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, 2026 to December 31, 2026.

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

Tiers:

Incentive payments are attributed to eligible providers at the TIN level for achieving the required targeted tier for each specific HEDIS® measure. Specialty providers of targeted services for behavioral health and perinatal care can earn flat-rate incentives based on referral-based care for behavioral health and/or perinatal care services. For most tiered measures, incentives can increase as performance improves at up to three levels.

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 2026 (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 year 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, GSD 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.