Quality Improvement
Program Purpose
CareSource North Carolina Co.® is committed to providing evidence-based care in a safe, member-centered, timely, efficient and equitable manner. The scope of our CareSource North Carolina Co. quality improvement (QI) program is comprehensive and includes clinical and non-clinical services.
CareSource North Carolina Co. monitors and evaluates the quality of care, encompassing the safety and service delivered to our members with an emphasis on accessibility to care, availability to care, availability of services and physical and behavioral health care delivered by network practitioners and providers. CareSource North Carolina Co. also monitors the quality and safety of member services through review of practitioner, provider, hospital, utilization management, care management and pharmacy program results.
Member satisfaction and health outcomes are monitored through routine health plan reporting and annual Healthcare Effectiveness Data and Information Set (HEDIS®). In addition, Marketplace members complete the annual Quality Health Plan Enrollee Experience (QHPEE) Survey to capture member perspectives on health care quality. The QHPEE Enrollee Experience survey is a consumer survey that assesses the enrollee experience with plans offered through Marketplace plans. The survey includes a set of core questions that address key areas of care and service provided to members.
CareSource North Carolina Co. is accredited by NCQA. This accreditation status shows the commitment to service and clinical quality that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement as we work to improve members’ health care.
Program Scope
CareSource North Carolina Co. supports an active, ongoing and comprehensive quality improvement program, including review and resolution of quality-of-care concerns. The scope of the Quality Improvement program includes:
- Advocate for members across settings, including review and quality of care concerns
- Meet member access and availability needs for physical and behavioral health, other complex health, safety, or welfare needs
- Determine interventions for HEDIS overall rate improvement to improve preventive care scores and facilitate support of members’ acute and chronic health conditions and complex needs
- Determine interventions based on the QHP Enrollee Experience survey results for improvements that enrich member and provider experience and satisfaction
- Demonstrate enhanced care coordination and continuity across settings encompassing the social determinants of health
- Meet members’ cultural and linguistic needs encompassing the social determinants of health
- Monitor important aspects of care to ensure health safety and welfare of members
- Determine practitioner adherence to clinical practice guidelines
- Support member self-management efforts
- Partner collaboratively with network partners, practitioners, regulatory agencies and community agencies
- Ensure regulatory and accrediting agency compliance
Quality Resource
Provider Education Series: Quality OnboardingCareSource North Carolina Co. Quality Strategy
CareSource North Carolina Co. seeks to advance a culture of quality and safety that begins with our senior leadership and is cultivated throughout the organization. CareSource North Carolina Co. utilizes the Institute of Healthcare Improvement (IHI) framework developed to optimize health system performance. CareSource North Carolina Co. also utilizes Lean Six Sigma tools, when indicated, to focus on improving member experience, member safety and ensuring our processes consistently deliver the desired results.
CareSource North Carolina Co. aligns with the IHI Quintuple Aim framework to:
- Improve health outcomes
- Improve member experience
- Reduce Provider burden
- Reduce per capita cost of care
- Advance health equity
2025 Access Standards
CareSource’s Access and Availability Audit Program was developed to help ensure our members have access to our provider network. Participating providers are expected to have procedures in place to see patients within specific time frames, provide appropriate after-hours instructions, and offer office hours to their CareSource patients that are at least the equivalent of those offered to any other patient. CMS, NCQA, and our state contracts outline specific access standards.
| Primary Care Providers (PCPs) | 2025 Standards |
|---|---|
| Type of Visit | Should be seen… |
| Emergency Needs | Immediately upon presentation |
| Urgent Care | Not to exceed 48 hours |
| Routine Care | Not to exceed 15 business days |
| Non-PCP Specialists | |
|---|---|
| Type of Visit | Should be seen… |
| Emergency Needs | Immediately upon presentation |
| Urgent Care | Not to exceed 48 hours |
| Regular and Routine Care | Not to exceed 30 business days |
| Behavioral Health Providers | |
|---|---|
| Type of Visit | Should be seen… |
| Emergency Needs | Immediately upon presentation |
| Non-Life-Threatening Emergency | Not to exceed six hours |
| Urgent Care | Not to exceed 48 hours |
| Initial Visit for Routine Care | Not to exceed 10 business days |
| Follow-up routine care | Not to exceed 30 calendar days, based on the condition |
| Dental | |
|---|---|
| Type of Visit | Should be seen… |
| Regular and Routine Care | Six weeks |
| Urgent Needs | 48 clock hours |
| Telephone Access (PCP only) |
|---|
| Access 24/7 – Primary care providers (PCPs) must provide 24-hour availability to your CareSource patients by telephone. Whether through an answering machine or a taped message used after hours, patients should be provided the means to contact their PCP or a back-up physician to be triaged for care. It is not acceptable to use a phone message that does not provide access to you or your back-up physician and only recommends emergency room use for after hours. |
Quality Measures
CareSource North Carolina Co. continually assesses and analyzes the quality of care and services offered to our members. This is accomplished by using objective and systematic monitoring and evaluation to implement programs to improve outcomes.
CareSource North Carolina Co. uses HEDIS® to measure the quality of care delivered to members. HEDIS is one of the most widely used means of health care measurement in the United States. HEDIS is developed and maintained by the NCQA. The HEDIS tool is used by America’s health plans to measure important dimensions of care and service and allows for comparisons across health plans in meeting state and federal performance measures and national HEDIS benchmarks. HEDIS measures are based on evidence-based care and address the most pressing areas of care. Potential quality measures for the Health Insurance Marketplace are:
- Wellness and prevention
- Preventive screenings (breast cancer, colon cancer, cervical cancer, chlamydia)
- Well-child care
- Immunizations
- Maternity care
- Chronic disease management
- Comprehensive diabetes care
- Controlling high blood pressure
- Behavioral health
- Follow-up after hospitalization for mental illness
- Antidepressant medication management
- Safety
- Use of imaging studies for low back pain
Preventive and Clinical Practice Guidelines
CareSource North Carolina Co. approves and adopts evidence-based nationally recognized standards and guidelines and promotes them to practitioners to help inform and guide clinical care provided to members. Member health resources are available on the website and cover a broad range of wellness, preventive health and chronic disease management topics. Guidelines are reviewed at least every two years or more often as appropriate and updated as necessary.
The use of these guidelines allows CareSource North Carolina Co. to measure their impact on member health outcomes. Review and approval of the guidelines are completed by the Market CareSource North Carolina Co. Provider Advisory Committee (PAC). The CareSource Enterprise PAC also approves the guidelines. Topics for guidelines are identified through the analysis of member populations demographics and national or state priorities. Guidelines may include, but are not limited to:
- Behavioral health (e.g., depression)
- Adult health (e.g., hypertension or diabetes)
- Population health (e.g., obesity or tobacco cessation)
Guidelines may be promoted to providers through one or more of the following: newsletters, our website, direct mailings, provider manual, and through focused meetings with CareSource North Carolina Co. Provider Engagement Specialists. Information regarding clinical practice guidelines, Patient Safety program and other health information are made available to members via member newsletters, the CareSource North Carolina Co. member website, or upon request.
If you would like more information on CareSource North Carolina Co. quality improvement, please call Provider Services at 1-833-230-2101.
HEDIS Coding Guides
To ensure HEDIS measures are captured when billing CareSource North Carolina Co., please review the following HEDIS coding guidelines for children and adults and use the appropriate ICD-10 and certified procedural terminology (CPT) code:
Contact Us
If you would like more information about CareSource North Carolina Co. Quality Improvement, please call Provider Services Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET) at 1-833-230-2101.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Quality of Care Reviews:
CareSource North Carolina Co. ensures the provision of safe and quality care to members by investigating and mitigating potential quality of care concerns, that include:
- Inappropriate or inconsistent treatment
- Delay in receipt of Care
- Compromising member health, safety or welfare
- Having the potential to limit functional abilities on a permanent or long-term basis
To properly assess quality of care concerns CareSource North Carolina Co. Enterprise Quality Improvement initiates contact with providers to request medical records using established processes and timelines. As per our policies and provider contracts, we are authorized to ask for protected health information for health care operations, which includes quality issue reviews. Medical record requests are forwarded to providers via mail, e-mail or fax and may be returned to CareSource North Carolina Co. via these same mechanisms as detailed in the medical record request document.
All providers are expected to return medical record requests related to quality of care concerns within 14 days from initial receipt of the request, unless otherwise defined by program guidelines or state or federal law requirements. If a state, federal or regulatory agency, or if the health and safety of a member requires that medical records must be submitted under a shorter timeframe, providers are expected to comply with the shorter turnaround time. Providers and facilities that utilize third party health information management vendors are responsible for providing medical records to CareSource North Carolina Co. or facilitating delivery of medical records to CareSource North Carolina Co. by the identified contractor. We are legally bound to interact with providers only and CareSource North Carolina Co. is not subject to any fees charged by health information management companies for medical record retrieval or submission.
Your provider representative may contact you if medical records are not received within the 14-day timeframe to ensure you received the request. In addition, our market Chief Medical Officer may also be in contact to facilitate and ensure receipt of the required medical records to complete the quality-of-care reviews. Providers or facilities who repeatedly fail to return requested medical records are reported to the Credentialing Committee and may face other directed intervention or penalties up to and including contract termination.
Patient Safety Program
CareSource North Carolina Co. recognizes that patient safety is the cornerstone of high-quality health care, contributing to the overall health and welfare of our members. Our CareSource North Carolina Co. Patient Safety Program evaluates patient safety trends with the goal of reducing avoidable harm. Our patient safety program is developed in the context of our Population Health Management approach and includes:
- Regulatory/Accreditation
- Policies & Procedures
- Training & Implementation
- Continuous Monitoring
- Program Evaluation & Improvement
Safety events are monitored through retrospective review of quality of care concerns and real time reporting of Claims data. Data analysis of our provider and health system network ensures situational risks can be identified in a timely manner, reviewed and mitigated by proactive corrective action or performance improvement steps.