March 28, 2023
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 more information, see our Quality Improvement (QI) Toolkit and Tip Sheets. Reference and review the BCBSTX Preventive Care Guidelines (PCGs), Clinical Practice Guidelines (CPGs), and Texas Health Steps (THSteps) for Medical Providers, which includes all current vaccine schedules, ImmTrac2 and other important guidance for treating your patients.
Have questions?
Contact Jalena Johnson, Quality Management Specialist III at jalena_johnson@bcbstx.com.