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Risk Adjustment User Group

This user group session covers topics related to risk adjustment, including payment process, data validation, and operations updates. Attendees are encouraged to pre-register and submit questions beforehand.

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Risk Adjustment User Group

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  1. Risk Adjustment User Group March 2010

  2. Welcome to the MarchUser Group • Introduction • Payment Process • Data Validation • Operations Update • Questions and Answers • Closing

  3. Introduction INTRODUCTION

  4. INTRODUCTION 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

  5. INTRODUCTION • The 2010 monthly Risk Adjustment User Group dates are posted on the CSSC Operations website. www.csscoperations.com/new/usergroup/usergroupinfo.html • Please continue to review the website for updates to this information.

  6. INTRODUCTION 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: • Analyst@askriskadjustment.com for Payment Operations • Mary.guy@cms.hhs.gov for Data Validation

  7. Payment Process PAYMENT PROCESS

  8. PAYMENT PROCESS • Post transition • 100% resolved in December 2009 • 81% resolved in January 2010 • 73% resolved in February 2010

  9. PAYMENT PROCESS Question – Will CMS be eliminating the use of Evaluation and Management Consultation CPT codes for Medicare Providers?

  10. Data Validation DATA VALIDATION

  11. DATA VALIDATION CY 2007 • Pilot RADV (notified June 20, 2008) • Deadline for submission of corrective medical records and attestations was Sept. 16, 2009. • Medical Record Receipt Reports distributed in January.

  12. DATA VALIDATION • CY 2007 • Targeted RADV - Important Dates * Submission Deadline is 11:59 p.m. Eastern

  13. DATA VALIDATION CY 2008 • National RADV • Deadline for submission of medical records (medical records, coversheets, and attestations) is March 12, 2010. • Plans may submit medical records via VPN, electronic media (e.g., USB, CD, DVD), fax, or hardcopy.

  14. DATA VALIDATION CY 2007 Targeted & CY 2008 National RADV • Tips • CMS-generated attestation • Will only be accepted for physician/outpatient medical records. • Will be accepted if filled out completely as directed. • Should accompany the related record. • Do not alter or edit the CMS-generated attestation. • May provide the treating physician with: • A sample completed attestation; and • A cover note identifying the date of service requiring attestation. • Plan-generated attestations will not be accepted.

  15. DATA VALIDATION CY 2007 Targeted & CY 2008 National • Tips • Requests for medical records—ensure that: • Providers receive all information needed to comply; and • Your complete request is received by the intended recipient—CMS contacted by multiple providers who receive incomplete medical record requests and are unable to determine— • MA organization • Patient information • Specific date(s) of service required

  16. DATA VALIDATION • General Reminder--Observe CMS Requirements to Submit Documentation • MA organizations must ensure confidentiality of beneficiary information when sending protected health information (PHI) and/or personal identifiable information (PII) contained in medical records, attestations, and coversheets.

  17. DATA VALIDATION • General Reminder (cont’d) • Do not submit any medical records via email. This may compromise PHI and/or PII and will be reported to the CMS Security Division as described in Security and Privacy Reminders and Clarification of Reporting Procedures (12/16/2008 CPC memorandum, available on the CMS Health Plan Management System website). • All submitted medical records must comply with the medical record requirements set forth in the Instructions Packet.

  18. Operations Updates OPERATIONS UPDATES

  19. OPERATIONS Frequently Asked Question Q: Does the file size limitation of 1 million records per day also apply to vendors? A: The file size requirement applies to all submitters, including vendors. CMS is requesting files submitted for risk adjustment are limited to 1 million CCC (detail) records per day per submitter.

  20. Technical Assistance updates TECHNICAL ASSISTANCE UPDATES

  21. Questions & Answers QUESTIONS & ANSWERS

  22. closing CLOSING

  23. RESOURCES • Sean Creighton (Director, Division of Risk Adjustment & Payment Policy) Sean.Creighton@cms.hhs.gov • Henry Thomas (Training, Project Officer) Henry.Thomas@cms.hhs.gov • Louis Johnson (FERAS,GTL) Louis.Johnson@cms.hhs.gov • Chanda.McNeal (RAS Payment) Chanda.mcneal@cms.hhs.gov • Payment Research analyst@askriskadjustment.com • Jennifer Harlow (RADV) Jennifer.Harlow@cms.hhs.gov • Lateefah Hughes (RADV) Lateefah.Hughes@cms.hhs.gov • Mary Guy (RADV) mary.guy@cms.hhs.gov • LTC - www.tarsc.info • CSSC - www.csscoperations.com

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