Gap Report Instructions

Note: Benefit Transition Date no sooner than April 1, 2024

• Instructions also available in Portable Document Format (PDF)

School Based Health Center Medicaid Managed Care
Student Roster and Gap Report Sharing Instructions

The New York State Department of Health has issued a single template as a guide for Student Roster and Gap Report sharing between all medical and dental School Based Health Centers (SBHCs) and Medicaid Managed Care Plans (MMCPs) (See Gap Report Template). SBHCs and MMCPs may choose to utilize other formats to meet data sharing requirements; however, in doing so, these parties will be responsible for ensuring all applicable data sharing requirements have been met.

Student Roster

The first portion of the template is the Student Roster (illustrated above) to be completed by the SBHC. The SBHC is responsible for filling in the plan name, site name, tax ID, sponsor name, and the date the template has last been updated in the top line. The SBHC staff will then fill in the known identification information for enrolled students as illustrated above. This includes the student’s last name, first name, middle initial, Medicaid client identification number, the name of the MMCP the student is enrolled in, the student’s gender, date of birth, home address, and phone number. This information will be then filtered and a version of the template with only information for students enrolled in each specific MMCP will be shared with the appropriate plan.

Gap Report

Following receipt of the template with completed Student Roster data, the MMCP will verify that the contact information for the students provided in the Student Roster matches what is in the plan’s records and if there are discrepancies, the plan will coordinate with the SBHC to ensure all contact information is up-to-date for both entities.

The MMCP will then fill in the Gap Report data (see above) and return the report to the SBHC. The MMCP will fill in areas of service, service periods, and service notes (as needed) for the identified gaps, as well as the number of gaps for each student (this number will correspond to the number of rows included in the chart for the student). For each student, individual areas of service where gaps are indicated will be identified in separate rows. The plan is responsible for replicating rows for each student to include all areas of service with gaps in the Gap Report. The MMCP will also fill in the name and phone number of the Primary Care Provider (PCP) for each student as well as the last date the student was seen by the PCP, as known.

Identified service gaps will correspond to information collected by MMCPs for the Medicaid Managed Care Quality Assurance and Reporting Requirements (QARR). Included below is a list of recommended codes for QARR reporting measures for use to identify services with gaps in care, as appropriate. These codes may be utilized in the gap report as MMCP information systems may not accommodate longer identifiers.

Once all Gap Report data has been entered, the MMCP will update the date of the document (see [Insert Date] in chart on page 1) and return the complete report to the SBHC for ongoing coordination of care.

For further information regarding the transition of School Based Health Center Benefit and Population into Medicaid Managed Care, please go to the MRT 8401 website

Recommended Codes for Gap Report Measures

Administrative:

• AMS – Adherence to Antipsychotic Medications for People with Schizophrenia
• PMM – Annual Monitoring for Patients on Persistent Medications
• AMM – Antidepressant Medication Management
• TCP – Appropriate Testing for Children with Pharyngitis
• URI – Appropriate Treatment for Children with Upper Respiratory Infection
• AMR – Asthma Medication Ratio
• AAB – Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
• BCS – Breast Cancer Screening
• CVM – Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
• CCS – Cervical Cancer Screening (Also Hybrid)
• CIS – Childhood Immunization Status (Also Hybrid)
• CSW – Chlamydia Screening in Women (Enhanced for Medicaid; file not needed)
• CRS – Colorectal Cancer Screening (Also Hybrid)
• DMS – Diabetes Monitoring for People with Diabetes and Schizophrenia
• DSM – Diabetes Screening for People with Schizophrenia or Bipolar Disorder Using Antipsychotic Medications
• DAD – Disease–Modifying Anti–Rheumatic Drugs for RA
• FEM – Follow–Up After Emergency Department Visit for Mental Illness (Enhanced for Medicaid; separate file needed.)
• FED – Follow–Up After Emergency Department Visit for Alcohol and Other Drug Dependence (Enhanced for Medicaid; separate file needed.)
• FHM – Follow–Up After Hospitalization for Mental Illness (Enhanced for Medicaid; separate file needed. QHP only report numerators required by CMS.)
• FPM – Follow–Up Care for Children Prescribed ADHD Medication (Enhanced for Medicaid; separate file needed.)
• IAD – Immunizations for Adolescents (Also Hybrid)
• LSC – Lead Screening in Children (Also Hybrid)
• MMA – Medication Management for People with Asthma (QHP only report numerators required by CMS.)
• MAP – Metabolic Monitoring for Children and Adolescents on Antipsychotics
• NCS – Non–Recommended Cervical Cancer Screening in Adolescent Females
• PBH – Persistence of Beta–Blocker Treatment After a Heart Attack
• PMC – Pharmacotherapy Management of COPD Exacerbation
• PDC – Proportion of Days Covered
• STC – Statin Therapy for Patients with Cardiovascular Disease
• STD – Statin Therapy for Patients with Diabetes
• IBP – Use of Imaging Studies for Low Back Pain
• MCA – Use of Multiple Concurrent Antipsychotics in Children and Adolescents
• VLS – Viral Load Suppression – NYS* (NOT REQUIRED) (DOH calculated no plan reporting required.)
• AAC – Adult Access to Preventive/Ambulatory Care
• ADV – Annual Dental Visit
• CAC – Children's Access to PCPs
• IET – Initiation and Engagement of Alcohol & Other Drug Dependence Treatment
• FPC – Use of First–Line Psychosocial Care for Children and Adolescents on Antipsychotics
• WCV – Well–Child Visits in the First 15 Months of Life
• WCV – Well–Child Visits in the 3rd, 4th, 5th & 6th Year (Administrative method only for QARR.)
• WCV – Adolescent Well–Care Visits (Administrative method only for QARR.)
• AMC – Ambulatory Care (NOT Required)
• BWS – Bariatric Weight Loss Surgery
• TON – Tonsillectomy
• HVA – Hysterectomy, vaginal & abdominal
• COL – Cholecystectomy, open & laproscopic
• BSG – Back Surgery
• PCI – Percutaneous Coronary Intervention
• CCT – Cardiac Catheterization
• CAB – Coronary Artery Bypass Graft
• PRO – Prostatectomy
• MAS – Mastectomy
• LUM – Lumpectomy
• ADS – Identification of Alcohol and Other Drug Services
• ACR – All Cause Readmission
• IUG – Inpatient Utilization (General Hospital–Acute Care)
• IHU – Inpatient Hospital Utilization (IHU)
• EDU – Emergency Department Utilization
• MHU – Mental Health Utilization
• ABU – Antibiotic Utilization
• SHI – Standardized Healthcare–Associated Infection Ratio

Hybrid:

• APC – Adolescent Preventive Care Measures
• BMI – Adult BMI Assessment
• CCS – Cervical Cancer Screening (Also Administrative)
• CIS – Childhood Immunization Status (Also Administrative)
• CRS – Colorectal Cancer Screening (Also Administrative)
• CDC – Comprehensive Diabetes Care
• CBP – Controlling High Blood Pressure
• IAD – Immunizations for Adolescents (Also Administrative)
• LSC – Lead Screening in Children (Also Administrative)
• WAC – Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
• PPC – Prenatal and Postpartum Care
• OPC – Frequency of Ongoing Prenatal Care

Survey:

• ADU – Aspirin Discussion and Use
• FSA – Flu Shots for Adults Ages 18–64
• SCA – Medical Assistance with Smoking Cessation
• CHS – CAHPS Health Plan Survey 5.0H, Adult Version
• CHS – CAHPS Health Plan Survey 5.0H, Child Version
• QHP – QHP Enrollee Experience Survey