22-041m HEDIS Monthly Care Gap Report Adds Member COVID-19 Vaccine Records
Date: 01/20/22
This information applies to Physicians and Participating Physician Groups (PPGs).
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Use your care gap report to reach out to members who need a COVID-19 vaccine
Providers have a positive impact on helping members overcome vaccine hesitancy when they initiate discussions with their assigned members.
To help providers identify their members who have not received a COVID-19 vaccine, a new measure, Covid-19 Vaccine, was added to the Healthcare Effectiveness Data and Information Set (HEDIS®) Care Gap Report. It includes evidence of either partial or complete COVID-19 vaccination at a member level. This status is based on available data sources.
Only members with evidence of at least one dose of a COVID-19 vaccination are included in the report.
Who receives the Care Gap Report
The monthly report is sent to the participating physician groups (PPGs) via the provider portal. PPGs, in turn, distribute them to their primary care physicians (PCPs). If a PCP does not receive the report with the addition of COVID-19 vaccination data from their PPG, they should contact the PPG to request it. Providers using Cozeva® receive COVID-19 vaccination data directly from that platform.
How to determine unvaccinated
To identify unvaccinated members, compare the vaccine-eligible members (> 5 years old) in the monthly enrollment file to the Covid-19 Vaccine measure in the care gap report. Enrolled members who do not appear on the Covid-19 Vaccine measure have no record of any vaccination. These are the members who need to be contacted about getting their first COVID-19 vaccination.
Providers with access to Cozeva can get lists of unvaccinated members automatically in the platform. For more information about Cozeva, please contact your Provider Engagement representative or visit thr Cozeva website. Cozeva is offered free of charge, and you can sign up for an unlimited number of accounts.
Data sources used
The data used for the COVID-19 Vaccine measure in the report is identified from multiple sources with different frequencies, but the primary source of a member’s vaccination status is the California Immunization Registry (CAIR). It is necessary to continue to enter all vaccinations into CAIR in a timely manner.
The vaccination data is refreshed from all available sources and updated monthly in the HEDIS Care Gap report’s Covid-19 Vaccine measure. Data from more sources will be added to future reports as they are identified.
COVID-19 vaccine administration claims
Medi-Cal pays the Prospective Payment System (PPS) rate for COVID-19 vaccines administered during an in-person visit that meets the requirements of a billable office visit. Each dose is separately reimbursable, so you do not have to wait until both doses of the COVID-19 vaccine have been administered to submit a claim.
Guidance for FQHCs and RHCs
For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), payment for your vaccine administration is included in your visit rate1. If you only do the COVID-19 vaccine administration, you need to bill the Department of Health Care Services (DHCS) Fee-For-Service Medi-Cal2 directly and not submit a claim to Health Net.
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
1 California Primary Care Association
2 Department of Health Care Services Bulletin