U.S. Department of Health and Human Services (HHS) requires risk adjustment for commercial small group and individual benefit plans. Similar to the CMS risk adjustment program for MA benefit plans, HHS uses Hierarchical Condition Categories (HCCs) to calculate an annual patient risk score that represents the specific patient’s disease burden. Every year, CMS and HHS require information about the demographic and health of our members. Diagnoses do not carry forward to the following year and must be assessed and reported every year.
The risk adjustment data you give us, including clinical documentation and diagnosis codes, must be accurate and complete. It is critical for you to refer to the ICD-10-CM coding guide to code claims accurately. To comply with risk adjustment guidelines, specific ICD-10-CM codes are required.
We offer an alternate method of reporting CMS risk adjustment data in addition to the normal claim/encounter submission process. All encounter submissions are required to process 837 Claim Encounter in a HIPAA 5010-compliant format. To supplement a previously submitted 837 Claim/Encounter, you may submit an 837 replacement claim/encounter or send additional diagnosis data related to the previously submitted 837 through the Optum ASM Operations FTP process. If you choose to submit by ASM, you will first need to contact the Optum ASM Operations team at cas_ops@ingenix.com to start the onboarding process.