Quality Improvement

CareSource® continually assesses the quality of care and service offered to its members and implements programs to improve operational efficiency, delivery of health care services and health outcomes. In order to provide a structure, key processes and a culture of continuous improvement, CareSource has implemented a comprehensive Quality Improvement (QI) program. This is an evolving program and is responsive to the needs of our members, always taking into consideration standards established by the medical community through provider input, regulators and accrediting bodies.

To meet the objectives of the program, activities are focused in the following areas.

Improving the Health Status of Members

We offer preventive health programs, including:

  • Birthday card reminders recommending preventive health services for adolescents, men and women
  • A “gaps-in-care” alert system that reminds members of missed preventive services at points of member contact
  • Preventive health guidelines available to members and providers online and in print
  • Educational articles on preventive services in member and provider communications, such as newsletters
  • Disease management programs for members with chronic conditions such as asthma and diabetes
  • Case management for members with special and/or complex medical needs
  • Clinical practice guidelines available to members and providers online and in print
  • Integrated, comprehensive management of behavioral health care services
  • Participation in state-mandated Performance Improvement Projects (PIPs) – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and diabetes
  • Distribution of clinical practice registry to assigned primary care providers (PCPs) for identified gaps in care
  • Access to member profiles on the Provider Portal, allowing the assigned PCP to review identified gaps in care from CareSource’s claim data

Evaluating Over and Under Utilization of Health Care Services 

  • Continuous monitoring of aggregate utilization statistics to identify potential issues in rates of both under and over utilization of services
  • Monitoring of denial and appeal rates from prior authorizations
  • Quality of care issue review and resolution specific to inappropriate utilization of services
  • Evaluation of Healthcare Effectiveness Data and Information Set (HEDIS®) rates for preventive health services among CareSource members
  • Communication of focused HEDIS measures to providers through Clinical and Provider Relations staff
  • Clinical practice registry reports, either in print or on the Provider Portal, distributed to assigned providers to show gaps in care

Ensuring Quality of Care and Service Provided to Members 

  • Review and resolution of potential quality of care or member risk issues in coordination with involved providers
  • Review and resolution of potential quality of service issues in coordination with involved providers

Identify and Implementing Appropriate Safety and Error Avoidance Initiatives in Collaboration with Network Providers 

  • Implementation of the Medication Therapy Management (MTM) program
  • Articles contained in member newsletter mailings, such as medication adherence, medication interaction and questions to ask the doctor
  • Credentialing and recredentialing with ongoing monitoring
  • Developing and distributing preventive and clinical practice guidelines relevant to members to support delivery of appropriate health care

Improving the Coordination and Continuity of Member Health Care 

  • Bridge to Home®program coordinates transitions in level of care for CareSource members
  • Medical record review during HEDIS to determine evidence of compliance to clinical practice guidelines, as well as coordination and continuity of care
  • Provider satisfaction survey conducted every two years, with results reviewed for providers’ satisfaction with coordination of care between settings

Evaluating the Access and Availability of Care and Service 

  • Comprehensive quarterly network analyses for access to primary, specialty and ancillary care
  • Annual provider appointment and after hours availability surveys
  • Continuous monitoring of Member Services department call statistics and call quality to ensure results are within standards

Overseeing Member and Provider Satisfaction Measurement and Improvement Activities 

  • Annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) member satisfaction survey results reviewed and analyzed and work plan developed
  • Provider satisfaction survey conducted every two years, with results reviewed and analyzed and work plan developed

Evaluation of the Effectiveness of QI Activities in Producing Measurable Improvement in the Care and Service Provided to Our Members 

  • Annually, a written evaluation of the Quality Improvement program is conducted to determine the effectiveness of activities and is submitted to appropriate regulatory and accrediting bodies as required, with a cross-functional team participating in the evaluation process
  • CareSource shares a summary of the care and services provided to our members with an annual Quality Report Card, as well as periodic updates in CareSource newsletters

CareSource uses HEDIS as one measure of the quality of care delivered to CareSource members. HEDIS is a program of NCQA and is used by over 90 percent of all health plans to assess the quality of care delivered. HEDIS scores are compiled using claims and medical records data.

View our 2012 – 2014 HEDIS Survey Results and 2012 – 2014 CAHPS Survey Results.

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:

Access Standards

CareSource has a comprehensive Quality Improvement program to help ensure our members receive the best possible health care services. It includes evaluation of the availability, accessibility and acceptability of services rendered to patients by participating providers.

Please keep in mind the following access standards for differing levels of care. Participating providers are expected to have procedures in place to see patients within these time frames and to offer office hours to their CareSource patients that are at least the equivalent of those offered to any other patient. Thank you for adhering to these standards.

Primary Care Providers (PCPS)

Patients with…Should be seen…
Emergency needsImmediately upon presentation
Persistent symptoms*No later than the end of the following working day after their initial contact with the PCP site
Routine care needsWithin six weeks

Non-PCP Specialists

Patients with…Should be seen…
Emergency needsImmediately upon presentation
Persistent symptomsNo later than 30 days after their initial contact with the specialist site
Routine care needs (stable condition)Within 12 weeks

Behavioral Health

Patients with…Should be seen…
Non-life threatening emergenciesWithin six hours
Urgent care needsWithin 48 hours
Routine office visit needsWithin ten business days

For certain specialties with higher demand (such as dental, dermatology, orthodontia, endocrinology and orthopedics), patients with routine care needs should be seen within 16 weeks.

* A member should be seen as expeditiously as the member’s condition warrants based on severity of symptoms. It is expected that, if a provider is unable to see the member within the appropriate timeframe, CareSource will facilitate an appointment with a participating provider or a nonparticipating provider, if necessary.

HEDIS and CHIPRA Measures

HEDIS measures can help providers identify gaps in care for their patients. CareSource will focus on the following HEDIS and Children’s Health Insurance Program Reauthorization Act (CHIPRA) measures.

HEDIS Measures

Adults’ Access to Preventive/Ambulatory Health Services

Individuals 20 years of age and older who had an ambulatory or preventive care visit

Appropriate Treatment of Children With Upper Respiratory Infection

Children three months to 18 years of age who were given a diagnosis of upper respiratory infection and were not dispensed an antibiotic prescription

Cholesterol Management For Patients With Cardiovascular Conditions

Individuals 18 to 75 years of age discharged alive with an AMI, CABG, PCI, IVD LDL-C screening and control (< 100mg/dL)

Comprehensive Diabetes Care

Individuals 18 to 75 years of age with Type 1 or Type 2 diabetes who have each of the following:

  • Hemoglobin A1c testing and control
  • Eye exam (retinal) performed by an eye care professional (Optometrist or Ophthalmologist)
  • LDL- C screening and control (< 100mg/dL)
  • Medical attention for nephropathy – screening for nephropathy
  • blood pressure (BP) monitoring and control (< 140/90)

Controlling High Blood Pressure

Individuals 18 to 85 years of age with a diagnosis of hypertension have their BP documented in the medical record and their BP is controlled (defined as < 140/90)

Follow-Up After Hospitalization for Mental Illness

Individuals who were hospitalized for treatment of selected mental health disorders 6 years of age and older have a follow-up with a mental health practitioner [(psychiatrist, psychologist, psychiatric nurse practitioner or clinical nurse specialist, masters prepared social worker, and certified marital and family therapist (MFT) or professional counselor (PCC, PCC-S)] on or within 7 days of discharge

Please reference behavioral health coding guidelines.

Initiation and Engagement of Alcohol and Other Drug Dependence (AOD) Treatment

  • Initiation of AOD Treatment – Adolescents and adults with a new episode of AOD should have treatment initiated through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis
  • Engagement of AOD Treatment – Adolescents and adults who initiated treatment should have two or more additional services with a diagnosis of AOD within 30 days on the initiation visit

Prenatal and Postpartum Care

  • Prenatal Care – A visit within the first trimester
  • Postpartum Care – A postpartum visit on or between 21 and 56 days after delivery

Use of Appropriate Medications for People with Asthma

  • Individuals 5 to 64 years of age diagnosed with persistent asthma are prescribed an asthma controller medication.
  • Follow-up to ensure the member filled the prescription for the asthma controller medication.

Well-Child Visits for All Ages (0 to 21)

Must contain documentation of:

  • health education/anticipatory guidance
  • physical exam
  • health and developmental history (physical and mental)

CHIPRA (Children’s Health Insurance Program Reauthorization Act) Measures

  • Annual number of asthma patients with > 1 asthma related emergency room visit
  • Percent of live births weighing less than 2,500 grams

Contact Us

If you would like more information on CareSource Quality Improvement or HEDIS measures, please call Provider Services at 1-800-488-0134.

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).