Managed Care and Quality Tools

​​Cardinal Innovations operates a clinical system using tools available in a managed care system. We ensure a high-quality, financially-viable network, which provides the services needed by our members in the least restrictive settings possible. We monitor the care provided through prior and continuing authorizations, as well as retrospective reviews of care. We continually monitor and assess the performance of our network and expect high marks from the perspective of our members, providers, stakeholders and regulators when evaluated. Finally, we use high-intensity management strategies for our high-risk members to increase the likelihood of a positive outcome.

In this section, you will learn more about the tools we use to assure a system of care that provides a high-level of accessibility and quality. For full details of Cardinal Innovation's managed care tools, click here.

Access Call Center

Cardinal Innovations' Access Call Center is available free 24/7/365 at 1-800-939-5911, providing access to a qualified staff person about emergent, urgent and routine access to services, available community resources and other important information. For more information on how to access services, please click here to go to the access call center page.

Network Management

The Cardinal 1915(b) Waiver allows Cardinal Innovations to use a closed network of providers, allowing us to specifically tailor the service system to fit the unique needs of each community we serve. Go to the Network Management page​.

Credentialing

Cardinal Innovations uses credentialing to ensure each provider has the proper education, experience and licensure for the services provided.

Utilization Management and Clinical System Monitoring

Cardinal Innovations uses prior authorization (PA), tracking of under/over use, and quantitative and qualitative measurements of clinical quality to assure funded services are used appropriately.

High Risk Monitoring and Interventions

Utilization Management staffs cases with physicians, pharmacists, doctoral level clinicians and other experts, and uses data and referrals to identify for review certrain high-risk members and those where outcomes are not being achieved.

Cardinal Innovations employs care coordinators to assist high-risk members and other special populations to navigate and link to needed services and supports.

Quality Management and Performance Monitoring

We assess our clinical system through Consumer and Provider Satisfaction Surveys and Incident/Grievance Monitoring. We do on-site health and safety reviews of providers, justified cause audits, focused billing audits, investigations and follow the N.C. Department of Health and Human Services Provider Monitoring Process. Quality Management also directs all our continuous quality improvement initiatives and activities. Go to the Quality Management page.

Clinical Initiative Tracking

In 2014, Cardinal Innovations developed its Clinical Initiative Tracking System, allowing a wide variety of initiatives, intended to improve the quality of life and care for our members, to be monitored by our Clinical Management Team (CMT). Cardinal Innovations defines a "clinical initiative" as any new or significantly expanded activity primarily intended to improve members' lives in measureable ways.