) complaints or deficiencies in clinical care, as reported by providers, service coordinators, case management and members or a member’s authorized representative involving Providers that are in the network.
What is a Potential Quality of Care Concern?
A Potential Quality of Care concern is a dissatisfaction with the quality of clinical care rendered in individual occurrences. Medical PQoC concerns may include, but are not limited to:
- A condition that was not appropriately diagnosed
- A condition that was not appropriately treated
- A member had to obtain care elsewhere because of dissatisfaction or concern about care received from a contracted provider/facility
- Medication/treatment errors
- Delayed referrals
- Incidents affecting patient safety
Why is a PQoC Important:
As an organization we strive to ensure our members receive the most efficient experience while getting the best quality of care.
How to file a PQoC:
To file a Potential Quality of Care Complaint with BCBSTX, please submit to BCBSTX Appeals and Grievance Team via:
- Fax #: 1-855-235-1055 or
- Email: TX_Medicaid_A&G_complaints@bcbstx.com
Report Abuse to the Texas Department of Family and Protective Services (DFPS):
- Website: www.dfps.state.tx.us/contact_us/report_abuse.asp
- By phone for urgent matters: 1-800-252-5400 or
- Online for non-urgent situations: www.txabusehotline.org/Login/Default.aspx
Resources:
For Texas Medicaid Provider Quality Improvement, review the following resources ranging from quality measures data to current vaccine schedules:
- BCBSTX Preventive Care Guidelines (PCGs)
- Clinical Practice Guidelines (CPGs)
- ImmTrac2
- Quality Improvement (QI) Toolkit and Tip Sheets
- Texas Health Steps (THSteps) for Medical Providers
Have questions?
Contact Keisha Guzman Francis, Quality Management Specialist III at Keisha_Guzman@bcbstx.com.