Medicaid managed care has changed considerably over the past two decades. Expectations for data, access, quality, accountability, transparency, and outcomes have continued to evolve, requiring states to do more than demonstrate compliance. They need External Quality Review partners that understand the regulatory environment, can manage complex review activities, and can help translate findings into useful information for program oversight and improvement.
For Qsource, that work is not new. Qsource has more than two decades of External Quality Review experience, beginning with EQR work supporting Tennessee’s TennCare program in 2000. Since then, our experience has expanded across multiple state programs, including Tennessee, Arkansas, Indiana, and Florida Healthy Kids.
Today, Qsource serves as the External Quality Review Organization for Arkansas, Indiana, and Florida Healthy Kids, bringing together national subject matter experts, healthcare quality professionals, clinicians, analysts, technical writers, and project leaders to support state Medicaid and CHIP programs.
Experience Built Across Programs and Priorities
External Quality Review requires the ability to understand both the details and the larger picture.
Qsource evaluates the quality, timeliness, and access to healthcare services provided to Medicaid and CHIP managed care enrollees in accordance with federal requirements. Our teams have experience working with managed care organizations, prepaid inpatient health plans, prepaid ambulatory health plans, state agencies, and other partners across a range of healthcare populations and program structures.
Under the current CMS framework, EQR includes four mandatory activities:
- Validation of performance improvement projects
- Validation of performance measures
- Compliance reviews
- Validation of network adequacy
CMS also identifies seven optional EQR-related activities that states may use to strengthen managed care oversight, including encounter data validation, quality of care surveys, calculation of additional performance measures, additional performance improvement projects, focused studies, assistance with Medicaid and CHIP Quality Rating System activities, and assistance with evaluation activities related to state quality strategies, State Directed Payments, and In Lieu of Services and Settings.
That experience provides the foundation for Qsource’s work, but it does not define its limits.
Experience Beyond the Core EQR Protocols
State Medicaid and CHIP programs are complex, and the needs of each state extend beyond a standard set of review activities. Qsource has developed experience across a wide range of additional EQR-related activities that support program integrity, oversight, quality improvement, access, and accountability.
Our experience includes:
- Critical Incident Reviews
- Utilization Reviews
- Person Centered Service Plan Reviews
- Value Added Services Reviews
- Credentialing Reviews
- Eligibility Reviews
- Periodic Audits
- Medical Loss Ratio Reviews
- Quality Strategy Support and Evaluation
- Quality Forums
- Secret Shopper Activities
- Medical Record Reviews
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
- Quality Assurance and Performance Improvement (QAPI)
- Dual Eligible Special Needs Plans (D-SNPs)
- Home and Community Based Services (HCBS)
- Information Systems Capabilities Assessments (ISCA)
This breadth of experience is increasingly important as states look at quality across entire programs rather than through individual measures or isolated reviews. Access, network performance, clinical quality, member experience, program operations, information systems, and data reliability are interconnected.
A state may need to understand not only whether a health plan met a particular requirement, but also what the available evidence says about how its systems are performing for members. That is where depth of experience matters.
Supporting States Through Change
Qsource has helped states establish EQR programs and has supported programs as they transitioned to new managed care models. That experience has included readiness activities, technical assistance, program guidance, data analysis, audits, validation, and annual technical reporting. The environment continues to evolve.
CMS released updated External Quality Review Protocols in 2026 that place greater emphasis on quantitative outcomes, consistent review periods, meaningful data, and the role of EQR findings in broader state quality efforts.
The updated requirements reinforce something Qsource has learned through years of working with state programs: strong external quality review is most valuable when it gives state leaders information they can use.
A technically sound review is essential. Its value increases when findings help a state understand performance, identify recurring patterns, recognize areas of strength, and determine where closer attention or additional improvement may be needed.
More Than a Compliance Exercise
At Qsource, External Quality Review is grounded in the same principle that has guided our organization for more than 50 years: healthcare quality improves when reliable information leads to meaningful action.
Our history as a healthcare quality improvement organization gives our EQRO teams a perspective that extends beyond individual protocols. Qsource has worked across Medicaid and Medicare programs, healthcare providers, health plans, government agencies, and quality improvement initiatives. That experience helps us understand how regulatory expectations, healthcare delivery, data, and quality improvement intersect.
It also shapes how we approach state partnerships. States need an independent reviewer capable of maintaining objectivity and rigor. They also need a partner that understands the operational realities behind the data, communicates findings clearly, meets complex federal and state requirements, and can adapt as programs and expectations change.
That combination of independence, technical expertise, and healthcare quality experience has allowed Qsource to build long-standing relationships within Medicaid managed care.
Preparing for the Next Era of Medicaid Quality Oversight
External Quality Review continues to evolve as states face increasing expectations related to access, network adequacy, quality measurement, quality ratings, State Directed Payments, quality strategies, program evaluation, data integrity, and measurable outcomes.
For Qsource, those developments represent a continuation of work we have been doing for decades.
From our earliest EQR work in Tennessee to our current state partnerships, Qsource has continued to build the people, expertise, analytical capabilities, and infrastructure necessary to support increasingly complex Medicaid and CHIP managed care environments.
Our experience spans core EQR protocols and a much broader range of specialized activities. That means states can work with a partner that understands not only the federal framework, but also the many interconnected components required to evaluate healthcare quality at the program level.
The regulations will continue to evolve. Measures will change. New priorities will emerge. The need for credible, independent, experienced quality oversight will remain. Qsource is ready to help states meet that need.
Learn more about Qsource’s External Quality Review services and our experience supporting Medicaid and CHIP managed care quality at
Qsource.org/eqro-qa.