Quality Improvement

Program Purpose

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

• Coordinate care
• Promote quality
• Ensure performance and efficiency on an ongoing basis
• Improve the quality and safety of clinical care and services provided to members

The CareSource Quality Management and Performance Improvement program includes both clinical and non-clinical services and is revised as needed to remain responsive to member needs, provider feedback, standards of 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:

• National Committee for Quality Assurance (NCQA)
  • Compliance with NCQA accreditation standards
  • 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
• NCQA Health Plan Rating of 5
  • High level of HEDIS performance
  • Comprehensive population health management program
  • Comprehensive provider engagement program

Program Scope

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

• Meeting the quality requirements of CareSource’s contract with the Department of Community Health (DCH)
• Complying with 42 CFR 438.200, et seq. (CMO Standards), 42 CFR 438.310 et seq. (Quality Measurement and Improvement, External Quality Review), and 42 CFR Part 164 (Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Requirements)
• Establishing safe clinical practices throughout our provider network
• Providing quality oversight of all clinical services
• Ensuring compliance with NCQA accreditation standards
• Performing HEDIS compliance audit and performance measurement
• Monitoring and evaluating member and provider satisfaction
• Managing all quality of care and quality service complaints
• Developing organizational competency of the Institute for Healthcare Improvement (IHI) Model for Improvement
• Ensuring that CareSource is effectively serving members with culturally and linguistically diverse needs
• Ensuring that CareSource is effectively serving members with complex health needs
• Assessing the characteristics and needs of our member population
• Assessing the geographic availability and accessibility of primary care providers (PCPs) and specialists

The CareSource Quality Management and Performance Improvement program is overseen by the Georgia Chief Medical Officer, in conjunction with the Quality Improvement Director, and the CareSource Vice President, Quality Improvement and Performance Outcomes. On an annual basis, CareSource makes information available about our Quality Management and Improvement program to providers on our website. CareSource gathers and uses provider performance data to improve quality of services.

Quality Measures

CareSource complies with the Georgia Department of Community Health Quality Strategic Plan requirements to improve the health outcomes for all Georgia Families^® members. Improved health outcomes are documented using established performance measures. CareSource uses the Center for Medicare & Medicaid Services (CMS)-issued Children’s Health Insurance Program Reauthorization Act (CHIPRA) Core Set and the Adult Core Set of Quality Measures technical specifications along with the HEDIS and the Agency for Healthcare Research and Quality (AHRQ) technical specifications for the quality and health improvement performance measures. Performance targets are based on national Medicaid Managed Care HEDIS percentiles, as reported by NCQA, or other benchmarks as established by DCH and available at the DCH website.

CareSource also uses the annual member CAHPS survey to capture member perspectives on health care quality. CAHPS is a program overseen by the AHRQ. Potential CAHPS measures include:

• Customer service
• Getting care quickly
• Getting needed care
• How well doctors communicate
• Ratings of all health care, health plans, personal doctors and specialists

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 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

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.

Preventive and Clinical Practice Guidelines

CareSource approves and adopts evidence-based nationally recognized standards and guidelines to help inform and guide the clinical care provided to CareSource members. Guidelines are adopted from organizations that develop or promulgate evidence-based clinical practice guidelines and include professional medical associations, voluntary health organizations and the National Institute of Health (NIH) Centers and Institutes. In the absence of scientific evidence, the guidelines will be determined by board-certified practitioners from appropriate specialties. CareSource submits to DCH for review and prior approval and as updated thereafter all clinical practice guidelines. Provider utilization of guidelines allows for the measurements of member health outcomes. 

Evidence-based clinical practice and preventive health guidelines are established for acute and chronic medical and behavioral health care conditions that are relevant to the CareSource membership. The topics for these guidelines are identified through analysis of the enrolled membership. These guidelines are the clinical basis for the prevention, wellness, disease management and case management programs.

CareSource will adopt a minimum of five evidence-based clinical practice guidelines and a minimum of at least five preventive health guidelines. Such guidelines will:

• Be based on at least three medical conditions which can include the clinical basis for the CareSource Disease Management program
• Be based on at least two behavioral health conditions with at least one that addresses children and adolescents
• Be based on perinatal care, care for children up to 24 months of age, care for children 2-19 years of age, care for adults 20-64 years of age and care for adults 65 years of age or older
• Be based on the health needs and opportunities for improvement identified as part of the CareSource Quality Management and Performance Improvement program
• Be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field
• Consider the needs of the members
• Be adopted in consultation with network providers

The review and update process against clinical evidence will be completed for each guideline at least every two years or more frequently if the guideline changes. Clinical practice guidelines and preventive health guidelines are monitored to assure web links are active and that guidelines have not changed. Should changes be noted, the guideline will be revised with the input from a medical director of like specialty and then reviewed/approved by the Market Provider Advisory Committee and the Enterprise Provider Advisory Committee.

To ensure consistent application of the guidelines, CareSource will require providers to use the guidelines, and shall measure compliance with three of the guidelines, until 90 percent or more of the providers are consistently in compliance. CareSource will conduct this review on a quarterly basis. To further ensure consistent application of the clinical practice guidelines, CareSource will perform a review of a minimum random sample of fifty members’ medical records per each of the three evidence-based clinical practice guidelines each quarter.

The Georgia Department of Community Health (DCH) requires all Medicaid Care Management Organizations (CMOs) to complete quarterly provider audits for the following CPGs: depression, diabetes and hypertension. Refer to the brochure below for a detailed overview of the medical record audit process.

Clinical Practice Guideline Medical Record Audit booklet

Value-Based Purchasing

Your success is important to us. We offer a series of value-based purchasing (VBP) programs for our providers. These programs provide a progressive approach along a continuum of payment programs that will reward you as you attain higher levels of quality.

Our flexible approach will enable you to participate in VBP programs at an initial level and grow to successively higher levels of reimbursement. Under the guidance of the CareSource Quality Management and Performance Improvement program, you are rewarded for providing better value for services and achieving better health outcomes for our members.

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:

• Navigate 2024-2025 HEDIS Coding Guide

Contact Us

If you would like more information about CareSource Quality Improvement, please call Provider Services, Monday through Friday, 7 a.m. to 7 p.m. Eastern Time (ET) at 1-855-202-1058.

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).