HEDIS and Care Gaps

Why HEDIS?

Quality Corner

Coding Spotlight

This spotlight features codes that are often associated with routine health screenings for comprehensive diabetes care.

Focus on Diabetes (PDF)

See more spotlights.

Accurate coding of HEDIS (Healthcare Effectiveness Data and Information Set) measures can help identify and eliminate gaps in care and disparities in health and health care. This helps ensure care is timely and appropriate. It also helps monitor preventive care and facilitate timely claim adjudication, incentives, and payments.

Health plans are measured on how well they perform and improve in quality, effectiveness of care, access to care, and member satisfaction. These measures are calculated using specific CPT and ICD-10 codes found in claims and encounters data.

According to the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry. It consists of over 90 measurements that are used to compare health plan quality across the nation and are required for health plan accreditation. Accreditation helps ensure plan members receive quality care from their health plan and providers.

How can you improve HEDIS scores?

  1. Submit valid CPT and ICD-10 codes on each encounter or claim.
  2. Document services and medical findings in the patient’s medical chart.
  3. Encourage patients to schedule preventive exams.
  4. Remind patients to follow up with ordered tests.
  5. Make outreach calls to noncompliant patients.

HEDIS documentation

AmeriHealth Caritas Next HEDIS documentation can be found in NaviNet. There you can find a detailed overview of the HEDIS measures, including descriptions and actionable takeaways.

HEDIS care gaps

Care gaps are the missing recommended services that members need to complete to achieve optimal health. You may address these gaps when your patient comes in for an office visit. Care gaps are based on HEDIS measures and may impact your quality scores. Participating primary care providers can access and resolve HEDIS care gaps for AmeriHealth Caritas Next members via NaviNet using the following steps:

  • Log in to NaviNet.
  • Check the Activity tab to see alerts for care gaps that need your response.
    • Alternatively, to see the list of your patients who have care gaps, check Workflows > Patient Documents.
    • Care gaps can also be accessed via an Eligibility and Benefits Inquiry, a Member Clinical Summary, or a Care Gap Query Report.

As a reminder, it’s important we work together to identify, address, and help eliminate health disparities. Health and health care disparities are differences in health care treatment and outcomes, such as life expectancy and rates of chronic conditions, that are rooted in socioeconomic factors such as race, gender, and income and education level.1

When accessing and reviewing care gaps, be sure to also group the data by race, ethnicity, and language (REL) to identify the populations that are experiencing a disparity for a specific measure. Focusing efforts on starting with the population that has the lowest HEDIS compliance rate can help close gaps in care and work toward reducing disparities.

Tools and references

1Nambi Ndugga, et al., “Disparities in Health and Health Care: 5 Key Questions and Answers,” KFF, August 14, 2024, https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/

For Providers