Quality Improvement

Program Purpose

CareSource’s Quality Improvement (QI) Program design is to ensure the organization delivers on all aspects of care delivery for CareSource members based on their unique needs.

We monitor, analyze and identify opportunities for improvement across the comprehensive span of health care continuum using standardized metrics such as:

• Healthcare Effectiveness Data and Information Set (HEDIS)
• Qualified Health Plan Enrollee Experience Survey
• Provider Satisfaction Survey results
• Over and underutilization patterns and trends

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.

CareSource Health and Social Partnerships

CareSource 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.

We are dedicated to the communities in which we serve and making a positive impact in the lives of our members through the elimination of barriers in health care access and optimal health outcomes that adversely affect our members and partnering with community stakeholders to carry out this much needed work.

Our Nevada Life Services Department is dedicated to serving all communities and making a positive impact in the lives of member populations to support needs related to social drivers of health and eliminating barriers that adversely affect our members’ health outcomes and pursuit of optimal health.

The following is contact information for Nevada Life Services:

• Email address: NVLifeServices@CareSource.com
• Toll-free phone number: 833-230-2033

Nevada Life Services is taking an integrated approach to this work and embedding it across CareSource. As a result, we have developed our objectives based on Pillars of Life Services.

CareSource Life Services program is our Non-Medical Drivers of Health model designed to address and eliminate barriers that CareSource members often experience, such as access to nutrition, affordable housing, transportation, education, legal assistance, and sustained employment. Our life coaches work one-on-one with members to identify, navigate, and support members with these health related social needs.

CareSource Quality Strategy 

CareSource seeks to advance a culture of quality and safety that begins with our senior leadership and is cultivated throughout the organization. CareSource utilizes the Institute of Healthcare Improvement (IHI) framework developed to optimize health system performance. CareSource 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 aligns with the IHI Quintuple Aim framework to:

• Improve health outcomes
• Improve member experience
• Improve Provider experience
• Reduce per capita cost of care
• Advance health equity

HEDIS Coding Guides

To ensure HEDIS measures are captured when billing CareSource, please review the following HEDIS coding guidelines for children and adults and use the appropriate ICD-10 and certified procedural terminology (CPT) code:

• Coming Soon

Preventive and Clinical Practice Guidelines 

CareSource 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. Preventive and clinical practice guidelines are reviewed quarterly and updated as necessary.

Review and approval of the guidelines are completed by the CareSource Market Provider Advisory Board. The CareSource Enterprise PAC also approved the guidelines. The Quality Enterprise Committee (QEC) are notified of guideline approval. 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 and diabetes)
• Population health (e.g., obesity and 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 Provider Engagement Specialists. Information regarding clinical practice guidelines and other health information are made available to members via member newsletters, the CareSource member website, or upon request.

If you would like more information on CareSource quality improvement, please call Provider Services at 1-833-230-2101.

Program Scope 

CareSource supports an active, ongoing and comprehensive quality improvement program across the organization. To maintain a robust Quality Improvement program, our scope includes:

• Member advocacy across all settings
• Meet member access and availability needs for medical and behavioral health care 
• Determine interventions for HEDIS overall rate improvement to improve preventive care scores and facilitate support for members with acute and chronic health conditions and complex health safety or welfare needs
• Determine interventions for Qualified Health Plan (QHP) Enrollee Survey rate improvement that enrich member and provider experience and satisfaction
• Demonstrate enhanced care coordination and continuity across settings
• Meet the cultural and linguistic needs of our member populations encompassing the social determinants of health
• Monitor care measures to ensure the health, safety and welfare of members across all health care settings
• Determine provider adherence to clinical practice guidelines
• Support development of member self-management skills
• Partner collaboratively with network providers, regulatory agencies and community agencies
• Ensure regulatory and accrediting agency compliance

Quality of Care Reviews 

CareSource ensures the provision of safe and quality care to members by investigating and mitigating potential quality of care concerns, that include:

• Inappropriate treatment
• Delay in Care
• Compromising member health, safety or welfare
• Having the potential to limit functional abilities on a permanent or long-term basis

In order to properly assess quality of care concerns CareSource 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 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. In the event that 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 or facilitating delivery of medical records to CareSource by the identified contractor. We are legally bound to interact with providers only and CareSource is not subject to any fees charged by health information management companies for medical record retrieval or submission.

Your health partner 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.

Quality Measures 

CareSource continually assesses and analyzes the quality of care and services offered to our members. 

CareSource 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. Potential quality measures for the Health Insurance Marketplace are:

• Wellness and prevention
  • Preventive screenings (breast cancer, cervical cancer, chlamydia)
  • Well-child care
  • Adolescent care
• Chronic disease management
  • Comprehensive diabetes care
  • Controlling high blood pressure
• Behavioral health
  • Follow-up after hospitalization for mental illness
• Safety
  • Use of imaging studies for low back pain

Contact Us

If you would like more information about CareSource Quality Improvement, please call Provider Services Monday through Friday, 8 a.m. to 6 p.m. Pacific Time (PT) at 1-833-230-2101.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).