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Gaps in Care

CenCal Health’s Gaps in Care Program identifies members who are due for clinically recommended services to help Primary Care Providers continue providing high quality health care for members.

Providers can contact CenCal Heath’s Quality Improvement Department for more information at:

QI GCPhone: (800) 421-2560 ext.1997

Provider Quality of Care Performance Reports and Gaps in Care Reports are distributed to all Primary Care Providers (PCPs) on a monthly basis through the Provider Portal.

The Provider Quality of Care Performance Report includes:

  • CenCal Health’s quality measures for improvement
  • Priority quality measures
  • A PCP’s quality performance score by measure
  • A PCP’s quality performance score by measure compared to CenCal Health’s overall score
  • CenCal Health’s quality performance goal by measure
  • A PCP’s combined quality score for all measures
  • To view a sample report, click here

The Gaps in Care Report includes:

  • All members in the “Provider Quality of Care Performance” reports that are currently assigned to a PCP who are missing one or more aspect of care
  • Each member’s name, date of birth, and CenCal Health Member ID number
  • Each aspect of care the member is due for, according to data available to CenCal Health

Quality of care categories are identified for inclusion in the Gaps in Care Program based on various criteria such as areas of quality improvement for CenCal Health, the ability to accurately measure gaps in care using available data, and alignment with state recommended quality focus areas.

Quality of care measures fall into six clinical categories of care:

  • Behavioral Health
  • Women’s Health
  • Pediatric Care
  • Diabetes Care
  • Respiratory Care
  • Cardiac Care

CenCal Health’s quality measures for the Gaps in Care Program include aspects of care that PCPs can influence either through direct care or referrals.  Quality measures are consistent with accepted clinical guidelines and are clinically relevant to CenCal Health’s membership.

Measures are evaluated annually and as priorities regarding these criteria change, CenCal Health may update these measures.  Generally, measures remain in the Gaps in Care Program for at least 2 years.

All measure requirements reflect the NCQA HEDIS® Volume 2 Technical Specifications and are updated as measure specifications change.

The quality measures included in the program can be found here.

Codes pertaining to the Gaps in Care Program can be found here.

® HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

CenCal Health’s Quality Improvement Department is available to:

  • Provide PCPs with on-site orientation regarding CenCal Health’s quality measures
  • Provide strategies to maximize PCP data reporting including electronic data sharing
  • Share best practices to help PCPs maximize service utilization that is consistent with preventive health and clinical practice guidelines
  • Provide quality improvement training
  • Provide PCPs with health education materials for their members

provider training

Frequently Asked Questions

1. How often do PCPs receive reports?

PCPs can access their reports on the Provider Portal at any time.  This information is updated on a monthly basis.

2. How are quality measures calculated?

Quality measures are calculated using current NCQA HEDIS® Volume 2 Technical Specifications which reflect the most recent clinical recommendations and preventive health guidelines  that apply to the measurement periods.

3. How often are quality measures updated?

Generally, quality measures remain in place for at least 2 years to reinforce improvement priorities, support program stability for PCPs, and increase the ability to  achieve clinical excellence.

4. Why aren’t some services or quality measures included in the Gaps in Care Program?

CenCal Health includes quality measures in the Gaps in Care Program that meet certain criteria such as needed clinical improvement, alignment with state-wide quality priorities, and the ability to measure quality of care accurately with available data.  Quality of care measures that are not included in the Gaps in Care Program are measured through other processes. For example, annual HEDIS auditing and Facility Site Reviews.

5. Which members are included in the Gaps in Care Program?

All CenCal Health Medi-Cal members are included in the Gaps in Care Program except those with Medicare or Other Health Coverage as their primary insurance.  Members also covered by Medicare/Other Health Coverage are excluded because CenCal Health does not have access to complete claims data as evidence of their care.


6. How are quality of care scores calculated?

The quality of care scores are calculated by dividing the total number of a PCP’s assigned members who received an aspect(s) of care, by the total number of assigned members who were due for an aspect(s) of care. Members are only included if they were covered by CenCal Health for a sufficient time to receive recommended services.

7. Does the Gaps in Care Program promote withholding of services for members?

The Gaps in Care Program only includes quality measures that promote increased utilization of medically necessary services.

8. Is the Gaps in Care Program connected to the PCP Incentive Program?

The Gaps in Care Program is meant to be used as a tool to assist PCPs in continuing to provide high quality healthcare to our members.  It is not connected to any incentive payments at this time.