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(Rev. 118; Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010); Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010))
<aside> 💡 CMS requires Medicare Advantage plans to collect hospital inpatient, hospital outpatient, and physician risk adjustment data and submit the data to CMS at least quarterly for calculation of the risk score for use in the payment calculation and payment reconciliation. Each quarterly submission should represent approximately one-fourth of the data a plan submits during a data collection year.
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Once plans have collected the data and verified the data came from an acceptable data source, the plans submit the data using the Risk Adjustment Processing System (RAPS) format and provide the five required data elements in the cluster. Table 12 lists the five required elements and a description for each.
| Required Data Element | Description |
|---|---|
| Health Insurance Claim (HIC) Number | Beneficiary identification number issued by the Railroad Retirement Board (RRB) or the Social Security Administration (SSA). |
| Diagnosis code | International Classification of Diseases (ICD) codes are used to describe the clinical reason for a patient’s treatment. |
| Service from date | The dates of service define when a beneficiary received medical treatment from a physician or medical facility. For outpatient and physician services, the From Date and Through Date may be identical. For inpatient services, these dates are usually different from each other, and reflect the dates of admission to and discharge from a facility. |
| Service through date | |
| Provider type | The types of providers, for the purpose of risk adjustment, MA organizations must collect data from are: |
| • Hospital Inpatient facilities | |
| • Hospital outpatient facilities | |
| • Physicians |
Plans submit the five data elements in the RAPS format (or the Direct Data Entry, an online data entry application for the RAPS format) to the Front End Risk Adjustment System (FERAS) for initial edit checks. FERAS transmits files successfully passing the initial edit checks to RAPS for detailed editing and processing.
The FERAS and RAPS systems generate Transaction Reports describing the status of the transaction and any errors that occurred during processing. RAPS also provides Management Reports that identify the disposition of the submitted data so plans can verify their data and project their payment.
Finalized diagnosis clusters are stored in the RAPS database and used for calculation of risk scores. The Risk Adjustment System (RAS) extracts the diagnostic data from the RAPS database to calculate risk scores by executing the CMS-HCC payment model.
RAS sends the risk scores to the Medicare Advantage Prescription Drug System (MARx) for use in calculation of plan payments and payment reconciliation.
Figure 2 illustrates the risk adjustment collection, submission, and payment process.