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Quality Care Gap Closure

The presentation Quality Care Gap Closure will explain how care gaps are closed, hybrid & administrative data, coding claims to reflect services rendered, and using the Provider Tips Booklet.

Quality Care Gap Closure


Hello, and welcome to the Results and Recognition Program presentation on Quality Care Gap Closure.

Results and Recognition is also referred to as R&R.

Just a brief disclaimer that we are not certified coders and will not provide instruction on how to code or what codes to use for services rendered.

This presentation is designed to provide general information regarding the importance of accurate coding and clinical documentation to close gaps in care.

The objectives are to understand the importance of correct coding, understand the importance of clinical documentation, understand the ways to submit clinical documentation, and to apply suggested best practices.

The goal for quality gap closure is submission of claims and encounters with coding that administratively captures all required data through claims, decreasing the need for medical record review and improving timeliness of closing gaps in care.

Coding Correctly. HEDIS data collection is a year-round process using claims data as a primary source to close gaps in care.

Supplemental data submissions are secondary sources.

Complete and accurate coding of all claim submissions is a priority because it ensures the integrity of the data.

Claim submissions should be timely to avoid any delays in monthly updates for reporting data.

When you close care gaps it reflects on your performance report and you'll receive an incentive once that measure exceeds NCQA's 50th percentile benchmark or reaches the Star target.

The HEDIS value data set is a complete set of codes used to identify the services or conditions included in the measure.

HEDIS acceptable codes are published each October in the Value Set Directory, which is part of the final specifications published by NCQA.

NCQA is the National Committee of Quality Assurance, and it is an organization that developed HEDIS, which is a set of standardized performance measures designed to ensure that the public has information it needs to compare different organization's performance.

The HEDIS value set codes includes codes from CPT, Healthcare Common Procedure Coding System, also known as HCPCS, ICD-10, LOINC, and SNOMED.

These are bare bones definitions that are noted, it is not an all- inclusive list of value set codes. It is up to the practice, the provider, and the biller to know how to apply these services rendered.

Modifiers. Modifiers are used to report that the procedure has been altered by a specific circumstance.

It should not be used for multiple evaluation and management events unless the activity occurs as separate times on the same day.

When added to CPT or HCPCS codes, provide additional information about a service or procedure.

For more information on modifiers, please go to the Horizon NJ Health site under the provider manual.

HEDIS rates are captured either by administrative or hybrid data.

Both methods are used to look for numerator compliance.

Numerator is a term used to equate how many members are compliant for the measure.

Administrative data is used to identify the eligible population.

The eligible population is also known as the denominator.

The report rate is based on all members who have met the eligible population criteria and who have been found to have received that service for the numerator through administrative data.

Hybrid data is the information collected for medical records to meet the numerator criteria, if it is not received by administrative data.

HEDIS data collection is a year-round process using claims data as a primary source. In simple terms, administrative data comes from claims and hybrid data comes from medical record review. Accurate and timely submission of that administrative data, again, known as claims, reduces the necessity for medical record review.

Clinical documentation. Documentation plays an important role in data collection and reporting for HEDIS, as well as validating the services for any codes captured through claims.

Documentation is everything. You know how the saying goes, if it's not documented, it's not considered done.

There are 3 important reasons why documentation is important for claims.

First, it facilitates accurate and timely claims review and payment.

Second, it minimizes many of the difficulties related to claims processing and HEDIS chart requests.

And lastly, it supports the HEDIS codes reported on billing statements.

Correct coding is the most accurate way to capture clinical quality data. However, when the gap is not closed administratively, hybrid data may be submitted.

Clinical documentation should include patient's name, patient's date of birth, date of service, provider's signature and credentials, services rendered, a complete descriptive narrative of the service and care rendered during office visit or telehealth visit.

Some common reasons for noncompliant documentation include:

Missing or incomplete required documentation components.

Incomplete services rendered. Service provided outside the required timeframe.

Provider signature missing. Date of service missing.

Unique member identification missing, including date of birth, complete name, etc.

Claim/encounter and codes not submitted for services rendered.

EMR, also known as electronic medical record.

EMR templates help healthcare providers integrate all necessary components for proper clinical documentation in a clear, organized, structured manner. EMRs can provide reminders regarding patient screenings and preventative care, as well as flag areas where additional information is required.

EMR systems can collect essential HEDIS data and avoid errors in the medical record. EMRs can also track non-compliance and preventative services.

Another advantage of utilizing EMRs, is that medical records can be more easily read and are less prone to having errors go unnoticed.

Submitting clinical documentation. If you are submitting medical records for supplemental data, or any other documents, there are a few ways in which you can submit them securely.

The first way is through Horizon Docs, which is the preferred method.

Horizon Docs is a web-based, centralized document repository, that allows Horizon to exchange documents securely with network providers, and is accessible via NaviNet provider portal.

Secure Blue E-mail and Manage File Transfer, also known as MFT, are also options to send the received documents securely.

However, these 2 methods will eventually phase out at some point. So, if you haven't started using Horizon Docs, I highly suggest you do.

Provider tools and resources.

There are many tools and resources that we offer providers in the R&R Program. Let's talk about a few.

The first one is the Provider HEDIS Tips Booklet.

Now, historically we've distributed copies to the providers.

For this resource, it's now only available electronically via the Quality Resource Center, which I'll touch on shortly.

The HEDIS Tips Booklet lists things such as some key HEDIS measure descriptions, data collection methods, suggested codes, and best practices.

Always keep in mind that the most accurate way to close quality gaps in care is to submit data through correct coding and any codes used most support the services rendered and be reflected in the medical record documentation.

Here are some more HEDIS resources that are on our Quality Resource Center.

The Quality Resource Center can be accessed by visiting

Quality Resource Center and signing into NaviNet.

Here's another resource we provide our providers, which is a Provider Administrative Manual, a guide to the administrative procedures of Horizon NJ Health.

The manual is updated periodically, answers questions about referrals, authorization policies, member benefits, claim submissions, and other topics.

It provides day-to-day operational details that can be helpful to your practice.

To obtain the Provider Administrative Manual, please go to

And now let's get into some best practices.

Submitting accurate claim and encounter data for each and every service rendered and ensure that the medical record documentation reflects all services billed.

Submit claim encounter data on a timely basis.

Incorporate templates and ticklers into your EMR system as a reminder of HEDIS recommended screenings.

Maintain a complete and accurate record of all rendered services, including telemedicine services.

Submit supplemental data year round. The deadline is December 1st 2023.

And finally, utilizing the Quality Resource Center for provider billing tips, best practices, and program manuals.

Thank you for listening. If you have any questions, please email them to

Also, at the end of the transcript and below the webinar is a link to our Survey Monkey.

Please complete this brief survey. Your feedback is greatly appreciated.

Thank you.

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