Quality Improvement


The purpose of the CareSource® Quality Improvement program is to ensure that CareSource has the necessary infrastructure to:

  • Coordinate member care
  • Promote quality, evidence-based appropriate care
  • Ensure the provision of a high performing  and efficient  health care services on an ongoing basis
  • Improve the quality and safety of clinical care and services provided to CareSource members
  • Recognize the impact of social determinants of health on member health, safety & welfare, and initiate risk mitigation strategies

There are two guiding tenants for the program:

  • Our mission, which is our heartbeat, is to make a lasting difference in our members’ lives by improving their health and well-being. Our vision is to transform lives through innovative health and life services.
  • The Institutes for Healthcare Improvement’s Triple Aim: Simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and the per capita cost of care for the benefit of communities.

The Quality Improvement program includes both clinical and non-clinical services and is revised as needed to remain responsive to member needs, provider feedback, evidence-based standards of health care and business needs. 

Goals and Objectives

CareSource strives to be a top performing health plan nationally. Performance goals are determined and aligned with national benchmarks where available.

The goals and objectives of the program are:

  • High level of Healthcare Effectiveness Data and Information Set (HEDIS®) performance
  • High level of Consumer Assessment of Healthcare Providers and Systems (CAHPS®) performance
  • Comprehensive population health management program
  • Comprehensive provider engagement program
  • High level of HEDIS performance
  • High level of Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) performance
  • Comprehensive population health management program
  • Comprehensive provider engagement program
  • Medicare Advantage 5-Star Health Plan
  • High level of HEDIS performance
  • High level of MCAHPS performance


The Quality Improvement program governs the quality assessment and improvement activities for CareSource. The scope includes:

  • Meeting the quality requirements of the Centers for Medicare and Medicaid Services (CMS) as outlined in the CMS’s Medicare Managed Care Manual, Chapter 5, Quality Assessment; and 42 CFR§422.152
  • Establishing safe clinical practices throughout the network of providers
  • Providing quality oversight of all clinical services
  • HEDIS compliance audit and performance measurement
  • Monitoring and evaluating member and provider satisfaction
  • Developing organizational competency  in the use of the IHI Model Plan Do Study Act (PDSA) improvement methodology
  • Ensuring CareSource is effectively serving members with cultural and linguistic needs, as well as recognition of diverse member populations
  • Ensuring CareSource is effectively serving members with complex health needs
  • Assessing the characteristics and needs of the member population to implement appropriate interventions
  • Assessing the geographic availability and accessibility of primary and specialty care providers relative to our membership

On an annual basis, CareSource makes information available about its quality program to providers on the web. CareSource gathers and uses provider performance data to improve quality of care and service provided.

Quality Metrics

CareSource monitors member quality of care, health outcomes and satisfaction through the collection, analysis and the annual review of Medicare HEDIS, Health Outcomes Survey (HOS) and Medicare CAHPS. Medicare HEDIS, HOS and Medicare CAHPS form the basis for the Centers for Medicare & Medicaid Services (CMS) Star Ratings used to evaluate the quality of care provided to CareSource members.

CMS uses a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plan and the health care system. Star ratings are based on measures of the health plan’s rating across five categories:

  • Staying healthy (screenings, tests and vaccines): Includes whether members received various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
  • Member experience with the health plan: Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals.

For health plans covering drug services, the overall score for quality of those services covers many different topics that fall into four categories:

  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.

Tools are available for providers via the CareSource Provider Portal to determine services and recommended routine screening tests needed and historical medical and pharmacy data.

Clinical and Preventive Guidelines 

CareSource recommends nationally accepted evidence-based standards and guidelines to help inform and guide the clinical care provided to members. Guidelines are reviewed at least every two years or more often as appropriate, and updated as necessary. The use of these guidelines allows CareSource to measure the impact of guideline usage on health care outcomes. . Review and approval of the guidelines are completed by the CareSource Clinical Advisory Committee. The guidelines are then presented to the CareSource Quality Enterprise Committee. Topics for guidelines are identified through analysis of members. Guidelines may include, but are not limited to:

  • Behavioral health (e.g., depression)
  • Adult health (e.g., hypertension, diabetes, cardiovascular disease, cerebrovascular disease and chronic obstructive pulmonary disease)
  • Population health (e.g., obesity, tobacco cessation)

Guidelines are promoted to providers through provider newsletters, website, direct mailings, provider manual and through focused meetings with CareSource Provider Relations Representatives. Clinical and Preventive Guidelines and Health Links are also available to members via newsletters, the CareSource member website or upon request.

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:

Participation in CMS and HHS Quality Improvement Initiatives 

CareSource encourages providers to participate in CMS and Health and Human Services (HHS) quality improvement initiatives

If you would like more information on CareSource Quality Improvement, please call Provider Services at 1-833-230-2176

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).