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2006/2007 Monthly. Risk Adjustment User Group Session. A training initiative presented by. MARCH 2007. Welcome to the March User Group. Introduction Payment Process Data Validation Operations Update Training Update Questions and Answers Closing. INTRODUCTION. Introduction.
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2006/2007 Monthly Risk Adjustment User Group Session A training initiative presented by MARCH 2007
Welcome to the March User Group • Introduction • Payment Process • Data Validation • Operations Update • Training Update • Questions and Answers • Closing
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.
Payment Process • Mid-Year Data Submission Deadline Deadline (3/2/07) Dates of Service (1/1/06 – 12/31/06) • Duplicate Data Submission Update File size limits • Sweep Date - February 16, 2007 Dates of Service (1/1/05 – 12/31/05)
Data Validation • Calendar Year 2005 • Medical record reviews are in progress • Calendar Year 2004 • QA process is still in progress • June: anticipate communicating results to selected MA organizations
5% Benchmark 502 Duplicate Errors CMS has begun monitoring plans with error rates that exceed the benchmark. CMS defines a duplicate submission as a diagnosis cluster with the same attributes that are already stored in the RAPS database. Each duplicate cluster that receives a 502-error code counts toward the 5% benchmark. For example, if a record included 10 diagnosis clusters and each one was a duplicate of another cluster, there would be 10 502-error codes and all 10 would count towards the 5% benchmark.
5% Benchmark 502 Duplicate Errors (cont’d.) CMS will look at the overall metrics per file, as this is the easiest way to measure the benchmark. CMS will look at files on a weekly basis to determine volume and the number of duplicates the plan receives to determine if a compliance letter needs to be sent. Examples follow:
5% Benchmark 502Duplicate Errors (cont’d.) If a plan submitted one file in a given week with two records and they were duplicates, the plan would have a 100% duplicate rate, but with only two records. Afterwards, the plan submitted additional files that had 10,000 records and a 2% duplicate rate. In this case, CMS would not send this plan a compliance letter.
5% Benchmark 502 Duplicate Errors (cont’d.) If, on the other hand, a plan submitted a file with 2 million records and 1 million of them were duplicates, CMS would send a compliance letter.
Frequently Asked Question Use of Third Party Submitters: • If the submitter will be an entity other than a Medicare Advantage plan, the third party submitter must complete the Submitter ID Application form and the EDI Agreement. • The Plan must also complete the Submitter Application and EDI Agreement. The EDI Agreement must be completed, signed and returned for each Plan number submitting data.
Frequently Asked Question • A letter from the Plan, authorizing the third party to submit on their behalf, must accompany the EDI Agreement. • Regardless of who submits the data, CMS holds the Medicare Advantage organization accountable for the content of the submission. • Please note: In the event that CSSC does not have a letter of authorization on file from the plan (on company letterhead), the third party submitter will not be able to submit RAPS data for the plan.
Common RAPS Errors • 408 – Service From Date is not within MA organization’s enrollment period – ensure member is enrolled in your plan for the DOS that you are submitting. • 409 –Service Through Date is not within MA organization’s enrollment period - ensure member is enrolled in your plan through the DOS that you are submitting.
Common RAPS Errors • 501 – Valid diagnosis but not relevant diagnosis for Risk Adjustment during this service period.
Training Update 2007 Monthly Training Schedule Now Registering • Enrollment and Payment Training May 29, 2007 • Risk Adjustment Training May 30, 2007
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 *Registration Scheduled for March 19, 2007 www.medicaretraining.net
Resources • Sean Creighton (Director) 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 • Thomas Kornfield (Risk Adjustment Model) thomas.kornfield@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
