1. Risk Adjustment Process FAQs
Risk Adjustment Data Process
Q: Are health care prepayment plans under Section 1833 required to submit RAPS data?
A: No. CMS is considering this in the future, however.
Q: Does the file size limitation of 1 million records per day also apply to vendors?
A: The file size requirement applies to all submitters, including vendors. CMS is requesting files submitted for risk adjustment are limited to 1 million CCC (detail) records per day per submitter. This request is voluntary and is for all Connect: Direct, FTP, GENTRAN, and Secure Website submitters. CMS is making this request to reduce processing time that large files require.
If submitters are going to submit files with greater than 1 million records in a day, CMS requests that the plan inform the Customer Service and Support Center (CSSC) in advance so that the CMS data center can be notified to expect the large file, and if necessary schedule the submission. We may request that you schedule the submission on another day or days.
Q: What are the dates of service that plans can submit diagnoses for radiology?
A: Plans can submit diagnoses for radiology for dates of service between 2003 and 2004. The Advance Payment Notice for 2006 indicates the correct dates of service.
Q: What should a plan do if they submitted data for radiology services for dates of service in 2005?
A: CMS will not audit for compliance to enforce the elimination of diagnosis radiology for data collection year 2005.
Q: Are 502 errors measured by file or by total submission?
A: The 502 error benchmark is based on file submission. The error rate (percent) is calculated by dividing the number of 502 errors by the number of diagnoses submitted.
Q: To avoid submitting duplicate diagnosis clusters, plans may consider submitting one cluster per record. Is there a rule against plans submitting a hospital inpatient other (02 provider type) diagnosis cluster without an inpatient primary (01 provider type) diagnosis cluster?
A: While there are no submission requirements limiting plans to only submitting 02 provider type diagnosis clusters with an 01 diagnosis cluster, there may be implications regarding validation and reporting.
Q: Does the 5% benchmark for duplicates refer to duplicate clusters or records that contain duplicate clusters?
A: 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.
Q: When is the benchmark for duplicate diagnosis clusters going into effect?
A: CMS notified plans, via HPMS, that the benchmark for duplicate diagnosis clusters will be October 1, 2006. CMS will now start monitoring with the purpose of sending out compliance letters to plans with error rates that exceed the benchmark. Please note that an MA organization’s failure to comply with this requirement may result in suspension of its data submission privileges and impact its risk adjusted payments.
Q: Is the monitoring of the duplicates per file?
A: CMS put the requirement per file because that is the easiest way to measure the benchmark and will look at the overall metrics. If, for example, 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 it was 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. CMS will look at the files weekly for the volume and the number of duplicates. If, on the other hand, a plan submitted a file with 2 million records and a million of them were duplicates, CMS would send a compliance letter.