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Risk Adjustment User Group

Risk Adjustment User Group. January 2009. Welcome to the November User Group. Introduction Payment Process Data Validation Operations Update Questions and Answers Closing. INTRODUCTION. INTRODUCTION. User Group Process. All attendees must pre-register

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Risk Adjustment User Group

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  1. Risk Adjustment User Group January 2009

  2. Welcome to the NovemberUser 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. www.csscoperations.com/new/usergroup/usergroupinfo.html

  6. PAYMENT PROCESS

  7. PAYMENT PROCESS Final Reconciliation Submission Due Date • Due Date: January 31 2009 • 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 email 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) sean.creighton@cms.hhs.gov • Henry Thomas (Training, Project Officer) henry.thomas@cms.hhs.gov • Louis Johnson (FERAS,GTL) louis.johnson@cms.hhs.gov • Lateefah Hughes (RADV) lateefah.hughes@cms.hhs.gov • LTC www.tarsc.info • CSSC www.csscoperations.com

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