Resolve Care Gaps

Health Plans: 

  • AmeriHealth Caritas Delaware,
  • AmeriHealth Caritas District of Columbia (ACDC),
  • AmeriHealth Caritas Louisiana,
  • AmeriHealth Caritas Pennsylvania,
  • Blue Cross Complete of Michigan,
  • Keystone First,
  • Keystone First Community Health Choices,
  • Select Health of South Carolina

Workflow: 

  • Care Considerations

Each month, the health plan sends you care gap notifications for members who may be at risk due to missing or overdue services or medications. You can resolve the care gaps online and provide supporting documentation when needed.

This topic describes how to:

Would you rather try the online training? Check out Care Gaps Online Training.

Before you begin: To receive care gap notifications, you must use the Provider Filter to select the providers that you support. By doing so, you attest that you are authorized to access the Protected Health Information for the patients of those providers. 

Access Care Gap Notifications

You can access care gap notifications from the following areas in NaviNet:

From the Activity Menu

If you subscribe to care gap notifications, the system notifies you when new care gaps need your attention. Subscribe to and access the notifications from the Activity menu.

  1. On the upper-right of the NaviNet toolbar, click Activity.
  2. On the Settings tab, subscribe to care gap notifications:
    1. Under Notify Me About, select the Incoming Documents and Patient updates when running an E&B check boxes.
    2. Under Frequency of pop-up notificationschoose how often to receive pop-up notifications. Pop-up notifications appear at the top-right of the NaviNet screen. If you disable pop-up notifications, you can still access notifications from the Activity menu.
  3. View the care gap notifications: 
    1. On the Notifications tab, point to the notification, and then click View Documents, or
    2. On the Summary tab, under Patient Documents, click Response Requested or Unread

For more details, see Using the Activity Menu.

From the Patient Clinical Documents Workflow

  1. On the Workflows menu, click Patient Clinical Documents.
  2. In the Patient Clinical Documents screen, find the care gap notifications by using the filter and sort options. For example:
    1. Select the Patient Consideration filter under Document Category.
    2. Type Care Gap in the Document Tags field.
    3. Sort by Patient Last Name, Payer, or Last Document Received.
  3. Click a patient name to view the patient's care consideration detail screen in the document viewer. 

For more details about Patient Clinical Documents screen, see Patient Clinical Documents.

From Eligibility and Benefits

If you view eligibility and benefits for a patient that has a care gap notification, you see a pop-up notification in the upper-right of the screen.

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To resolve the care gap, click one of the Clinical Document links to view the patient's care consideration detail screen in the document viewer.   

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Resolve Care Gaps

When you access the care gap notifications, the system displays the patient's Care Consideration Detail screen in the document viewer. 

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The Response Required section lists the care gaps that need immediate attention. Care gaps that appear in other sections are for your information only.

To resolve the care gaps:

  1. Click Resolve Care Gaps. The Care Gap Response Form in the Provide Self-Service portal opens.
  2. Complete the response form for each care gap:
    1. Select a care gap.
    2. Fill in the required fields and attach the required documents. Note: To request an exclusion for breast cancer, cervical, or chlamydia screens, click Request Exclusion, and then attach the required documentation.
  3. Click Submit. After you submit your care gap response, a member from our team reviews the information and approves or rejects your response.
    1. If your response is approved, you no longer see a notification for the care gap and it moves to the Up-to-Date section in the patient's Care Consideration Detail screen.
    2. If your response is rejected, you see a new care gap notification, and the care gap status is Rejected in the patient's Care Consideration Detail screen. Click Resolve Care Gaps, review the reviewer's comments, and then resubmit your response. 

View Outstanding Care Gaps

To view all outstanding care gaps:

  1. Sign in to NaviNet. On the Health Plans menu, click your health plan.
  2. Under Workflows for This Plan, select Report Inquiry, and then click Clinical Reports.
  3. Choose Care Gap Query from the Select Report drop-down menu.
  4. In the screen that appears, choose the report criteria, and then click Search. The report appears.

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