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What Have I Learned?

• [ ] 10 - General Payment Rules
• [ ] 20 - Methodology for Determining Annual Capitation Rates
• [ ] 30 - Announcement of Annual MA Capitation Rates and Benchmarks and Announcement of Changes in Payment Methodology
• [ ] 40 - Adjustments to Annual MA Capitation Rates
• [ ] 50 - Adjustment to MA Payments Under the CMS-HCC Risk Adjustment Models

Beneficiary Demographic Input File - Contains beneficiary demographic data captured from Common Medicare Environment. The demographic data is used by the Risk Adjustment System (RAS) to calculate a beneficiary’s risk score and to determine payment.

Beneficiary Diagnosis Input File - Contains beneficiary diagnosis data captured from

Risk Adjustment Processing System (RAPS) and National Medicare Utilization Database (NMUD). The diagnosis data is used by the Risk Adjustment System to calculate a beneficiary’s risk score and to determine payment.

Common Medicare Environment (CME) – Tables sourced from the Medicare Beneficiary Database (MBD) and the Enrollment Database (EDB) that provide beneficiary demographic and enrollment data.

Connect: Direct - A type of electronic connection between MA organizations and CMS used to submit risk adjustment data and receive information. This connection involves mainframe-to-mainframe connection with a submission response from FERAS.

Data Collection Period - The 12 month period from which CMS uses diagnoses submitted by MA organizations to calculate a beneficiary’s risk score.

Data Submission - The process in which MA organizations submit required data elements to CMS for risk adjustment purposes.

Data Validation - The process of validating that enrollee diagnosis codes submitted for payment by MA organizations are supported by the medical record documentation.