1. Risk Adjustment User Group
January 2009

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 Final Reconciliation Submission Due Date
Due Date: January
Dates of Service:1/1/07 -12/31/07

8. PAYMENT PROCESS
Payment Research Updates

9. DATA VALIDATION

10. DATA VALIDATION Calendar Year 2007
January 2006 through December 2006 dates of service will be reviewed
Samples include beneficiaries with at least one CMS-HCC and were enrolled in the selected contract from January 2006 through January 2007
RADV Samples
Contract-specific
Pilot
Targeted
Random
National

11. 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)
Instructions Packet to be distributed soon
Selected plans to be notified via when packet is released
Plans will have 12 weeks to submit medical records
Random RADV
To be implemented soon

12. DATA VALIDATION Calendar Year 2007 (cont’d)
National RADV (notified on Dec. 3, 2008)
Instructions were distributed by traceable carrier to Primary Contact on Dec. 10, 2008
Teleconference for plans in this sample held on Dec. 17, 2008
Plans may submit medical records via virtual private network (VPN), electronic media (e.g., USB, CD), fax, or hardcopy
Deadline for medical record submission is Feb. 27, 2009

13. DATA VALIDATION Calendar Year 2007 (cont’d) IMPORTANT REMINDERS
CMS and its contractor have received medical records directly from providers rather than from the MA organization
Records should only be submitted through the MA organization, because it is responsible for selecting “the one best medical record”

14. DATA VALIDATION MA organizations should
Direct providers to send all medical records to the requesting MA organization
Select and submit “the one best medical record” to the Medical Records Coordinator at Healthcare Management Solutions (HMS), CMS’ RADV Contractor

15. DATA VALIDATION Calendar Year 2007 IMPORTANT REMINDERS (cont’d)
MA organizations are encouraged to follow up with providers
Providers have contacted CMS for various reasons, such as an incomplete fax or other request for records being received from an MA organization
When possible, CMS directs the provider to the MA organization’s primary contact
MA organizations should not highlight material in the medical record to draw attention to it; upon contractor scanning, it becomes illegible text

16. OPERATIONS UPDATES

17. OPERATIONS: New Plan requirements
A CMS Risk Adjustment Data EDI Agreement must be completed by each Plan and on file with CSSC, prior to submitting Risk Adjustment Data. The agreement must be signed by an authorized agent of the organization and returned to CSSC Operations.
Use of Third Party Submitters: If the submitter will be an entity other than an MA organization, the Submitter must complete the Submitter ID Application form and the MA organization must complete the EDI Agreement. This EDI Agreement must be completed, signed and returned for each plan number submitting data. Regardless who submits the data, CMS holds the MA organization accountable for the content of the submission. A letter authorizing the third party to submit on your behalf is also required.

18. OPERATIONS: New Plan requirements
A Submitter ID (SHnnnn) will be assigned to you by the CSSC and will remain effective for ongoing submission of risk adjustment data. This is the unique ID assigned to the plan or entity that will submit data and retrieve reports.

19. TECHNICAL ASSISTANCE
UPDATES

20. TECHNICAL ASSISTANCE UPDATES
Next User Group Meeting
February 18, 2009

21. QUESTIONS & ANSWERS

22. CLOSING

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