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Risk Adjustment User Group. July 2010. Welcome to the July User Group. Introduction Payment Process Data Validation Operations Update Questions and Answers Closing. INTRODUCTION. INTRODUCTION. User Group Process. All attendees must pre-register It is only necessary to register once

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Welcome to the july user group
Welcome to the JulyUser Group

  • Introduction

  • Payment Process

  • Data Validation

  • Operations Update

  • Questions and Answers

  • Closing


User Group Process

  • All attendees must pre-register

  • It is only necessary to register once

  • Retain unique PIN for all sessions

  • Session will last for one hour

  • Session slides will be available by the Tuesday before the session

  • Panel will answer questions during the Q&A portion of the session


  • The 2010 monthly Risk Adjustment User Group dates are posted on the CSSC Operations website.

  • Please continue to review the website for updates to this information.



Q&A Resources

  • User Group Calls cover 2 risk adjustment areas: Payment Operations and Data Validation.

  • On the calls, subject matter experts are available from each area to answer questions.

  • To submit questions outside of User Group:

Payment process

  • Response Rate:

    • 100% resolved in April 2010

    • 90% resolved in May 2010

    • 95% resolved in June 2010

Payment process1

  • Highlights:

    • Update on implementation of ICD-10 diagnosis codes;

    • The final 2009 reconciliation update is scheduled for the August payments;

    • Plans should see the appropriate adjustments for part c and d under:

      • ARC 25 FOR Part C

      • ARC 37 FOR Part D

    • The rerun for Payment Years 2006, 2007, 2008 is scheduled for the August payments

Payment process2

Question –

Please explain what information is provided on the HCC Model Output Report (MOR).  Do the reports reflect only the diagnoses submitted during the prior month or are they cumulative?

Data validation

  • CY 2007 Targeted Sample

  • CY 2008 National Sample

  • CY 2008 Contract – Level Sample

Data validation1

  • CY 2007 Targeted Sample

    • Intake Technical Assistance Report: will soon be released

      • The Intake TA Report will identify inconsistencies in date of service and/or provider type as well as other inconsistencies (e.g., obscured text).

      • CMS will hold a teleconference to coincide with the distribution of Intake TA Reports

        • CMS will discuss:

          • Format of the report

          • Time period and requirements for plan response

          • Importance of reviewing and reporting any issues to the IMRRC

        • Date, time, and dial-in information will be forthcoming.

      • Intake TA Reports and teleconference information will be sent by the IMRRC (Healthcare Management Solutions) via email to CY 2007 Targeted Sample plan-designated contacts.

      • A Medical Record Receipt Report will also be included with the Intake TA Report.

Data validation2

  • CY 2007 Targeted Sample Contact


    • This request was sent to previously-confirmed contacts and the

      CEO for each plan in the sample. The IMRRC has received

      responses from all plans. Thank you for your prompt response

      to this request.

    • Adding or changing contact information for the CY 2007

      Targeted Sample does not update your plan’s information

      in the HPMS system.

Data validation3

  • CY 2008 National Sample

    Under the Improper Payments Information Act (IPIA), CMS must annually measure and report the Part C payment error rate to OMB

    A key component of the Part C payment error rate is payment error identified under RADV

    Medical record review has been completed, CMS is currently analyzing results

Data validation4

CY 2008 Contract-Level Sample

  • MA organizations (MAOs) selected for this sample will be notified

  • Notification will be sent to MAO CEO and MCO

  • Training will be provided—

    • In-person at CMS, and

    • Via Webinar

Data validation5

  • RADV Mailbox – [email protected]

    • MAOs may submit RADV questions to this mailbox

    • Questions will be reviewed by the RADV team and answered via this mailbox

    • Several questions have been received, CMS is working on issuing individual responses


  • Reasons to Delete Diagnosis Cluster

  • Diagnosis cluster submitted erroneously (e.g., data from an interim bill was submitted for hospital inpatient, type of bill 112 / 113. When TOB 114 has been received, correct previously submitted claim with the correct diagnosis clusters.

  • Incorrect HIC number used for submission on a beneficiary’s claims.

  • An error in a diagnosis cluster field (i.e., “Provider Type,” “Dates of Service,” “Diagnosis Code”).


  • Method 1 for Deleting Clusters

  • Submit RAPS format using normal submission process with appropriate HIC number included.

  • Enter information in the diagnosis cluster fields (9.0, 9.1, 9.2, 9.4, 9.5) exactly as it appeared in the original submission.

  • In field 9.3 enter a “D” for delete.

  • Enter the appropriate information in all other records to ensure the submission file is complete.

  • Transmit the file to FERAS. (See www.csscoperations.com for details.)


Method 2 for Deleting Clusters:

  • Create a file using the Direct Data Entry (DDE) screens available through FERAS at Palmetto

  • Enter information exactly as it appeared in the original submission.

  • In the DDE “CCC” record screen, hit the down arrow key and select “D.”

  • Proceed with entering all appropriate information.

    5. Upload the file created in DDE to FERAS at Palmetto.