What a care gap is
A care gap exists when an eligible patient is missing a recommended service within the measurement period. The definition usually comes from a quality measure, such as a HEDIS measure for colorectal cancer screening or blood pressure control. Each measure spells out who is eligible, what counts as done, and the deadline.
Health plans and ACOs send practices gap lists, often as spreadsheets or portal exports, showing which attributed patients have open gaps. Closing a gap means the service is completed and documented, or a valid exclusion is recorded. Claims lag, so lists often show gaps that were already closed elsewhere.
Most of the work is outreach and scheduling. Rivvi is a HIPAA-compliant AI workspace. Staff upload a payer gap list, ask which patients to call first, and run the outreach by phone or text. When the schedule lives in the EHR, Rivvi warm-transfers the patient to staff or creates a task, and logs every outcome.