Managed Care Tools - Full Description

​​Cardinal Innovations operates a high functioning clinical system by using various management tools available in a managed care system.  We ensure a high-quality, financially viable network that provides the services needed by our members in the least restrictive settings possible. Additionally, 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. Finally, we use high-intensity management strategies for our high-risk members to increase the likelihood of a positive outcome.

Specifically, we use the following tools to ensure a high-quality, highly accessible system of care.

Access Call Center

Cardinal Innovations maintains a 24/7/365 Access Call Center (1-800-939-5911) through which individuals, families, community stakeholders and others can speak directly with a qualified staff person to inquire about services; be connected to services (emergently, urgently, or routinely); and inquire about community resources. Appointments with many of our providers can be made anytime, day or night, through this access line. Cardinal Innovations contracts with providers in every county to ensure emergent access for individuals within two hours, urgent access within 48 hours and routine access within 14 days. In addition, Cardinal Innovations contracts with Comprehensive Community Clinics (see below) in each county to offer same-day access to assessments during business days each week.

Network Management

The 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 in which we are the payer.

  • Cardinal Innovations selects high performing providers, as evidenced by close monitoring and evaluation described in the Quality Management (QM) and Network Development Plans. Our monitoring includes review of complaints and grievances against providers, as well as concerns recorded in our electronic Provider Concerns Module by our internal staff.
  • Our company selects providers in a way that accounts for high-quality service accessibility and financial viability adapted for each service area. New providers are not added without demonstrated need and evidence of appropriate qualifications. We understand that providers are only able to provide high quality, evidenced-based services if they are financially viable. Therefore, we complete a yearly Community Needs Assessment to assess the adequacy of our network of providers. Additionally, we use selective rate setting to promote greater availability of least restrictive, evidence-based practices and services. For example, we enhanced rates above the North Carolina base Medicaid rates for behavioral health prescribers (Psychiatrists, Psychiatric Nurse Practitioners, and Physician Assistants), crisis services, and our Comprehensive Community Clinics (described below).


Cardinal Innovations verifies the credentials of each licensed provider prior to permitting them to provide services. Doing so ensures each provider has the proper education, experience and licensure for the services provided.

Utilization Management and Clinical System Monitoring

Cardinal Innovations uses several clinical tools to assure that high-quality funded services are used appropriately. These tools include prior authorization (PA), tracking of under/over use, and both quantitative and qualitative measurements of clinical quality. It is vital that Cardinal Innovations members receive care that is medically necessary, in the right amount, for the right duration, and in the least restrictive setting.

The Utilization Management (UM) Department is the focal point for managing member care. UM Care Managers are responsible for the majority of member care management activities, and for initiating the use of additional tools (such as care coordination) when necessary to ensure high quality care and positive member outcomes. The UM Department must look at aggregate data as well as individual data to complete its functions. The following UM monitoring and management tools help ensure these goals are met.

Prior Authorization

Prior authorization (PA) means that Cardinal Innovations requires submission of a Treatment Authorization Request (TAR), before a service is provided so that medical necessity can be adequately assessed. PA is required in the following kinds of instances:

  1. High-cost and/or highly-restrictive services (e.g., enhanced, residential and inpatient levels of care)
  2. Low-cost, minimally-restrictive services used in amounts that are greater than community norms (e.g., outpatient therapy, psychological testing)
  3. Individual Support Plans (ISPs) for consumers enrolled in the Innovations Waiver
  4. Non-entitlement services (IPRS/State Funded Services) where funding sources are strictly limited

Over/Under Utilization Tracking

Cardinal Innovations reviews claims data and compares it to expected norms. The goal is to identify instances when services are used too little to be effective, or too often.  These indicators reflect the need for a different level of care or that low-quality care has been provided. Also, Cardinal Innovations reviews coding to ensure providers are not over- or under-coding for specific services. Examples of over/under utilization data include the following:

  1. Length of stay
  2. Rates of use of add-on/crisis codes
  3. Rates of use of basic/crisis services for consumers also in enhanced or residential level services
  4. Units/sessions used per unit of time (compared to peer benchmarks or best practices)
  5. Member engagement in services (units/sessions used toward the beginning of a service)

Quantitative Clinical Data Monitoring

Quantitative claims, authorizations, and other data can be a proxy indicator of clinical quality. Cardinal Innovations reviews certain types of data to assess provider quality and member safety. These types of data include the following:

  1. Rates of crisis system use
  2. Readmission rates to specific services at various time intervals
  3. Prescribing practices
  4. Total cost of care (Medicaid only)
  5. Level of care (e.g., LOCUS, CALOCUS, ASAM) measures match with level of care requested/provided

Qualitative Clinical Data Monitoring

Certain aspects of clinical quality can only be obtained by manually reviewing the medical records of our members. Cardinal Innovations gathers these data through two types of reviews:  Quality Management (QM) and Utilization Management (UM).

  1. QM Monitoring can be performed on a routine or problem-focused basis. From a clinical standpoint, QM audits look at compliance with the following:
    1. Statutory regulations
    2. Medicaid and State Service definition and Clinical Coverage Policy requirements
  2. UM audits are called Utilization Reviews (URs). URs are used to evaluate certain aspects of clinical quality related to funded services. URs can be routine, in which all providers meeting specific clinical criteria are reviewed. URs also may be focused, in which a specific provider is reviewed because of concerns about quality of care. While each review requires service-specific questions, most URs evaluate clinical quality by reviewing the following aspects of care:
    1. Diagnostic integrity (comprehensiveness of symptom evaluation and diagnostic accuracy)
    2. Medical necessity
    3. Treatment goals related to diagnosis, adaptive functioning, and/or level of risk
    4. Effective coordination of care and communication with other providers and/or invested parties
    5. Appropriate discharge planning and referrals
    6. Use of and fidelity to evidence-based practices/best practices and adopted clinical guidelines
    7. Measurement/Evaluation of progress (e.g., use of measurement-based care tools, and monitoring of progress toward treatment goals)
    8. Adequacy of informed consent and respect for member rights
    9. Compliance with service definitions (staffing, documentation, service provision)

Special Initiatives:

In 2014-2015, Cardinal Innovations UM department is continually using greater data-based management solutions with the goal of reducing prior authorization management strategies and redistributing clinical care management resources towards targeted retrospective reviews of care (UR) in our more established network areas. The following are priorities for this transition:

  1. Standardizing our clinical management for every service by developing and updating expected best-practices, expected outcomes, and monitoring strategies for every service. These standards are incorporated into all service-specific UR tools.
  2. Prioritizing provider monitoring based upon provider performance by developing a new Provider Profile Tool that will rate clinical, quality and compliance performance. High performing providers will receive reduced UM and QM oversight.

High Risk Monitoring

Cardinal Innovations uses various data-driven and manual referral processes to select high-risk cases and/or cases with poor outcomes to be reviewed thoroughly by clinical staff.

  • UM Care Managers staff cases with in-house experts and consultant experts (physicians, pharmacists, and doctoral level clinicians) based upon specific criteria that include complex medical issues, lack of improvement, highly restrictive care, complex or off-label medication use, and crisis/legal system involvement. Specifics about these criteria are covered below in the "Special Populations" section of this document.
  • UM and Care Coordination staff can initiate case conferences with a multidisciplinary group of stakeholders. Criteria are established for each type of staffing and are regularly reviewed. The staffing includes the following:
    • Community of Care of North Carolina (CCNC) joint staffing for medically complex members
    • High Risk Case Conferences
    • Care Reviews
    • Child and Family Team Meetings (for children in or at risk of out of home placement) 
  • A Cardinal Innovations Medical Director performs a Level III Incident Review for all Level III Incidents, which indicate a death or permanent injury due to a behavioral health disorder or for an unknown cause. Whenever a Medical Director, Clinical Director, or other designee feels a more thorough review is necessary, a Morbidity and Mortality Conference is held for an interdisciplinary internal review. Recommendations for system changes are made, and implementation of the recommendations is monitored by our Continuous Quality Improvement Committee.
  • Cardinal Innovations has qualified professionals (licensed clinicians for MH/SA populations and both licensed and unlicensed staff for ID/DD populations) who serve as Care Coordinators. Care Coordinators are assigned to members who meet criteria for special populations deemed to be high priority or high risk.
  • For children and adolescents, Cardinal Innovations follows the System of Care model, which integrates a comprehensive network of community-based services to meet the needs of families who are involved with multiple child service agencies (child welfare, mental health, schools, juvenile justice and health care).

For more information on high-risk and special populations, see the Special Populations section below.

Quality Management and Performance Monitoring

In addition to reviewing individual members care through care management, Cardinal Innovations assesses the function of our clinical system more globally through the following tools:

  • Consumer and Provider Satisfaction Surveys: A critical component of our external quality program is to obtain both consumer and provider feedback on our performance. An annual survey is used to obtain, compile and analyze information, identifying opportunities for improvement in service, timeliness, communication and other key areas.
  • Incident/Grievance Monitoring: Information is received daily from providers about unexpected incidents that have occurred such as falls, medication-related incidents, and reports of abuse, injuries and deaths. This information is tracked and trended to identify opportunities to minimize the recurrence of these events. Equally important is the grievance process, which allows consumers to communicate their dissatisfaction about care they received from a network provider.
  • Measures of Performance: Organizations such as Agency of Healthcare Research and Quality (AHRQ), National Quality Forum (NQF), Healthcare Effectiveness Data and Information Set (HEDIS), Substance Abuse and Mental Health Services Administration (SAMHSA), Division of Mental Health (DMH), Division of Medical Assistance (DMA) and several others are working to achieve consensus on indicators that define best practice standards. Although the development and measurement of behavioral indicators are in the early stages compared to physical healthcare, measures that guide the delivery of high-quality care and service are critical to the success of our quality management program.
  • Our quality management dashboard is a valuable tool used to assist us in measuring our performance against targets and benchmarks in order to prioritize our opportunities for improvement. Comprised of both internal and external indicators, it is designed to capture and communicate our performance in the areas of clinical care, service, coordination and timeliness/access to care.
  • Cardinal Innovations has also developed a set of core clinical performance measures called Key Performance Indicators (KPIs).  KPI results are reported routinely to the Care Management Team.  Clinical KPI data is used to evaluate the effectiveness of care management activities and processes, as well as achievement of established program goals. The Key Performance Indicators that have oversight are as follows:
  • Accessibility of behavioral health care services for urgent and routine needs
  • Follow-up after discharge from acute inpatient stay within seven days
  • Timeliness and outcome measures for initial clinical review and appeals process
  • Provider and member satisfaction survey responses related to the UM program
  • Screening, Triage, and Referral (STR) response and follow up timeliness
  • Access Call Center reporting; Call abandonment and call monitoring
  • MH/SA and ID/DD Utilization reporting including  discharge, admission, average length of stay, readmission, population demographics and other contractual reporting requirements
  • Timely initiation and engagement
  • Quality Indicators identified for the NC Innovations Waiver
  • Provider Monitoring: Cardinal Innovations monitors its providers through various methods. Current monitoring processes are noted below.
    • On-site Health and Safety Reviews – Initial on-site review assessments occur when a new provider enters the network or when an existing provider adds a new site. 
    • NC DHHS Provider Monitoring Process – Providers are reviewed in accordance with the DHHS Provider Monitoring Process to assess quality of service provision and compliance with State Standards. The Provider Monitoring Process is comprised of a hierarchy system which is designed to encourage Providers to adopt innovative and quality practices.      

The Quality Management Department conducts on-going monitoring reviews according to the NC DHHS Provider Monitoring Review Process using standardized review tools.  Monitoring Reviews occur according to timeframes outlined by NC DHHS Provider Monitoring Process. Providers are required to meet an 85% threshold during a review. Providers who do not meet the required threshold are subject to more frequent monitoring reviews.  

  • Justified Cause Audits – Audits are conducted when a credible allegation of fraud is identified.  A justified cause audit can be identified during a profile review, through the concern line/grievance process, or can be recommended by any Cardinal Innovations committee.  Justified cause audits are performed when issues are identified.
  • Focused Billing Audits – Focused audits typically occur when concerns arise regarding adherence to service definitions. 
  • Investigations – Investigations are typically conducted when there is a quality of care or service delivery allegation.  Investigations are performed as issues are identified. 
  • Continuous Quality Improvement:  The Corporate Continuous Quality Improvement Committee (CQI Committee) is a critical component of our infrastructure that reviews, analyzes, and prioritizes opportunities for improvement. Comprised of members of the executive leadership team as well as operational directors for various areas, the CQI Committee has the primary responsibilities noted below.
    • Identifying and prioritizing performance trends, patterns, and improvement
    • Monitoring the quality or care, provider performance, and quality improvement indicators through the use of dashboards, surveys and other reports
    • Recommending initiatives and process changes to address opportunities for improvement
    • Maintaining oversight to ensure completion and that the recommendations and corrective action plans are fully implemented

​Quality Improvement Activities (QIAs) represent a requirement by the National Committee for Quality Assurance (NCQA) to identify three clinical areas of improvement and two service opportunities. Our CQI committee selects the QIAs from review and prioritization of identified areas of opportunity and monitors incremental improvement to achieve better outcomes.

Clinical Initiative Tracking

In 2014, Cardinal Innovations developed its Clinical Initiative Tracking System, which allows 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). New clinical initiatives can be submitted by any Cardinal Innovations staff member for review and if accepted as an initiative, a system is in place to track progress. As of early 2015, Cardinal Innovations has over 40 clinical initiatives in planning, implementation or monitoring phases.

​Cardinal Innovations defines a "clinical initiative" as any new activity or significant expansion of an existing activity that is primarily intended to improve the lives of consumers. Examples may include the development and implementation of a new service, the use of a new evidence based practice, or new​ collaboratives intended to address member needs. Typically, a clinical initiative will address one or more of the following aspects of the clinical system of care:

  1. Prevention
  2. Screening/detection
  3. Access to treatment and/or social services, which will improve the likelihood of successful care
  4. Engagement in treatment
  5. Expansion or improvements in treatment and/or use of best practices

The Importance of Data-Based Decision-Making

As is evident throughout this Managed Care Tools section, care is managed most effectively through the following means:

  1. Prevention efforts
  2. Targeted interventions toward high-risk and high-cost consumers
  3. Ensuring a high-quality network of providers who provide evidence-based, effective services
  4. Ensuring these services are highly accessible to members who need them.​

In an effort to improve these efforts, Cardinal Innovations is depending on data-based decision-making more than ever. To further the success of these strategies, Cardinal Innovations has partnered with the Jordan Institute for Families at the UNC School of Social Work for the following initiative:

Special Initiative:

Accountable Behavioral Care (ABC) Project - The purpose of the ABC Project is to enhance the capacity of Cardinal Innovations and its service providers to manage the care of the people they serve. The project includes activities that will add value to the work of Cardinal Innovations leadership team, staff, providers, community stakeholders and consumers. This project is administered by the Jordan Institute for Families at UNC-Chapel Hill. The ABC Project's four primary goals are to

  1. Strengthen the capacity of MCOs to make management decisions through the use of cross agency, longitudinal data;
  2. Demonstrate a model for using shared data to make management decisions with other public agencies;
  3. Create a resiliency inventory to identify and describe MCO characteristics that support long-term organizational viability; and
  4. Teach evidence-based business practices within the Cardinal Innovations provider community.

​​The Jordan Institute has completed most of the activities to address initiative goals. They used different activities to complete goals such as Data Summits, webinars on business practices for providers, a series of community dialogues in the Five County Community Operations Center (COC), and a survey with Cardinal Innovations staff. The community dialogues are currently being conducted in the Five County COC.​