At Blue Cross and Blue Shield of North Carolina (Blue Cross NC), we appreciate all that our providers do to support the health and well-being of our members. Dual Eligible Special Needs Plan (D-SNP) members are individuals who qualify for both Medicare and Medicaid. Our goal is to enhance care coordination, address social determinants of health, and support high-need populations through targeted care management and aligned provider engagement.

As part of our continued commitment to delivering high-quality, value-based care to North Carolinians, Blue Cross NC is implementing a special provider incentive program, “QUALI-D,” focused on closing care gaps for our D-SNP members for 2025. This effort includes two key components designed to maximize quality of care for our 2025 D-SNP population:

I. Provider Care Gap Incentive – $50 per closed gap for the following HEDIS measures:

• BCS -E¹, Breast Cancer Screening
• COL-E¹, Colorectal Cancer Screening
• GSD, Glycemic Status Assessment for Patients with Diabetes HbA1c Control <=9%
• EED, Eye Exam for Patients with Diabetes
• COA, Care for Older Adults – Medication Review Indicator
• CBP, Controlling High Blood Pressure
• FMC, F/U After ED Visit for People with Multiple High-Risk Chronic Conditions
• TRC, Transitions of Care – Medication Reconciliation Post-Discharge Indicator
• SPC, Total Statin Therapy for Patients with Cardiovascular Disease
• OMW, Osteoporosis Management in Women Who Had a Fracture
• Medication Adherence for Cholesterol (Statins)
• Medication Adherence for Hypertension (RAS Antagonists)
• Medication Adherence for Diabetes Medications
• Kidney Health Evaluation for Patients with Diabetes

Including the corresponding CPT service codes is crucial for automatic gap closure. Below is a summary of some additional tips on CPT category II codes to help support our collective efforts in quality reporting and member care. These informational codes support timely care gap closure and help ensure the health plan maintains accurate and up-to-date member profiles for quality reporting purposes.

However, they are not a substitute for the official measure specifications documents or reference guides. Always reference the latest HEDIS Technical Specifications and the Provider Reference Guides that we share to ensure accurate and up-to-date documentation.

• CBP, Controlling High Blood Pressure: (The percentage of members 18 – 85 years of age who had a diagnosis of hypertension [HTN] and whose BP was controlled during the measurement year.)
  • BP Goal is 139/89 or lower.
  • Include the appropriate CPT II Code: 3074F, 3075F, 3077F, 3078F, 3079F, 3080F, according to the most recent blood pressure value.
• EED, Eye Exam for Patients with Diabetes: (Members 18 – 75 years of age with diabetes [types 1 and 2] who had a retinal eye exam.)
  • If you have or reviewed a report from the patient’s ophthalmologist or optometrist, submit a claim with appropriate CPT II code: 2022F, 2023F, 2024F, 2025F, 2026F, and 2033F.
• GSD, Glycemic Status Assessment for Patients with Diabetes/Glycemic Status > 9.0%: (The percentage of members 18 – 75 years of age with diabetes [types 1 and 2] whose most recent glycemic status [hemoglobin A1c [HbA1c]] or glucose management indicator [GMI] was controlled.)
  • Include CPT II codes according to the HbA1c value: 3044F, 3046F, 3051F, 3052F.
  • Include code 97506-0 in the LOINC code field to indicate a result is a GMI, not an HbA1c. This LOINC code must be reported with a numeric value in the result field. Submissions without a value will not meet the numerator criteria.
• COA, Care for Older Adults – Medication Review Indicator: (The percentage of adults 66 years and older who had a medication review during the measurement year.)
  • Include CPT Category II code 1160F if you reviewed current medications.
• TRC, Transitions of Care – Medication Reconciliation Post-Discharge Indicator: (Members 18 years and older as of December 31 of the measurement year who had a medication reconciliation post-discharge.)
  • Include CPT Category II code 1111F if the discharge medications were reconciled with the current medication list in the outpatient medical record within 30 days of discharge.

II. Provider Annual Preventative Visit Incentive – $75 per closed gap for APV’s:

Codes Associated with Annual Preventive Visits

• 99391 through 99397: Annual Comprehensive Preventive Visit
• 99381 through 99387: Initial Comprehensive Visit
• G0402 – Welcome to Medicare Exam: Physical examination; face-to-face visit, services limited to new beneficiaries during the first 12 months of Medicare enrollment.
  • The Welcome to Medicare Exam can only be performed ONCE per lifetime. This is different from the Annual Exam codes.
• G0438 – Initial Annual Exam: Includes a personalized prevention plan of service (PPS), initial visit.
  • The Initial Annual Exam can only be performed ONCE per lifetime. This code is different from the Welcome to Medicare Exam.
• G0439 – Annual Exam: Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit.

The HEDIS Pocket Guide (PDF) can assist you with code requirements for the various HEDIS measures as well as lookback periods, according to the latest HEDIS Technical Specifications.

Blue Cross NC will issue incentive payments in the summer of 2026 to providers who close the above-listed care gaps for dates of service between 1/1/2025 and 12/31/2025.

If you have questions or need additional information, please email Blue Cross NC’s Quality Management team.

Thank you for being a valued partner of Blue Cross NC.