HEDIS Care Gaps
Participating primary care providers can access and resolve Healthcare Effectiveness Data and Information Set (HEDIS) Care Gaps for AmeriHealth Caritas Delaware members via NaviNet.
Care Gaps identify missing recommended preventive care services so that you may address them when your patient comes in for an office visit. Care Gaps are based on HEDIS measures and may impact your quality scores.
Once you’ve logged in to NaviNet, check the Activity tab to see alerts for Care Gaps that need your response. Alternatively, you can click on Patient Clinical Documents under Workflows to see the list of members who have Care Gaps. You will also see Care Gaps for your patients upon using the Eligibility and Benefits Inquiry, and on the Member Clinical Summary and Care Gap Query Report.
Learn more about HEDIS Care Gaps
Guides to HEDIS coding and documentation
- Adult HEDIS guidelines (PDF).
- Child HEDIS guidelines (PDF).
- Quick tips — Coding well-child visits (PDF).
- Behavioral health HEDIS guidelines (PDF).
- 2020 Adult HEDIS guidelines (PDF).
- 2020 Child HEDIS guidelines (PDF).
- 2020 Behavioral health HEDIS guidelines (PDF).
Care Gap timing and specifications
The medical and pharmacy specification documents below provide a high-level explanation of each measure's purpose. Member and provider data is used to determine whether or not a member has a gap in care. For more information on the schedule for how measures are calculated, see the NaviNet Care Gap Timing and Status chart (PDF).
- Diabetes Eye Exam (PDF)
- Diabetes HbA1C Test (PDF)
- Diabetes Lipid Test (PDF)
- Diabetes Macroalbumin Test (PDF)
- Adolescent Well-Care (PDF)
- Adults' Access to Care (PDF)
- Breast Cancer Screening (PDF)
- Cervical Cancer Screening (PDF)
- Colorectal Cancer Screen (PDF)
- Diphtheria, Tetanus, and Pertussis Vaccination (DTAP) (PDF)
- EPSDT — Developmental Screening (PDF)
- EPSDT — Hearing (PDF)
- EPSDT — Vision (PDF)
- Lead Screening in Children (LSC) (PDF)
- Primary Care Visits 1 to 2 Years (PDF)
- Primary Care Visits 3 to 6 Years (PDF)
- Primary Care Visits 7 to 11 Years (PDF)
- Well-Child Visit 18 Months and Younger (PDF)