Gaps in Care are incomplete healthcare appointments or screenings as identified by members' Managed Care Organizations (MCO). This data is then sent to the Health Homes and imported by FCM. Examples of gaps in care are annual physical or dental visits, cancer screenings, or periodic medication refills. A list of the different Gaps in Care explanations from the various MCOs can be found in this article.
In FCM, there are two statuses that Users will see in a member's Gaps in Care tab:
- MCO Gap Status
- CM Status
The MCO Gap Status does have a description available by clicking the tool tip box in blue:
This status is updated based on the data files that are sent by the MCO. Their records must indicate that the gap has been closed in order for the MCO Gap Status to show a "closed" measure. This is typically reflected by a claim that is submitted to the MCO by the provider. This claim may take several weeks or months to reflect in the MCO's system even after a member has closed their gap. This will only update in FCM if the MCO marks the member's status as closed on the file we import into FCM.
The CM Status is the status reflected after the CM has confirmed with the member or their provider that the gap has been closed. This may differ from the MCO Gap Status because the MCO may still be waiting for the claim from the provider or processing the claim to confirm services were rendered. Updating the CM Status does not update the MCO Gap Status.
Questions?
Submit a support ticket and we'd be happy to help!