Risk Adjustment User Group Session 2006/2007 Monthly Risk Adjustment User Group Session A training initiative presented by APRIL 2007 1

Welcome to the April User Group Introduction Payment Process Data Validation Operations Update Training Update Questions and Answers Closing 2

INTRODUCTION 3

Introduction User Group Process All attendees must pre-register. Panel will answer questions during the Q&A portion of the session. Session will last for one hour. Q&A document and session notes will be available within 2 weeks after the session. Session slides will be available by the Tuesday before the session. 4

PAYMENT PROCESS 5

Payment Process Definition of Sweep Date 2004 and 2005 Reconciliation Model Output Reports 2005 ESRD Reconciliation 6

DATA VALIDATION 7

Data Validation Calendar Year 2005 Calendar Year 2004 Medical record reviews are in progress Provider credential issues identified Reviewers are unable to determine credentials for providers that signed records for face-to-face visits CMS to request that specific organizations submit additional information to confirm provider credentials for risk adjustment Calendar Year 2004 QA process is still in progress June: anticipate communicating results to selected MA organizations 8

Data Validation Recommendations for MA Organizations: Conduct ongoing internal medical record reviews Do not wait until your MA organization is selected for validation before implementing an internal data validation process Medical records do not have to include the actual ICD-9-CM codes; rather they must include all appropriate clinical signs and / or narratives that support the ICD-9-CM code 9

OPERATIONS UPDATE 10

502 Errors & 5% Benchmark Calculation 502 Errors (duplicate DX cluster) are generated on a diagnosis cluster. A duplicate submission occurs when a diagnosis cluster is submitted with the exact attributes that are already stored in the RAPS database. These attributes include the HICN, from date of service, through date of service, provider type and ICD-9-CM code. Up to 10 diagnosis clusters may be included in one record. Tips regarding 502 errors are available at http://www.csscoperations.com/new/references/cmsinstructions.html 11

502 Errors & 5% Benchmark Calculation The 5% Benchmark used for the 502 Error Rate is based on the total number of 502 errors received per contract number per file submitted. CMS will conduct weekly reviews of 502 errors received, by contract, from the daily file submissions. CMS’ weekly review will determine which plans will receive compliance letters. 12

File Size Limitation Large files require considerable data processing time and resources. In order to reduce excessive processing time and resources, CMS will soon institute the following per submitter per day maximum file size limits:  Connect: Direct – 1,000,000 CCC Records FTP – 1,000,000 CCC Records GENTRAN - 1,000,000 CCC Records Secure Website - 1,000,000 CCC Records This limit applies regardless of the number of files submitted (i.e., a submitter could submit one file with 1M CCC records or multiple files as long as their total does not exceed 1M CCC records per day). 13

TRAINING UPDATE 14

2007 Regional Training Schedule* Training Update 2007 Regional Training Schedule* June 18 – 22, 2007 Chicago, IL June 25 – 27, 2007 Baltimore, MD August 7 – 9, 2007 Las Vegas, NV *Register online at www.medicaretraining.net 15

QUESTIONS AND ANSWERS 16

CLOSING 17

Resources Sean Creighton (Director, Division Risk Adjustment Opertations) sean.creighton@cms.hhs.gov Henry Thomas (Training, Project Officer) henry.thomas@cms.hhs.gov Lateefah Hughes (Data Validation, Team Lead) lateefah.hughes@cms.hhs.gov Louis Johnson (FERAS, Risk Adjustment Coordination) louis.johnson@cms.hhs.gov Chanda McNeal (Payment Issues) chanda.mcneal@cms.hhs.gov LTC www.Medicaretraining.net CSSC www.csscoperations.com 18