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120 – Operations

120.2 – Submission and Flow of Risk Adjustment Data

• [ ] 120.2.1 – Data Exchange Requirements
• [ ] 120.2.2 – Format
• [ ] 120.2.3 – Diagnosis Cluster
• [ ] 120.2.4 – Valid Diagnosis Codes
• [ ] 120.2.5 – Tips for Reducing Duplicate Diagnosis Cluster Errors
• [ ] 120.2.6 – Health Insurance Portability and Accountability Act (HIPAA)
• [ ] 120.2.7 – Submission Timeline
• [ ] 120.2.8 – Status Reports of Risk Adjustment Submissions

120.2 - Submission and Flow of Risk Adjustment Data

(Rev. 114, Issued; 06-07-13, Effective: 06- 07-13, Implementation: 06-07-13)

The following outlines the flow of risk adjustment data:

• Hospital/Physician submits data to MA organization using standard claims formats, or through review of medical records.
• The MA organization submits required data at least quarterly to FERAS via Direct Data Entry (DDE) or RAPS format.
• FERAS checks the file-level data, batch-level data, and first and last detail records on each Batch Record within the file.
• If any data are rejected, the rejections are reported on the FERAS Response Report.
• After passing the FERAS checks, the file is submitted to RAPS where detail editing is performed and applicable reports are generated.
• The RAPS Return File contains the entire submitted transaction and identifies errors.
• The RAPS Transaction Error Report communicates errors found in CCC records during processing.
• The RAPS Transaction Summary Report summarizes the disposition of the diagnosis clusters.
• The Duplicate Diagnosis Cluster Report identifies diagnosis clusters with the 502error message. Duplicate clusters are accepted but not stored.
• The RAPS Monthly Plan Activity Report and Cumulative Plan Activity Report provides a summary of the status of submissions by submitter ID and plan number.
• Distributed monthly and quarterly, the Error Frequency Report provides an overview of all errors associated with files submitted in test and productions.