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

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

3. INTRODUCTION 3

4. 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

5. PAYMENT PROCESS 5

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

7. DATA VALIDATION 7

8. 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

9. 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

10. OPERATIONS UPDATE 10

11. 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 11

12. 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

13. 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

14. TRAINING UPDATE 14

15. 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 15

16. QUESTIONS AND ANSWERS 16

17. CLOSING 17

18. Resources
Sean Creighton (Director, Division Risk Adjustment Opertations)
Henry Thomas (Training, Project Officer)
Lateefah Hughes (Data Validation, Team Lead)
Louis Johnson (FERAS, Risk Adjustment Coordination)
Chanda McNeal (Payment Issues)
LTC
CSSC 18