Assigned PCPs, pediatricians, behavioral health providers and OB/GYNs are paid extra for closing certain HEDIS^® care gaps in eligible members during the measurement year. 

Participating providers with a member panel of 100 or greater are eligible to earn P4P incentives and would typically receive tiered incentives based on their member panel. Specialty providers of targeted services for behavioral health and perinatal care would receive flat-rate incentives based on referral-based care for behavioral health and/or perinatal care services. 

The measurement year is defined as January 1, 2025 to December 31, 2025.

There are two methods of payment: a tier method and an annual flat rate method. 

Tiers:

• Reaching the 50th percentile
• Reaching the 75th percentile
• Reaching or exceeding the 90^th percentile

Providers receive compensation for all gaps closed when the next performance tier is reached. 

Annual flat rate:

Flat rate measures are paid to eligible providers at the same rate for each gap closure.

Pay-for-Performance measures, targets and payment tiers for 2025 (PDF)

Use reports in the Availity portal to track your progress. Your PR rep can assist with registration.

Provider P4P Program Partnership Program - Partnership bonuses

Health Risk Survey (HRS) completion

• Providers will receive $25 for every HRS completed for a new member in the first 60 days. Get the HRS form here.
• Providers receive $10 per HRS completed for all other members.

Data exchange

• Providers with more than a thousand members will receive a one-time $1,000 bonus for new supplemental data source (SDS) feed for data transfer to the health plan.

Notification of Pregnancy

• Providers can earn $30 per notification of pregnancy. Get the NOP form here.

Assess and enter Z-code (Z59.x) for problems related to housing and economic circumstances

• Providers will receive an additional $25 per member per day for entry of Z-code (Z59.x) for problems related to housing and economic circumstances.

CPT II Code

• Providers can receive $25 per compliant CBP, BPD, HBD and EED (negative only) codes on each claim billed.

We now provide monthly quality care gaps reports in Availity. These reports — with a detailed billing view — show our members assigned to your care with open care gaps. You can use this data to identify claims that need additional coding and members for outreach. You’ll also see your potential pay-for-performance (P4P) earnings from closing the care gaps.

Learn more here (PDF)

Get more info about HEDIS measures.