1. Risk Adjustment User Group
December 2008

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

3. 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 2008 monthly Risk Adjustment User Group Q & A and Notes documents are posted at the CSSC Operations website.
Please continue to review the website for updates to this information.

6. PAYMENT PROCESS

7. PAYMENT PROCESS Duplicate Diagnosis Cluster Submissions I. Definition:
A duplicate diagnosis cluster is one with the same attributes:
-HIC Number
-Provider Type
-From Date
-Through Date
-Diagnosis Code
II. Cluster with the same attributes will receive 502 Error Message, which is:
(“Diagnosis clusters was accepted but not stored. A diagnosis cluster with the same attributes is already stored in the RAPS database”)

8. PAYMENT PROCESS Submission Requirements Note:
Must report data at least once per enrollee in the data collection period;
Must submit data at least quarterly;
Submit quarterly submission that represent approximately one-fourth of the data that will be submitted during the data collection period.
Note:
In order to detect data collection and submissions problems early, CMS recommends that MA organizations submit more frequently than quarterly.

9. PAYMENT PROCESS December, 2008 Payment Adjustments SHMO
Other Adjustments

10. DATA VALIDATION

11. DATA VALIDATION Calendar Year 2007
January 2006 through December 2006 dates of service will be reviewed
Enrollee samples will include beneficiaries who were in the selected contract from January 2006 through January 2007
RADV Samples
Contract-specific
Pilot
Targeted
Random
National

12. DATA VALIDATION Calendar Year 2007 (cont’d)
Pilot RADV (notified June 20, 2008)
IVC review completed
SVC review is in progress
Targeted RADV (notified Nov. 10, 2008)
CMS’ contractor, HMS, will distribute Instructions Packet shortly
Plans will have 12 weeks to submit medical records
Random RADV
To be implemented after release of the Instructions Packet

13. DATA VALIDATION Calendar Year 2007 (cont’d)
National RADV (notified on Dec. 3, 2008)
Under the Improper Payments and Information Act (IPIA), CMS must annually measure and report the Part C payment error rate
CMS recently completed its first analysis, reporting a 10.6 percent Part C national error rate for payment year 2006
CMS will report a Part C payment error rate for 2007 at the end of fiscal year 2009
Request plans’ best efforts to assist in correcting and improving payment error

14. DATA VALIDATION Calendar Year 2007 (cont’d) National RADV (cont’d)
Contact Information Sheet was updated to include mailing address for Primary Contact
Instructions were distributed by traceable carrier to Primary Contact on Dec. 10, 2008
Teleconference for plans in this sample is scheduled for Dec. 17, 2008 (2-4 p.m., Eastern)
Plans may submit medical records via VPN, electronic media (e.g., USB, CD), fax, or hardcopy
Deadline for medical record submission is Feb. 27, 2009

15. OPERATIONS UPDATES

16. OPERATIONS CSSC Operations Holiday Closings: - Thursday, December 25th
- Wednesday, December 24th
- Thursday, December 25th
- Thursday, January 1st
Please note: the Front-End Risk Adjustment System (FERAS) will be available during this time for RAPS submissions.

17. CSSC Operations Reminder
Submission Deadline
The final submission deadline for claims with dates of service 01/01/07 through 12/31/07 is 01/31/09.
Submit all outstanding claims.
Research errors, make possible corrections, and resubmit corrected data.

18. TECHNICAL ASSISTANCE
UPDATES

19. TECHNICAL ASSISTANCE UPDATES
Next User Group Meeting
January 21, 2009

20. QUESTIONS & ANSWERS

21. CLOSING

22. RESOURCES
Sean Creighton (Director, Division Risk Adjustment Operations)
Henry Thomas (Training, Project Officer)
Louis Johnson (FERAS,GTL)
Lateefah Hughes (RADV)
LTC
CSSC