2013 NATIONAL TECHNICAL ASSISTANCE. Risk Adjustment 101 July 22, 2013

Transcription

1 2013 AIAL HIAL AIA isk Adjustment 101 July 22, 2013

2 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 2

3 Purpose Provide an introduction and overview of the risk adjustment process Address: onnectivity/testing Key data elements for submission isk Adjustment Processing ystem (AP) eports Introduce terminology, online resources, and contacts for risk adjustment I D U I 3

4 isk Adjustment 101 ools he materials provided in this training include: Participant Guide Provides additional material to support the session Designed as a reference for future use Presentation lides Highlight the information covered during the session 4 I D U I

5 Questions & Answers I D U I Your Questions are Important! hank you!

6 ontact Information For questions regarding logistics or registration by phone call During the webinar all Press 1 I D U I After the webinar: riskadjustment@cms.hhs.gov 6

7 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 7

8 verview Learning bjectives Learn the purpose and history of risk adjustment Define important risk adjustment terms and acronyms V V I W

9 isk Adjustment Definition he method used to adjust bidding and payments based on the health status and demographic characteristics of an enrollees V V I W 9

10 isk Adjustment Data Flow Physician or Facility MA Medicare Advantage rganization FA Front-nd isk Adjustment ystem AP isk Adjustment Processing ystem A isk Adjustment ystem MAx Medicare Advantage Prescription Drug ystem V V I W 10

11 isk Adjustment History Balanced Budget Act (BBA) 1997 Medicare Prescription Drug, Improvement, and Modernization Act (MMA) V V I W Benefits Improvement Act (BIPA) 11

12 isk Adjustment erms and Acronyms Demographics FA H MAx UI Model un AP A isk Adjustment Model tatus V V I W 12

13 Questions & Answers V V I W Your Questions are Important! hank you!

14 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 14

15 onnectivity Learning bjectives Access the lectronic Data Interchange (DI) Agreement required for plans to participate in risk adjustment Describe connectivity options for plans to submit risk adjustment data Identify testing requirements for connectivity I V I Y MA

16 AP Introduction Letter AP Introduction Letter DI Agreement AP ubmitter Information AP onnect:direct Application 16 I V I Y

17 17 I V I Y

18 DI Agreement AP Introduction Letter DI Agreement AP ubmitter Information AP onnect:direct Application 18 I V I Y

19 19 I V I Y

20 AP ubmitter Information AP Introduction Letter DI Agreement AP ubmitter Information AP onnect:direct Application 20 I V I Y

21 21 I V I Y

22 AP onnect:direct Application AP Introduction Letter DI Agreement AP ubmitter Information AP onnect:direct Application 22 I V I Y

23 23 I V I Y

24 I V I Y

25 onnection ptions onnect:direct Mainframe-to-mainframe File ransfer Protocol (FP) Modem-to-modem Gentran hrough vendor or web interface IB MF IP Internet transmissions 25 I V I Y

26 onnectivity esting Verifies successful flow of data from submitter to FA nsures submitted data is valid and formatted correctly I V I Y 26

27 27 I V I Y

28 onnectivity esting (continued) ontact perations to send data in test format all I V I Y ending Data in est Format 28

29 est Your Knowledge What are the connectivity options? onnect:direct FP Gentran IB MF Which one of these does your plan have? I V I Y hat depends 29

30 est Your Knowledge Who is the main contact for connectivity information and to arrange testing? When do plans submit test data? I V I Y Within three months of their HPM effective date 30

31 Questions & Answers I V I Y Your Questions are Important! hank you! 31

32 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 32

33 Key Data lements Learning bjectives List the five (5) required data elements submitted for risk adjustment, plus the additional data element that will be required beginning with dates of service January 1, 2014 Identify acceptable sources for data collection 33 K Y D A A L M

34 Data lements K Y Data lements: include demographic and disease data are used to calculate a risk score for each beneficiary 34 D A A L M

35 ubmitted Data lements isk Adjustment requires five (5) minimum data elements : HI (Health Insurance laim) umber Provider ype From Date of ervice hrough Date of ervice Diagnosis ode 35 K Y D A A L M

36 HI umber Descriptions K Y HI YP M B pre-1964 B post-1964 DIPI 9-Digit ocial ecurity number alpha suffix A beneficiary B spouse children D divorced spouse, widow, widower alpha-numeric suffix - indicates number of children 1 first child alpha prefix 6-digit random numbers alpha prefix 9-digit ocial ecurity number 36 D A A L M

37 K Y D A A L M

38 Provider ype Hospital Inpatient Hospital utpatient Physician ervices 38 K Y D A A L M

39 Acceptable ources K Y Diagnoses submitted for risk adjustment must result from a face to face encounter with either: an acceptable physician specialty an acceptable facility 39 D A A L M

40 Hospital utpatient xample Q: Does a claim from an outpatient hospital encounter have to be accompanied by a face-to-face physician visit in order to be eligible for risk adjustment? A: he diagnoses submitted to AP must result from a faceto-face encounter with an acceptable physician specialty from an encounter in an acceptable facility. 40 K Y D A A L M

41 Physician Data K Y D A A 41 L M

42 Dates of ervice When a beneficiary received medical treatment from a physician/facility From and through dates may be identical for outpatient/physician services eflect admission and discharge dates for inpatient services 42 K Y D A A L M

43 Diagnosis odes Procedure codes (Ps or HP) not allowed Medical record documentation required AP format ID-9-M through 9/30/14 ID-10-M replacing ID-9-M effective 10/1/ K Y D A A L M

44 ew Field nrollee isk Assessment ode Beginning with dates of service January 1, 2014, MAs are required to populate a new field to identify diagnoses obtained from enrollee risk assessments More information and guidance will be provided on the process for flagging enrollee risk assessments in the isk Adjustment Processing ystem submissions 44 K Y D A A L M

45 est Your Knowledge What five data elements must plans submit for risk adjustment? HI umber Provider ype From & hrough D Diagnosis ode What about the demographic data? It is already in the system 45 K Y D A A L M

46 est Your Knowledge Where do the diagnoses come from? Hospital Inpatient Hospital utpatient Physician ervices an diagnoses from a sports medicine specialist be submitted for risk adjustment? Yes - Beginning with 2011 Dates of ervice 46 K Y D A A L M

47 Questions & Answers K Y D A A Your Questions are Important! hank you! 47 L M

48 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 48

49 AP Learning bjectives Define AP Describe the elements contained within a diagnosis cluster in the AP format Follow the data flow for isk Adjustment Access the AP submission timeline A P 49

50 isk Adjustment Processing ystem (AP) Definition ystem that processes risk adjustment data Data passes through FA before going to AP AP edits all detail records and stores them in AP database HI umber Date of Birth (if submitted) Provider ype From Date hrough Date Diagnosis ode A P 50

51 isk Adjustment Data Flow Hospital/Physician A P MA rganization AP Format or DD Palmetto Front-nd isk Adjustment ystem (FA) FA esponse eports 51

52 isk Adjustment Data Flow (continued) M isk Adjustment Processing ystem (AP) A P M isk Adjustment Processing ystem (AP) Database M isk Adjustment ystem (A) M Medicare Advantage Prescription Drug ystem (MAx) 52

53 AP File Logic AAA ecord A P File Level BBB ecord Batch Level YYY ecord ecord Detail Level Detail Level ZZZ ecord BBB ecord Batch Level YYY ecord ecord Detail Level Detail Level 53

54 AP Format File Layout ecord ypes: AAA File Header BBB Batch Header Detail YYY Batch railer ZZZ File railer A P

55 AP Format Data lements Data lements: HI umber Date of Birth (optional) Provider ype From and hrough Dates of ervice Delete Indicator Diagnosis ode A P 55

56 AP ubmission imeline A P Payment Year Model un Dates of ervice Deadline 2013 Initial 7/1/2011 6/30/2012 9/7/ Mid-year 1/1/ /31/2012 3/1/ Final 1/1/ /31/2012 1/31/

57 AP ubmission Deadline xample Q: We received a diagnosis from a provider 12/2012, but we didn t submit it to AP by the 3/2013 deadline. When will the beneficiary s risk score be adjusted? A P A: ince the plan missed the March deadline, the diagnosis will not be included when the beneficiary s risk score is updated in July In this case, the payment adjustment based on that diagnosis will not be included in the plan s payment until the final reconciliation payment in August of

58 A P 58

59 est Your Knowledge What are the three levels of data in the AP file layout? File-level Batch-level Detail-level A P Which of these data levels contains the key data elements? Key data elements are stored in the (detail) record file 59

60 est Your Knowledge What dates of service are included in the Mid-Year Model un for the 2013 Payment Year? 1/1/12 12/31/12 A P Where can the isk Adjustment ubmission imetable be found? 60

61 Questions & Answers A P Your Questions are Important! hank you! 61

62 IK ADJUM 101 Introduction verview Key Data lements AP onnectivity/esting eports esources 62

63 eports Learning bjectives Discuss the editing logic applied by FA and AP Identify AP transaction and management reports P 63

64 FA and AP dit Logic FA: hecks file and batch level for errors hecks first and last detail record to see if totals agree ejects complete file if errors are found P AP: hecks all detail records for format, integrity, and validity 64

65 FA and AP dit Logic FA format checks integrity checks validity checks on A, B, Y, Z, and first and last records File accepted rrors, file rejected esolve P AP format edits integrity edits validity edits on all records rrors, file rejected esolve 65

66 FA rror odes FA D LVL XPLAAI 100 File-level errors on the AAA or ZZZ records 200 Batch-level errors on the BBB or YYY records 300 and 400 Detail-level errors on the records P 66

67 FA rror xample Q: Why did FA reject an entire file with error message 100? A: he plan submitted a file with AA1 entered in the record type AAA, field 1. his field must be populated with AAA. P 67

68 AP rror odes I XPLAAI AD QU ecord-level errors Diagnosis cluster errors Diagnosis delete errors Informational message P 68

69 AP rror ode xample Q: Why did we receive a AP error code 411? A: rror code 411 refers to the date of death, and plans receive the 411 error code if the date of death is prior to the service through date. P

70 AP diting Process tage 1 Field Validity and Integrity dits tage 2 Field-to-Field dits tage 3 ligibility dits tage 4 Diagnosis ode dits P 70

71 tage 1 Field Validity and Integrity dits hecks format and integrity on all -level fields ntire record is rejected if data in the HI rror ode or Diagnosis ode - Filler fields Dates within a diagnosis cluster must be valid P 71

72 tage 2 Field-to-Field dits From Date hrough Date Hospital outpatient and physician provider types comply with 31-day span rule econciliation data submitted properly P 72

73 tage 3 ligibility dits ross-checks fields against common tables between MBD and MAx hecks HI umber, date of birth, and Medicare entitlement nsures HI umber exists on common tables P 73

74 tage 4 Diagnosis ode dits nsures each diagnosis code is valid hecks each diagnosis code against service dates and sex hecks to see if diagnosis codes are in the risk adjustment model P 74

75 Duplicate ubmissions riginal ubmission Duplicate ubmission HI umber = HI umber From Date of ervice = From Date of ervice hrough Date of ervice = hrough Date of ervice Diagnosis ode = Diagnosis ode Provider ype = Provider ype P 75

76 Duplicate Diagnosis luster xample Q: If a beneficiary goes to a doctor on separate occasions and receives the same diagnosis each time, is that diagnosis code stored each time it is sent to AP? an diagnosis clusters be duplicated over time? P A: ach of the clusters is a unique diagnosis cluster because they have different dates of service. However, it will only be counted once in the risk score calculation. 76

77 FA esponse eport P 77

78 AP ransaction Processing eports AP eturn File flat file layout AP ransaction rror eport AP ransaction ummary eport AP Duplicate Diagnosis luster eport eport layout P 78

79 eturn File xample Q: We received 502 errors for a member, but cannot locate where the diagnosis cluster was sent on the return file. What should we do? P A: Plans may contact the ustomer ervice and upport enter () to assist in locating the files that triggered the duplicate diagnosis cluster. csscoperations@palmettogba.com Duplicate Diagnosis lusters 79

80 AP Management eports AP Monthly Plan Activity eport AP umulative Plan Activity eport AP Monthly rror Frequency eport AP Quarterly rror Frequency eport P 80

81 Analysis of AP Management eports AP MHLY PLA AIVIY P P ead the management reports left to right and then top to bottom. 81

82 Plan onsiderations Is my organization collecting enough data from physicians and providers? Is my organization collecting the correct data from physicians and providers? Are external issues affecting data collection? Are internal processes supporting data submissions? P 82

83 eminders Plans are responsible for downloading and maintaining reports. Plans should correct errors and resubmit as soon as possible. he cut-off time for data submission and completion of file transfer is 5:00 PM, Monday through Friday. P

84 est Your Knowledge What does AP check that FA does not check? All the detail records P What happens if FA finds any errors? he entire file is rejected 84

85 est Your Knowledge Which AP report has a flat file layout? he AP eturn File Why are the reports important? P rror notification Data management Process improvement 85

86 Questions & Answers P Your Questions are Important! hank you! 86

87 IK ADJUM 101 Introduction verview onnectivity/esting Key Data lements AP eports esources 87

88 esources Learning bjectives Know how to access risk adjustment resources Identify appropriate contacts for risk adjustment U 88

89 M Website U 89

90 M Website isk Adjustment Announcements and Documents atebooks and upporting Data Medicare Advantage and Prescription Drug Plans ommunications User Guide (PUG) ID-9-M ID-10-M U 90

91 enters for Disease ontrol and Prevention (D) U ID-9-M: ID-10-M: 91

92 he Health Plan Management ystem (HPM) U UA Access Form available on M website. 92

93 M ustomer ervice and upport enter () U 93

94 Website - isk Adjustment Information nroll to ubmit isk Adjustment Front-nd isk Adjustment ystem (FA) Job Aids eferences isk Adjustment Processing ystem (AP) raining raining (archived) U 94

95 echnical Assistance egistration ervice enter (A) U 95

96 Medicare Advantage & Prescription Drug ystem User Interface MAx UI U 96

97 isk Adjustment Points of ontact M Medicare Plan Payment Group (MPPG) MAPD Helpdesk ustomer ervice and upport enter () echnical Assistance egistration enter (A) ID-10 PM Mailbox isk Adjustment Data Validation (ADV) Mailbox U 97

98 isk Adjustment Acronyms U 98

99 ummary Defined isk Adjustment Introduced the process for connecting to AP Described the data elements submitted for isk Adjustment U xplained the format, flow, and timeline for AP Discussed the data logic, editing processes and reports for the FA and AP Identified key resources and contacts for risk adjustment 99

100 Questions & Answers U Your Questions are Important! hank you! 100

101 valuation Please take a moment to complete the evaluation form for isk Adjustment U Your Feedback is Important! hank you! 101