Home

RESOURCE GUIDE

1. D V R P D V R Email No Email Remote 9 9 VE C Office CC 3 OX 3 CHEI 369 Xx Ec 3 26 36 96 gt E 3 39 36 JE b Subsystems P D V R P D V R PHI CICS 90 9 OMVS 96 0 SEA1 DB2 06 90 TSO H 90 9 01 IDMS 90 0 WYLBUR 6 0 Other M204 06 0 OTHER 6 0 NDM 90 90 9 C 0 9 c Expected Frequency of Use non CMS only Daily Monthly Quarterly Annually 4 Reason for Request 5 Authorization We acknowledge that our Organization is responsible for all resources to be used by the person identified above and that requested accesses are required to perform their duties We understand that any change in employment status or access needs are to be reported immediately via submittal of this form Requesting Official Approving Official CMS RACF Group Administrator for non CMS user only PintNam Signature Signature Signature Date Telephone Number CMS Userid Tite Organization Telephone Number Contract Number Contract Exp Date Telephone Number CMS Userid Desk Location Organization Not to Exceed Date J 2001 PRIVACY ACT ADVISORY STATEMENT Privacy Act of 1974 P L 93 579 The information on side 1 of this form is collected and maintained under the authority of T
2. 46 5 9 1 Record E Prailty s aae 46 5 9 2 Record G Non Community Indicator 46 5 9 3 Record Type Non 70 30 Blend 5 47 5 9 4 MCOS Usmsthie La Matar sso ees icc 47 6 Rules for Storing RAFS 48 6 1 DROP Ru 48 6 2 48 6 3 Final Reconciliation RUN deii oii 48 o c cor E 48 Appendix A GIOSSAEY 49 Appendix B Fu File FOrmat dcosescssvecestvsessacnacsdssevedessccvdsesessectisnsevees 50 Appendix C Translation Between Business Rules and System Developer Criteria 53 Table of Tables Table 1 RA Payment RAPS and Sources cos tao ees de is pear anode nde tna de ne aee 7 Table 2 RAFs Produced HCC and ESRD 13 Table 3 RAS for Each Beneficiary Type eene 14 Table 4 Ratebooks and RAFS 15 Table Anticipated 1 it ieee 16 Table 6 Schedule For Receipt of Software Tables and Ratebooks 42 Table of Figures Figure l RA D cision DISPTAHE 3 e oe
3. 910 UOISIAIG UOISIAIG 16 w J032041U0 Uunndosuo 5 amp 40peJIq UOISIAIG V N 9230 P2lO1d 94 191024 530 peloid 396300 JO peloug JO 0051617 SWD JO J9uMQ SpJ029 M JO W JS S JosiAJedns 910 JD IJO P2lO1d JD IJO P2lO1d 19210 p d JO 403eu1pJ005 N3dSv 40 SISVO SAWN uVOSO J03eUIpJ00 OY JosiAJedns le DIJO bunsenbDeu J9quJe W N Qus JaquJe W d Jopua q UOU 4032043100 493U jep J J9u10 je puas J03 edsu Jo DIYO JoupuJeesau Ue d pebeue J111 3 AJe IpauuJ91U W JS N 93e1S eo o dui3 SWI 195 SIND Jo dAL SUJ93s S Jo3nduio 5 SIND 0 5922 104 104 poainbo y
4. R 33 4 3 14 34 4 3 15 Default for New Transplant 36 4 3 16 New Enrollee Post Transplant 37 4 3 17 Default for New Enrollee Post Transplant Payment 38 4 3 18 Community Post Transplant Payment eene 39 4 3 19 Institutional 1 eese 41 D 42 5 1 CMS HOCOMOUBD uicti de pues bay tni coegi te aera bailed 43 252 ESRD MOUSE irae 43 5 3 Risk Adjustment Family of RateboORs uu eost ee tue inner 43 5 3 1 Risk Adjustment RatebBOOk u eee 44 5 3 2 Phase I Demonstration Risk Ratebook 44 5 3 3 Phase II Demonstration Risk Ratebook eene 44 RA Operational Specification Page 3 of 54 December 3 2003 5 4 ESRD Risk Ratebook sc ee 44 25 59 New Enrollee Base Default ie e eia cu idees 44 5 6 New Enrollee ESRD Default Table eee eee senten enne 45 5 7 Fu File RAS File to G P MMCS iiie i ene 45 5 6 Section Reserved EE RU 45 5 9 2004 Contract Level Payment File ssa a eost aute
5. 6 3 8 4 8 5 9 4 1 Payment Rules Tor All Paythelils 10 4 1 1 Lag Non L g 10 4 1 2 Changes in Plan Enrollment during the Payment Year 10 4 1 3 Changes in Contract during the Payment 10 4 2 Overview of Choosing the RA Payment Type sese 11 4 3 Details for Each Payment 16 4 3 1 16 4 3 2 New Ensrollee Paviment o ass 17 4 3 3 New Plus Frailty 44 19 4 3 4 Default for New 21 4 3 5 Default for New Enrollee Plus Frailty 22 4 3 6 Community Payment 24 4 3 7 Community Plus Frailty Payment esee 26 4 3 8 Institutional Mixed Payment esee 28 4 3 9 Demostaplie eiie atis ead dde 29 4 3 10 PACE WPP ESRD Demographic rye ee ede ena enne ntn 30 4 3 11 New Enrollee Dialysis 31 4 3 12 Default for New Enrollee Dialysis 32 T3135 Dialysis Payment
6. 25 54 78 2 095 2 325 B 101 109 60 X 3 79 81 7 0 PATIENT DOB 9 8 82 89 2115 DMG02 8 0 DOB ERROR CODE X 3 90 92 DIAGNOSIS CLUSTER d occurs 10 times 93 412 9 1 PROVIDER TYPE X 2 93 94 9 2 FROM DATE 9 8 95 102 2135 DTP01 232 9 3 THRU DATE 9 8 103 110 2135 DTP01 233 9 4 DELETE IND X 1 111 CCC 9 5 DIAGNOSIS CODE 5 112 116 2225 101 02 9 6 DC FILLER X 2 117 118 9 7 DIAG CLUSTER ERROR 1 X 3 119 121 9 8 DIAG CLUSTER ERROR 2 X 3 122 124 YYY 1 0 RECORD ID X 3 1 3 20 SEQ NO 9 7 4 10 3 0 5 11 15 2 325 NM101 PR NM109 YYY 4 0 CCC RECORD TOTAL 9 7 16 22 ZZZ 1 0 RECORD ID X 3 1 3 ZZZ 2 0 SUBMITTER ID 6 4 9 1 020 101 41 109 15 06 5502 ZZZ 3 0 FILE ID X 10 10 19 1010 BGNO02 ZZZ 4 0 BBB RECORD TOTAL 9 7 20 26 Aspen Systems Corporation 56 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RAPS NSF 030402 FRONT END RISK ADJUSTMENT SYSTEM NSF FORMAT TO RISK ADJUSTMENT FILE FORMAT RECORD FIELD FIELD RECORD FIELD FIELD EUROS IEIEEDIN
7. ESRD 16 Working Aged 1 63 63 Y Working Aged 17 Institutional 1 64 64 Y Institutional m 65 65 Y Nursing Home Certifiable da esee 66 66 Y Medicaid Status 20 FILLER 67 67 SPACES m Aspen Systems Corporation 21 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE MMR FLAT FI LE LAYOUT CONTI NUED Field Name Len Pos Description 21 Medicaid Indicator 1 68 68 Y Medicaid Addon _ PIP DCG Category Only on 2004 22 PIPSDER 7 adjustments Y default RA factor use e For pre 2004 adjustments a Y indicates that a new enrollee RA factor is in use 23 Default Indicator 1 71 71 e For post 2003 payments and adjustments Y indicates that a default factor was generated by the system due to lack of a RA factor 24 Risk Adjuster Factor yag 298 25 Risk Adjuster Factor B Jas 100000 Number of Paymt Adjustmt 28 Months Part A 20 87 ii Number of Paymt Adjustmt 27 Months Part ad di 28 Adjustment Reason Code 2 90 91 a Always Spaces on Payment 29 Paymt Adjustmt Start Date NI 92 99 YYYYMMDD 30 Paymt Adjustmt End Date e 100 107 YYYYMMDD 31 Demographic Paymt Adjustmt 108 116 9 5 99 Rate A 32 Demographic Paymt Adjustmt 117 125 5555 99 Rate 33 Risk Adjuster Paymt Adjustmt gt 126 134 9 99 Rate A 34 icd Paymt Adjust
8. Prescription Drug Hierarchical Condition Category Statistical Analysis Software Submitter CMS Contract Number Social Health Maintenance Organizations Skilled Nursing Facility Aspen Systems Corporation 3 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ACRONYM TERM SSD Selected Significant Disease Model SSN Social Security Number SUB ID Submitter ID SVC Second Validation Contractor TOB Type of Bill UB 92 Uniform Billing Form 92 VA Veterans Administration WPP Wisconsin Partnership Program Aspen Systems Corporation 4 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CMS WEB RESOURCES Aspen Systems Corporation 5 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CMS Main Page http www cms hhs gov Announcement Letter on Resumption of Data Collection March 29 2002 http cms hhs gov healthplans riskadj Advance Notice of Methodological Changes for Calendar Year CY 2004 45 Day Notice http cms hhs gov healthplans rates 2004 45day pdf Announcement of Calendar Year CY 2004 Medicare 4 Choice Payment Rates May 12 2003 http cms hhs gov healthplans rates Cover Letter Regarding Revised Medicare Advantage R
9. and ANSI X12 837 All organizations that collect electronic fee for service claim or encounters from their provider networks shall utilize the data from these transactions to prepare their risk adjustment data submissions M C organizations with capitated or mixed networks may also choose to use an electronic claim or encounter format to collect risk adjustment data from their capitated providers When Health Insurance Portability and Accountability Act HIPAA transaction standards become mandatory all electronic claims or encounters sent from providers physicians and hospitals to health plans M C organizations will constitute HIPAA covered transactions Any M C organization that utilizes an electronic claim or encounter format for their risk adjustment data collection will need to convert to ANSI X12 837 version 40 10 when HIPAA standards become mandatory organizations may elect to utilize a superbill or the minimum data set HIC diagnosis from date through date and provider type to collect risk adjustment data Use of a superbill or the minimum data set to collect diagnoses does not violate HIPAA transaction standards since neither of these data collection methods constitutes a covered transaction i e these transactions are not claims or encounters However organization that utilizes an electronic claim or encounter to collect diagnoses from their providers shall submit the diagnoses collected
10. cms hhs gov CMS Contacts for Technical Issues Cynthia Tudor ctudor cms hhs gov Jeff Grant jgrantl cms hhs gov Henry Thomas hthomas cms hhs gov Jan Keys jkeys cms hhs gov CUSTOMER SERVI CE AND SUPPORT CENTER CSSC hittp www csscoperations com The CSSC website provides one stop shopping for organizations regarding risk adjustment data submission needs Visit www csscoperations com to register for email updates from the CSSC The updates will serve as notification that new or updated information has been added to the website CSSC Contact Information 877 534 2712 toll free csscoperations palmettogba com ASPEN SYSTEMS CORPORATION For general questions about training and Risk Adjustment User Groups please email Aspen Systems Corporation at CMStraining aspensys com Aspen Systems Corporation i 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE TABLE OF CONTENTS RISK ADJ USTMENT ACRONYMS AND TERMS 1 1 CMS WEB RESOURCES 5 E amu EE ER mE SERRE ME REG RENE UE EE 5 CMS REFERENCE DOCUMENTS isasasssaEuuuunAaun Ru TES sn navA FARNE ER MER E ER M RUNE E EE CE MERE RR ERE ERE ai E 8 Accessing HPMS eene eer rennen t nana an E es aaa araa SE
11. 111 CCC 9 5 DIAGNOSIS CODE X 5 112 116 2 231 HI01 02 BK HIO1 02 BF CCC 9 6 DC FILLER X 2 117 118 CCC 9 7 DIAG CLUSTER ERROR 1 X 3 119 121 CCC 9 8 DIAG CLUSTER ERROR 2 X 3 122 124 YYY 1 0 RECORD ID X 3 1 3 YYY 2 0 SEQ NO 9 7 4 10 YYY 3 0 PLAN NO X 5 11 15 20352015 2 NM109 85 87 YYY 4 0 CCC RECORD TOTAL 9 7 16 22 ZZ 1 0 RECORD ID X 3 1 3 ZZ 2 0 SUBMITTER ID X 6 4 9 1 020 101 41 109 777 3 0 FILE ID X 10 10 19 1010 777 4 0 BBB RECORD TOTAL 9 7 20 26 Aspen Systems Corporation 55 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ANSI UB92v3051 RISK ADJUSTMENT PROCESSING SYSTEM ANSI X12 3051A CROSSWALK RECORD FIELD FIELD NAME FIELD POSITION ANSI POSITION ANSI SEGMENT ID TYPE NO LENGTH NUMBER AAA 1 0 RECORD ID X 3 1 3 AAA 2 0 SUBMITTER ID X 6 4 9 1 020 101 41 NM109 ISA06 5502 3 0 FILE ID X 10 10 19 1010 BGNO02 AAA 4 0 TTRANS DATE 9 8 20 27 1010 BNG03 GS04 AAA 5 0 PROD TEST IND X 4 28 31 ISA15 BBB 1 0 RECORD ID X 3 1 3 BBB 2 0 SEQ NO 9 7 4 10 3 0 BBB 3 0 PLAN NO X 5 11 15 2 235 E NM101 PR NM109 1 0 RECORD ID X 3 1 3 CCC 20 SEQ NO 9 7 4 10 CCC 3 0 SEQ ERROR CODE X 3 11 13 4 0 PATIENT CONTROL NO X 40 14 53 1130 CLMO01 5 0
12. Registration System OfRegister for Email O Register for User Group CMS User Group Registration Meetings Contact Us Please note electronic mail is not necessarily secure against interception If your communication is very sensitive or includes personal information you may want to send it by postal mail instead Palmetto GB Aspen Systems Corporation 34 2005 Risk Adjustment Data Basic Training CANIS For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Link to CMS Website http csscoperations com new references officiallinks html Official Links Microsoft Internet Explorer File Edt View Favorites Tools ay Back 2 x Search Favorites Media A 2 M 2 1 Address http csscoperations com newj references officiallinks htrnl v gt Go Link gt Group Training __ Map Search References Home Page Hot Topics System Status RAL S Official Links Please click on the circle to go to the desired topic To go to all other pages use the blue menu bar at the top of the page Risk Adjustment Technical Notes Medicare Advantage Payment Rates CMS Web Site 2 Medicare Health Plans Medicare Training Schedule American Hospital Directory O Hospital Provider Number Lookup
13. deduced unless you have been specifically authorized to do so e Donot intentionally cause corruption or disruption of CMS data files A violation of these security requirements could result in termination of systems access privileges and or disciplinary adverse action up to and induding removal from Federal Service depending upon the seriousness of the offense In addition Federal State and or local laws may provide criminal penalties for any person illegally accessing or using a Government owned or operated computer system illegally f you become aware of any violation of these security requirements or suspect that your identification number or pass word may have been used by someone else immediately report that information to your component s I nformation Systems Security Officer Signature of User Date Instructions for Completing the Application for Access to CMS Computer Systems This form is to be completed and submitted whenever the following situations occur A user requires access to a CMS computer system to perform their job duties Submit NEW Request A user changes names has a change in access needs job duties or moves to another component Submit CHANGE Request A user receives notice that they must recertify their access needs Submit RECERTIFY Request A user retires resigns is removed from a contract with CMS or for any reason no longer requires access Submit DELETE Request Section 1 Type of Requ
14. they have a copy available APPLICATION FOR ACCESS CMS COMPUTER SYSTEMS Read and complete both sides of this form in ink 1 Type of Request NEW CHANGE Last Name First Name MI Check only one RECERTIFY DELETE 2 User Information Office of the Inspector General Current UserID CMS Employee Fraud Investigation Railroad Retirement Board Social Security Admin End Stage Renal Disease Network Medicare Contr Intermediary Carrier CAPITAL LETTERS FMC Federal other than CMS Peer Review Organization 0123456789 Contractor non Medicare Mgd Care Org Group Health Plan Researcher State Agency Vendor Other specify a SSN see Privacy Act Advisory Statement on back e Email Address non CMS only b Mailing Address Mail Stop f CMS Organization or Company Name c Central Office Desk Location 9 Company Telephone Number d Daytime Telephone Number h Contract Number s non CMS only 3 Type of Access Required P Production D Development V Validation R Remote Dialup Access a Application s d CMS Standard Desktop Software LAN
15. 1 2002 Data from that date forward must be submitted for relevant diagnoses noted during hospital inpatient stays and hospital outpatient and physician visits M C organizations may begin submitting data on October 1 2002 and must meet their first quarterly submission requirement by December 31 2002 In addition these instructions provide the guidelines for submitting 2003 reconciliation data for the PIP DCG model after October 1 2002 Reporting The requirements as described herein shall apply to all organizations the Program of All Inclusive Care for the Elderly PACE and all active capitated demonstrations except United Mine Workers Association UMWA and the Department of Defense DOD Tricare Additional data requirements may be required for demonstrations at the time of their renewal typically under the Special Terms and Conditions section of their waiver Provider Type Definitions The following sections define the provider types from which organizations may submit diagnoses Any diagnoses received from the provider types as defined may be submitted For information on the minimum requirements for diagnosis submission see the data submission instructions below The provider types and their respective codes are hospital inpatient which is further subdivided into principal hospital inpatient 01 and other hospital inpatient 02 hospital outpatient 10 and physician 20 Hospital I npatient Data Inpatient hospital d
16. 1 3 YAO 10 RECORD D X 3 1 3 YYY 20 SEQ NO 9 7 4 10 YYY 3 0 PLAN NO X 5 11 15 BAO 9 0 NUMBER Hnnnn 15 48 62 QUE 40 CCC RECORD gj EE 7 16 22 YAO 10 0 BATCH CLAIM COUNT 9 7 61 67 227 10 RECORD ID X 3 1 2 2 0 10 RECORD D X 3 ie ZZZ 20 SUBMITTER ID X 6 4 9 2 0 20 SUBMITTER ID SHnnnn 16 4 19 ZZZ 3 0 FILE ID X 10 10 19 5 0 SUBMISSION NUMBER 9 6 35 40 BBB RECORD 227 ccn 9 7 17 23 2 0 80 BATCH COUNT 9 4 66 69 Aspen Systems Corporation 57 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RAPS UBF 030402 FRONT END RISK ADJUSTMENT SYSTEM UB 92 FORMAT TO RISK ADJUSTMENT FILE FORMAT RECORD FIELD FIELD RECORD FIELD FIELD TYPE No FIELDNAME Exc pg POSITION aver NO FIELDNAME rcr POSITION AAA 10 RECORDD X 3 1 3 20 SUBMITTERHD 6 4 9 01 20 SUBMITTER ID SHnnnn 10 3 10 FILE SEQUENCE AAA 30 FILED X 10 10 19 01 Jue EE X 6 137 142 AAA 40 TRANS DATE 98 20 27 01 200 PROCESSING DATE 98 155 162 AAA 50 _ PROD TEST IND 4 28 31 01 18 0 TEST PROD INDICATOR 4 143 146 10 RECORDD X 3 1 3 20 SEQ NO 9 7 4 10 10 30 NUMBER XQ 6 7 BBB 30 PLAN NO X 5 11 15 31
17. Accountability Act Health Maintenance Organization Health Outcomes Survey Health Plan Management System International Classification of Diseases Ninth Revision Clinical Modification Internal Claim Number Internet Protocol Initial Validation Contractor Joint Commission on Accreditation of Health Care Organizations Medicare Advantage Medicare Advantage Prescription Drug Plan Medicare Beneficiary Database Medicare 4 Choice Organization Managed Care Option Information System Medicare Data Communications Network Minimum Data Set Medicare Prescription Drug Modernization Act of 2003 Medicare Managed Care System Monthly Membership Report Minnesota Disability Health Options Model Output Report Medical Savings Account Message Minnesota Senior Health Options National Claims History National Council on Prescription Drug Program National Committee for Quality Assurance Network Data Mover National Medicare Utilization Database National Standard Format Office of Inspector General Original Reason for Entitlement Code Palmetto Government Benefits Administrators Program of All Inclusive Care for the Elderly Patient Control Number PACE Health Survey Principal Inpatient Diagnostic Cost Group Preferred Provider Organization Quality Improvement Organization Risk Adjustment Processing System Risk Adjustment Processing System Database Risk Adjustment System Rural Health Clinic Railroad Retirement Board Report Record Type
18. Advance Notice of Methodological Changes for CY 45 Day Notice for 2005 MA Rates 2005 Contact Us Please note electronic mail is not necessarily secure against interception If your communication is very sensitive or includes personal information you may want to send it postal mail instead Aspen Systems Corporation 35 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CSSC REFERENCE DOCUMENTS Aspen Systems Corporation 36 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE TO Managed Care Organizations Submitting Risk Adjustment Data RE EDI Enrollment and Submitter Application for Risk Adjustment Data Processing Welcome to the Customer Service and Support Center CSSC for Medicare Managed Care Organizations submitting Risk Adjustment Data The CSSC and the Front End Risk Adjustment System FERAS look forward to working with you in all aspects of the submission of risk adjustment data The following information must be completed and sent to the CSSC for enrollment for the submission of data for Risk Adjustment EDI Agreement for Risk Adjustment Data collection Submitter Application Risk Adjustment NDM Specifications For NDM users only Please note the following for submitting
19. Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE FINAL INSTRUCTIONS AS THEY APPEAR THE RENEWAL AND NONRENEWAL INSTRUCTIONS FOR THE 2003 CONTRACT YEAR FOR MEDI CARE CHOI CE ORGANIZATI ONS dated 05 03 02 http www cms hhs gov healthplans letters default asp Instructions for Risk Adjustment I mplementation Background The Balanced Budget Act of 1997 gave the Secretary of Health and Human Services the authority to collect inpatient hospital data for discharges on or after July 1 1997 CMS implemented the Principal Inpatient Diagnostic Cost Group PIP DCG risk adjustment method based on the principal inpatient hospital discharge diagnosis The encounter data collection was expanded in 2000 2001 to include physician and hospital outpatient data In May 2001 the Secretary announced a suspension of the requirements for filing physician and hospital outpatient encounter data collection pending a review of the administrative burden that was associated with that effort As a direct result of that review including consultation with M C organizations these instructions implement a streamlined process for organizations to collect and submit data for risk adjustment balancing burden reduction with improved payment accuracy Effective Dates These instructions are effective for all risk adjustment data submitted for dates of service on or after July
20. File RETURN FLAT RPTiHHHH ZIP RAPS RETURN FLAT zip format RAPS Error Report RPT RPT RAPS ERROR RPT RPTiHHHH ZIP RAPS ERROR RPT zip format RAPS Duplicate Diagnosis Cluster Report RPTiHHHHERPT RAPS DUPDX RPT RPT ZIP RAPS_ DUPDX zip format RAPS Transaction Summary Report RPT RPT RAPS SUMMARY RPTiHHHHEZIP RAPS SUMMARY zip format RAPS CMS generated reports monthly RAPS Monthly Plan Activity Report RPTiHHHHERPT RAPS MONTHLY RPT ZIP RAPS MONTHLY zip format RAPS Cumulative Plan Activity Report RPT RPT RAPS CUMULATIVE RPT ZIP RAPS CUMULATIVE zip format All reference material is available on the www csscoperations com web site We encourage you to visit the site and register for e mail notification of all updates Please contact the CSSC Help Line with any questions regarding the information provided CSSC Operations PO Box 100275 AG 570 Columbia SC 29202 3275 1 877 534 CSSC www csscoperations com FAX 1 803 935 0171 Aspen Systems Corporation 38 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Medicare Choice Organization Electronic Data Interchange Enrollment Form MANAGED CARE ELECTRONIC DATA INTERCHANGE EDI ENROLLMENT FORM ONLY for the Collection of Risk Adjustment Data and or With Medicare Choice Eligible Organizations
21. Medicaid and Previously Disabled Dialysis factors will be different from the Base Dialysis factors Medicaid probably will be The table design is intended to accommodate whatever decision is made 5 7 Fu File RAS File to GHP MMCS The RAS system will produce the RAFs identified in Section 2 Table 2 and hand them to MMCS via the Fu RAS File For the January 2004 payments Fu will provide this file to GHP MMCS On the Fu File New Enrollee factors and RAFs will be mutually exclusive For the initial implementation Fu and RAS will send RAFs to GHP MMCS via a flat file The file layout coming from Fu and RAS will be generally the same with some exceptions The file layout coming from Fu is defined in Appendix B RAS will provide the data in the same format with the exception of the following The RAS file will not contain the long term institutional flag in field 10 In the RAS file this field will be a filler of spaces The layout for this file appears in Appendix B Fu File Format 5 8 Section Reserved RA Operational Specification Page 45 of 54 December 3 2003 5 9 2004 Contract Level Payment File source of this file is unknown as of 5 29 03 It will contain the following four different record types Record Type F contains Frailty Factors Record contains the Non Community Indicator Record Type H contains the Non 70 30 blend MCOs Record Type MCOs using the Lag Factor 5 9 1 Re
22. Risk Adjustment Data ACMSRisk Adjustment Data EDI Agreement must be completed by each submitter 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 at the address provided gt Use of Third Party Submitters If the submitter will be an entity other than an organization the Submitter must complete the Submitter ID Application form and the 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 organization accountable for the content of the submission ASubmitter ID SHnnnn will be assigned to you by the CSSC and will remain effective for ongoing submission of risk adjustment data This 15 the unique ID assigned to the Plan or entity that will submit data and retrieve reports Please complete the Submitter Application return it to CSSC Operations with the completed EDI Agreement gt You will be submitting all Risk Adjustment Data to the FERAS Data may be submitted in one of the following formats RAPS format UB92 NSF and or ANSI data submitted to the front end will be sent to the Risk Adjustment Processing System RAPS in the risk adjustment data layout gt If you are submitting the UB92 NSF or ANSI file format it will be necessary to identify to the front end
23. SPACE CYL 75 10 RLSE DCB RECFM FB LRECL 80 BLKSIZE 27920 Note For testing use MAB PROD NDM EDS TCLMA UBF submitter 1 DSN MAB PROD NDM EDS CLMA NSF submitter 1 DISP NEW CATLG DELETE UNIT SYSDG SPACE CYL 75 10 RLSE DCB RECFM FB LRECL 80 BLKSIZE 27920 Note For testing use MAB PROD NDM EDS TCLMA NSF submitter 1 Please note that the test prod indicator in the file must match the DSN Aspen Systems Corporation 46 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CODI NG RESOURCES Aspen Systems Corporation 47 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE E CODES I CD 9 CM CODE SHORT DESCRIPTION OF I CD 9 CODE DISEASE GROUP E95 POISON 55 E950 SUIC SELF POIS W SOL LIQ 55 E9500 POISON ANALGESI CS 55 E9501 POISON BARBITURATES 55 E9502 POISON SEDAT HYPNOTIC 55 E9503 POISON PSYCHOTROPIC AGT 55 E9504 POISON DRUG MEDICIN 55 E9505 POISON DRUG MEDICIN NOS 55 E9506 POISON AGRICULT AGENT 55 E9507 POISON CORROSIV CAUSTIC 55 E9508 POISON ARSENIC 55 E9509 POISON SOLID LIQUI D NEC 55 E951 POISON UTILITY GAS 55 E9510 POISON PIPED GAS 55 E9511 POISON GAS IN CONTAINER 55 E9518 POISON UTILIT
24. decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a Default for New Enrollee Dialysis payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is not in the transplant period amp e The beneficiary is on dialysis amp f The beneficiary does not have a dialysis RAF amp 6 There is not a New Enrollee Dialysis Factor for the beneficiary on the RAS Fu File Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Adjusted ESRD Risk Portion of New Enrollee X X Blend A 5 Ratebook Beneficiary Dialysis Factor Payment Source is the TE New Enrollee 7 ESRD Default defined in defined 40 7 Table defined 593 in 45 6 id RA Operational Specification Page 32 of 54 December 3 2003 4 3 13 Dialysis Payment A Dialysis payment is made when the beneficiary is receiving dialysis If the beneficiary is receiving dialysis at any time within the month then the dialysis payment is made for the entire month This
25. enough data is available to determine a regular RAF The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a New Enrollee Dialysis payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is not in the transplant period amp e The beneficiary is on dialysis amp f The beneficiary does not have a dialysis RAF amp 2 There is a New Enrollee Dialysis Factor for the beneficiary on the RAS Fu File Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Adjusted New Enrollee ESRD Risk EE no Portion of Dialysis Factor Ratebook Beneficiary Payment Source is the RAS Fu file sites ue defined 4 5 7 593 RA Operational Specification Page 31 of 54 December 3 2003 4 3 12 Default for New Enrollee Dialysis Payment A Default for New Enrollee Dialysis Factor payment is made when a beneficiary is on dialysis and MMCS GHP does not have a RAF The chart below follows the
26. form Once you have submitted the form you will be taken to Step 2 where you will be instructed to Subscribe to the email lists of choice If you are already on the mailing list for RAPS you Do Not need to complete the registration form again Simply click on the Already Registered for RAPS button to be taken directly to Step 2 for instructions to either Subscribe to PART D if you only want information on PART D or Subscribe to RAPS amp PART D if you want to be the email list for both RAPS and PART 0 If you wish to be removed from any of the email lists you will need to click on the Already Registered for RAPS button to be taken to Step 2 for instructions to E Unsubscribe to the appropriate ernail lists New Already Registrations Registered for Only RAPS http www csscoperations com new rapformat mco_ registration html Z Service Registration Microsoft Internet Explorer File Edit Favorites Tools Help Qe Q x a e Jp Search She Favorites media ex p 3 Address http www csscoperations com new rapformat mco_registration html Go Links Home Page ICESCTA System Status Re arences User Group Training Site Map Site Search Medicare Advantage Registration Please click on the circle to go to the desired topic To go to all other pages use the blue menu bar at the top of the page Medicare Advantage Information
27. has a functioning graft and they are subject to a long term institutional RAF The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then an Institutional Post Transplant payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is not in the transplant period amp e The beneficiary is not on dialysis amp f The beneficiary has Community and Institutional Post transplant RAFs 6 The beneficiary is enrolled in an Institutional Mixed Plan amp h The beneficiary has an MDS flag Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Adjusted Institutional Risk Portion of Post transplant X Adjustment X Blend Benefici Factor Ratebook Payment Source pe Defined in defined RAS Fu file 9 5 3 1 ind defined in 4 5 7 593 RA Operational Specification Page 41 of 54 December 3 2003 5 Sources The purpose of this section is to define the items to be provided to GHP and DMCS to suppo
28. hospital is a Medicare certified hospital inpatient facility If the provider is a Medicare certified hospital inpatient facility the organization should submit the diagnoses from this facility If the hospital is not Medicare certified but is a Department of Veterans Affairs VA or DOD facility the organization must verify that it is a legitimate inpatient facility by contacting the Customer Service and Support Center CSSC prior to submitting data from that facility If the hospital is not Medicare certified or VA DOD the organization should contact CMS to verify that the facility qualifies as a hospital inpatient facility prior to submitting any diagnoses from that facility To aid in determining whether or not a provider is a Medicare certified hospital inpatient facility the M C organization may refer to the Medicare provider number The Medicare provider number has a two digit state code followed by four digits that identify the type of provider and the specific provider number Table 1 outlines the number ranges for all facility types that CMS considers to be Medicare hospital inpatient facilities The XX in the first two positions of every number represents the state code If the facility s Medicare provider number is unknown the organization may verify the provider number with the facility s billing department Some hospitals also operate Skilled Nursing Facilities SNFs as separate components within the hospital
29. or have components with swing beds that can be used for either hospital inpatient or SNF stays organizations shall not submit any diagnoses for stays in the SNF component of a hospital or from swing bed stays when the swing beds were utilized as SNF beds Stays in both of these circumstances qualify as SNF stays and do not qualify as hospital inpatient stays If the Medicare provider number is on the incoming transaction from the facility the organization may distinguish the SNF or SNF swing bed stays by the presence of a U W Y or Z in the third position of the Medicare provider number e g 11U001 Principal Hospital Inpatient and Other Hospital I npatient Diagnoses organizations must differentiate between the principal hospital inpatient diagnosis and all other hospital inpatient diagnoses when coding the provider type on the new risk adjustment transaction According to the Official ICD 9 CM Guidelines for Coding and Reporting the principal diagnosis is defined in the Uniform Hospital Discharge Data Set UHDDS as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care The principal diagnosis as reported by the hospital shall be coded as Provider Type 01 Principal Hospital Inpatient CMS strongly recommends that organizations continue to collect electronic encounter data or claims from hospital inpatient stays to ensure the proper identific
30. the data is being submitted for translation to the RAPS format using the appropriate receiver ID as designated below gt UB 92 Institutional Data 80884 RTO1 6 gt NSF Professional Data 80883 0 17 0 ANSI 4010 Institutional 80884 and Professional 80883 ISA08 GS03 NM109 1000B Aspen Systems Corporation 37 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Datasets are required to be set up for NDM users The Risk Adjustment NDM Specifications should be completed and returned to the CSSC with the Submitter Application and the EDI Agreement Technical Specifications are available based on the communication medium that is currently in use NDM instructions and the FERAS User Guide are available on the mcoservice com web site Testing instructions for each medium are included within the document On Line transaction data entry is available through the secure MDCN FERAS web site This option allows the user to key risk adjustment data directly into the front end creating the file for direct data submission Reports are returned on all data submitted The following report files are available for data submitted Response report generated by FERAS per file submission FERAS Response Report RSP HH RSP FERAS RESP RS P ZIP FERAS RESP zip format RAPS CMS generated reports per file submission RAPS Return
31. 0 0010 and 99 9990 Present only if new enrollee flag is set to Y NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 Present only if new enrollee flag is set to Y NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero RA Operational Specification December 3 2003 Page 51 of 54 RISK ADJUSTMENT DOWNLOAD RECORD FOR CY2004 next to field number denotes change from previous version FIELD NAME START FORMAT COMMENTS POSITION 20 Transplant Factor Not missing NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 2 Community NN DDDD format Post Transplant Leading N may be left blank Factor Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 Institutional NN DDDD format 2 Leading may be left blank Factor Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 RA Operational Specification Page 52 of 54 December 3 2003 Appendix Translation Between Business Rules and System Developer Criteria When the payment rule set in paragraph 4 Says The programmers will know this because The beneficiary is i
32. 0 FILE ID X 10 10 19 1010 BGN02 ZZZ 4 0 BBB RECORD TOTAL 9 7 20 26 Aspen Systems Corporation 54 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ANSI NSF 4010 RISK ADJUSTMENT PROCESSING SYSTEM ANSI X12 4010B CROSSWALK RECORD FIELD FIELD NAME FIELD POSITION ANSI POSITION ANSI SEGMENT ID TYPE NO LENGTH NUMBER AAA 1 0 RECORD ID X 3 1 3 AAA 2 0 SUBMITTER ID X 6 4 9 1 020 101 41 109 3 0 FILE ID X 10 10 19 1010 BHTO03 AAA 4 0 TRANS DATE 9 8 20 27 BHT04 AAA 5 0 PROD TEST IND X 4 28 31 0010 ISA15 BBB 1 0 RECORD ID X 3 1 3 BBB 20 SEQ NO 9 7 4 10 BBB 3 0 PLAN NO X 5 11 15 20352015 2 NM109 85 87 CCC 1 0 RECORD ID X 3 1 3 CCC 20 SEQ NO 9 7 4 10 CCC 3 0 SEQ ERROR CODE X 3 11 13 4 0 PATIENT CONTROL NO X 40 14 53 2130 0 1 109 1 ccc 50 25 54 78 20152 325 NMi09 C1 60 HIC ERROR CODE X3 79 81 7 0 PATIENT DOB 9 8 82 89 2 032 DMG02 CCC 8 0 DOB ERROR CODE X 3 90 92 DIAGNOSIS CLUSTER Z0 occurs 10 times 93 412 CCC 9 1 PROVIDER TYPE X 2 93 94 CCC 9 2 FROM DATE 9 8 95 102 2455 472 coc 93 THRU DATE 9 8 103 110 2455 472 CCC 9 4 DELETE IND X 1
33. 15 0 CONTRACTOR NUMBER X 5 178 182 CCC 1 0 RECORD ID X 3 CCC 20 9 7 4 10 SEQ ERROR de 255 X 3 11 13 PATIENT PATIENT CONTROL ece 40 14 53 20 20 5 25 50 HIC NO XQ5 54 78 30 70 X 19 35 53 HIC ERROR eee oor REE X 3 79 81 70 PATIENT DOB 9 8 82 89 20 X 8 56 63 DOB ERROR X 3 90 92 DIAGNOSIS 90 CLUSTER 93 412 occurs 10 times CCC X 2 93 94 40 4 OF BILL STATEMENT COVERS ccc 92 FROM DATE 9 8 95 102 20 E 98 133 140 STATEMENT COVERS ccc 93 THRU DATE 98 103 110 20 Bir 98 141 148 CCC 94 DELETEND x 111 DIAGNOSIS 40 PRINCIPLE OTHER 000 98 X 5 112 116 70 19a Dacos CODES JBIEACH 225 76 96 DC FILLER 117 118 DIAG CLUSTER eco 119 121 DIAG CLUSTER X 3 122 124 10 RECORD ID xG 159 YYY 20 SEQ NO 9 7 4 10 YYY 30 PLAN NO X 5 11 15 31 150 CONTRACTORNUMBER 178 182 CCC RECORD YYY 40 9 7 16 22 95 6 0 NUMBER OF CLAIMS 9 6 25 30 TOTAL 277 10 _ RECORD ID X 1 3 227 20 SUBMITTERHD 6 4 9 99 20 SUBMITTER ID 8 X00 3 12 227 FILE ID 10 10 19 01 172 6 137 142 BBB RECORD NUMBER OF BATCHES 272 9 7 20 26 99 94 22 25 Aspen Systems Corporation 58 2005 Risk Adjustment Data Basic Training For Medicar
34. 15 04 7 1 04 12 31 04 1 12 31 03 2004 Final 01 01 04 05 31 05 07 15 05 9 1 05 Reconciliation 12 31 04 In the Mid year calculation RAS will compute a non lag RAF for all beneficiaries However those plans designated as Lag plans will not be paid using this recalculated beneficiary RAF but rather using the initial RAF calculation This is only applicable to the Mid Year calculation RA Operational Specification December 3 2003 Page 8 of 54 CMS HCC Model Runs Regular Cycle For Payment Year 2005 Name of Run Data Data RAF Payment Made from RAF Collection Submission Transmitted Period Deadline to MMCS Initial RAF 07 01 03 09 30 04 11 15 04 2005 Payments made between Calculation 06 30 04 1 1 05 6 30 05 2005 Mid Year 01 01 04 03 31 05 5 15 05 7 1 05 12 31 05 Calculation 12 31 04 2005 Final 01 01 05 05 31 06 07 15 06 9 1 06 Reconciliation 12 31 05 The Risk Adjustment System RAS will produce RAFs based on running a cohort of data beneficiaries through models For 2004 there will be 2 models the CMS HCC model defined in this section of the document and the ESRD model defined in section 3 27 RAS will process more than one run of model s within a payment year and it is anticipated that there will be different cohorts for each run within the 2004 payment year as follows e For the initial run Fu will process all
35. 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RESOURCE GUI DE About this Guide This Resource Guide is intended to help Medicare Advantage organizations providers physicians and third party submitters locate information specific to risk adjustment The purpose of this Resource Guide is to identify and supply resources that will simplify and clarify both the terminology and the processes employed in the submission of risk adjustment data An emphasis is given to recent policy relevant material This Resource Guide is a helpful tool for those who need a quick reference for technical concepts or for those who need to provide employees with an introductory presentation to the risk adjustment data process Where possible and appropriate screen shots of important resources on the Internet have been included These pages may also be utilized as a suitable visual aid for risk adjustment data instructors to enhance their presentation The information listed in the Resource Guide is arranged in nine sections RISK ADJUSTMENT ACRONYMS AND TERMS CMS WEB RESOURCES CMS REFERENCE DOCUMENTS CSSC WEB RESOURCES CSSC REFERENCE DOCUMENTS CODING RESOURCES RISK ADJUSTMENT PROCESSING SYSTEM CROSSWALKS CMS OPERATIONS SPECIFICATIONS APPLICATION FOR ACCESS GENERAL CONTACT I NFORMATION CENTERS FOR MEDI CARE amp MEDI CAI D SERVI CES CMS http
36. 40M beneficiaries through the CMS model Fu will also process all ESRD beneficiaries through the ESRD model e For the mid year calculation RAS will run all beneficiaries that are enrolled in on or after January 1 2004 through the CMS HCC model RAS will also run all ESRD beneficiaries through the ESRD model e For the 2004 final reconciliation RAS will run all 40M beneficiaries through the CMS HCC model RAS will also run every beneficiary that was ESRD between January 1 and December 31 2004 through the ESRD model The Final Reconciliation RAF file will be received in July of the following year July 2005 for 2004 payment year The final set of RAFs causes recalculation of all beneficiary payments for the entire 2004 payment year January 2004 December 2004 This final RAF is the basis for all adjustments for the 2004 payment year The cohort for the 2004 Final Reconciliation which is run in 2005 will include all beneficiaries who were alive on 1 1 04 The ESRD Demonstrations are expected to go live in April 2004 4 PAYMENT RULES The purpose of this section is to define the following for each type of payment e rules for determining which RAF to use for payment RA Operational Specification December 3 2003 Page 9 of 54 e The beneficiary level payment calculations and e Identify the source of the data factors for GHP MMCS NOTE Section 5 will provide a more in depth description of each s
37. AMES inen POSTION FIELD xor POSITION AAA 10 RECORD D X 3 1 3 1 0 _ RECORD ID X 3 1 3 20 SUBMITTER ID 6 4 9 20 SUBMITTER ID SHnnnn 16 4 19 AAA 30 _ FILE ID 10 10 19 5 0 SUBMISSION NUMBER 9 6 35 40 4 0 _ TRANS DATE 9 8 20 27 TEST PRODUCTION AAA 5 0 PROD TEST IND X 4 28 31 BAG cite 254 257 10 RECORD D X 3 1 3 BAO 10 RECORD ID XG 1 3 20 SEQ NO 9 7 4 10 BBB 3 0 PLAN NO X 5 11 15 BAO 90 PLAN NUMBER 15 48 62 CCC 1 0 RECORD ID X 3 1 3 1 0 RECORD ID X 3 1 3 CCG 20 9 7 4 10 SEQ ERROR ccc 307 Pare X 3 11 13 PATIENT PATIENT CONTROL e 14 53 BU X 17 6 22 50 X 25 54 78 DAO 18 0 NUMBER x 25 157 181 HIC ERROR ccc X 3 79 81 CCG 70 PATIENT DOB 9 8 82 89 80 PATIENT DATE OF BIRTH X 8 59 66 DOB ERROR ccc 24 X 3 90 92 DIAGNOSIS ccc 9 0 CLUSTER 93 412 occurs 10 times X 2 93 94 92 FROM DATE 98 95 102 FAO 50 FROM DATE 98 40 27 CCC 9 3 THRU DATE 9 8 103 110 FAO 6 0 SERVICE TO DATE 9 8 48 55 CCC 94 DELETE IND X 1 111 DIAGNOSIS 320 DIAGNOSIS CODE 1 BE leant X6 112 116 e DEUS X 5 179 198 CCG 96 DC FILLER 117 118 DIAG CLUSTER GCG X3 119 121 DIAG CLUSTER ccc X 3 122 124 10 RECORD D X 3
38. E9588 INJ URY NEC 55 E9589 INJ URY NOS 55 959 LATE OF SELF INJ URY 55 Aspen Systems Corporation 49 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE V CODES I CD 9 CM CODE SHORT DESCRIPTION OF I CD 9 CODE DISEASE GROUP V08 ASYMP HIV INFECTN STATUS 1 V421 HEART TRANSPLANT STATUS 174 V426 LUNG TRANSPLANT STATUS 174 V427 LIVER TRANSPLANT STATUS 174 V4281 TRNSPL STATUS BNE MARROW 174 V4282 TRSPL STS PERIP STM CELL 174 V4283 TRNSPL STATUS PANCREAS 174 V4284 TRNSPL STATUS INTESTINES 174 V432 HEART REPLACEMENT NEC 174 V4321 HEART ASSIST DEV REPLACE 174 V4322 ARTFICIAL HEART REPLACE 174 V44 ARTIFICIAL OPNING STATUS 176 V440 TRACHEOSTOMY STATUS 77 V441 GASTROSTOMY STATUS 176 V442 ILEOSTOMY STATUS 176 V443 COLOSTOMY STATUS 176 V444 ENTEROSTOMY STATUS NEC 176 V445 CYSTOSTOMY STATUS 176 V4450 CYSTOSTOMY STATUS NOS 176 V4451 CUTANEOUS VESICOS STATUS 176 V4452 APPENDICO VESI COS STATUS 176 V4459 CYSTOSTOMY STATUS NEC 176 V446 URINOSTOMY STATUS NEC 176 V448 ARTIF OPEN STATUS NEC 176 V449 ARTIF OPEN STATUS NOS 176 V451 RENAL DIALYSIS STATUS 130 V461 DEPENDENCE ON RESPIRATOR 71 V497 STATUS AMPUT 177 V4970 STATUS AMPUT LWR LMB NOS 177 V4971 STATUS AMPUT GREAT TOE 177 V4972 STATUS AMPUT OTHR TOE S 177 V4973 STATUS AMP
39. For CHANGE Requests Note the nature of the action requiring a change For name changes include previous and new names For organizational changes indude old and new organization names If Other is checked in block 3 b Subsystems or block 3 d CMS Standard Desktop Software LAN specify here For RECERTIFY Requests Provide an explanation of what job duties require you to access a CMS computer system Include applicable non CMS only project accounting numbers If Other is checked in block 3 b Subsystems block 3 d CMS Standard Desktop Software LAN specify here For DELETE Requests Note the nature of the action requiring the removal of accesses Read sign and date the back of the form Then obtain signatures for Section 5 Section 5 Authorization COMPLETE FOR ALL REQUESTS requested information must be supplied or noted N A CMS Employees Requesting Official The immediate supervisor must sign and complete the Requesting Official block The RACF Group Administrator must also sign and complete the signature block where noted These responsibilities cannot be delegated Non CMS Employees Requesting Official The Project Officer if designated must sign and complete the Requesting Official block For Medicare Contractors I ntermediaries Carriers a designated company contact must sign and complete the Requesting Official block For others the CMS Liaison Contact or ADP Coordinator must sign and complete the
40. OPANAMR ORA S DK SIRA nda anaa 114 Aspen Systems Corporation ii 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RISK ADJ USTMENT ACRONYMS AND TERMS Aspen Systems Corporation 1 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ACRONYM ANSI ANSI X12 837 ASC Aspen BBA BBRA BIC BI PA FERAS FFS FQHC FTP GHP GROUCH GUI H HCC HCFA 1500 HCPCS HEDIS RISK ADJ USTMENT ACRONYMS AND TERMS TERM Adjusted Community Rates Adjusted Community Rate Proposal Alternative Data Sources Activities of Daily Living AT amp T Global Network Services American Medical Association American National Standards Institute Variable Length File Format for Electronic Submission of Encounter Data Ambulatory Surgical Center Aspen Systems Corporation Balanced Budget Act of 1997 Balanced Budget Refinement Act 1999 Beneficiary Identification Code Benefits Improvement and Protection Act of 2000 Coronary Artery Disease Chief Financial Officer Congestive Heart Failure Community Mental Health Center Centers for Medicare amp Medicaid Services CMS Refined Hierarchical Condition Category Risk Adjustment Model Chronic Obstructive Pulmonary Disease Current Procedural Terminology Customer Serv
41. Option and Demo Type Code for an ESRD Demonstration The beneficiary has a functioning graft On the MBD the beneficiary has had a transplant period for which we have paid for 3 months The transplant failure date does not exist The beneficiary is not deceased The beneficiary does not have a current dialysis period for the given payment month The beneficiary does not have a functioning graft On the MBD the beneficiary is currently on dialysis or deceased for the given payment period The beneficiary is on dialysis On the MBD the beneficiary has a dialysis period during the given payment month The beneficiary is not on dialysis On the MBD the beneficiary does not have a dialysis period during the given payment month The beneficiary is not in the transplant period The beneficiary does not have a dialysis RAF Age is calculated as of February 1 2004 RA Operational Specification December 3 2003 Page 54 of 54 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE APPLI CATI ON FOR ACCESS Aspen Systems Corporation 114 The Application For Access CMS Computer Systems form is being replaced The new version cannot be made available on the Internet until the form approval process has been completed Users may continue using either the form below or the new form if
42. Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Code all documented conditions that coexist at time of the encounter visit and require or affect patient care treatment or management Do not code conditions that were previously treated and no longer exist However history codes V10 V19 may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment Physicians and hospital outpatient departments shall not code diagnoses documented as probable suspected questionable rule out or working diagnosis Rather physicians and hospital outpatient departments shall code the condition s to the highest degree of certainty for that encounter visit such as symptoms signs abnormal test results or other reason for the visit Alternative Data Sources ADS Alternative data sources include diagnostic data from sources other than inpatient hospital outpatient hospital and physician services M C organizations may use ADS as a check to ensure that all required diagnoses have been submitted to CMS for risk adjustment purposes Two examples of ADS include pharmacy records and information provided to national or state cancer registries Note that organizations may not utilize ADS as an alternative to diagnoses from a provider If M C organizations elect to utilize one or more ADS they must ensure that the diagnosis
43. PA 9 Instructions for Risk Adjustment I mplementation 10 Monthly Membership Report Flat File 21 CSSC WEB RESOURCES DEREN PREMIT 27 CSSC REFERENCE DOCUMENTS issa o pani kaszt iai eR PR IEEE RRoPa RP ANE IMPER PEE 36 CISC lt lt a nv ee ont ew Us eres ow ce on ewes coe ano 37 CMS EDI Agreement RR RR 39 CSSC Risk Adjustment Data Submitter Application 42 Specifications RAPS Application 44 CODING lt 5 5 47 48 MEOS 50 Neoplasm Guidelines 52 RISK ADJ USTMENT PROCESSI SYSTEM CROSSWALKS 53 CMS OPERATIONS SPECI FI CATI OBS iosiassn acus snsada pase RA nah ia aua Ea Fe Ubi Ea osa ReaUREesS 59 APPLICATION FOR ACCESS uana 1R
44. Post Trangpl Frailty Community Nav Eros See 1 4 3 1 4 3 9 See d 4 3 13 See 44 3 11 4 3 16 See 4 3 2 Enrolled In Fralty Yes v Default for New Default for New Enrollee Frailty Enrollee See d 4 3 5 See 4 3 4 RA Operational Specification December 3 2003 Page 12 of 54 Use the logic in the chart in Figure 1 above to find the appropriate driving the payment formula These formulas by RAF are explained in paragraph 4 3 GHP MMCS will determine the appropriate RAFs for beneficiaries within a Demonstration by using the logic in the chart in Figure 1 At the time of discussion this includes the following Demonstrations PACE WPP Massachusetts Dual Eligible Demonstration MnDHO and MnSHO The Risk Adjustment System RAS will produce RAFs based on running a cohort of beneficiaries through models As shown in Table 2 below the RAS system will produce the following RAFs as a result of running a cohort of beneficiaries through either the CMS HCC Model or the ESRD model Table 2 RAFs Produced by HCC and ESRD Models RAF HCC Model ESRD Model New Enrollee Factor X Community Factor X Institutional Factor X As a result of running beneficiaries through the CMS HCC model and the ESRD model RAS will have the following types of RAFs for each beneficiary type RA Operational Specification Page 13 of 54 Dece
45. Post transplant RAF amp The beneficiary does not have a New Enrollee Post transplant RAF Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Base Factor Default for New Enrollee Post Transplant Source is the New Enrollee Base Default Table defined in 4 959 Drug Add on Risk Default for New Enrollee X X X Blend ons Ratebook Transplant Source is the Defined Source New Enrollee in 5 3 1 defined Base Default in 1 Table defined 5 9 3 in 5 5 Risk Adjusted Portion of Beneficiar y Payment RA Operational Specification December 3 2003 Page 38 of 54 4 3 18 Community Post Transplant Payment A Community Post Transplant Factor payment is made when a beneficiary has a functioning graft and they are not subject to a long term institutional RAF The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for either of the scenarios are true then a Community Post Transplant payment should be calculated for the beneficiary For 2004 either Scenario a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstrat
46. RE amp MEDICAID SERVICES RESOURCE GUI DE WWW CSSCOPERATI ONS COM http www csscoperations com CSSC Operations Microsoft Internet Explorer File Edit iew Favorites Tools Help gt JO Search jf Favorites QP media B BS 1 Address El http www mcoservice com index html Go d Customer Service and Support Center p There s a new System Status Alert Internet Aspen Systems Corporation 28 2005 Risk Adjustment Data Basic Training CIs For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RAPS Resources http csscoperations com new rapformat newraps html RAPS Microsoft Internet Explorer File Edit View Favorites Tools ex gt 2 x a JO Search Sip Favorites QD R p EJ 2 Go Links gt 1 Address a http csscoperations com new rapformat newraps html el RAPS ferences User Group Training FAQs Site Map Site Search P Hot Topics System Status RAPS Risk Adjustment Processing System Please click on the circle to go to the desired topic To go to all other pages use the blue menu bar at the top of the page RAPS Format ORAPS Record Layout RAPS Error Codes O Error Code Listing RAPS FERAS Error Code Lookup O Error Code Lo
47. Requesting Official block IT IS IMPORTANT THAT CONTRACT NUMBER AND EXPIRATION DATE ARE INCLUDED WHERE APPLICABLE IF ACCESS IS REQUIRED FOR MULTIPLE CONTRACTS THE NUMBER AND EXPIRATION DATE FOR THE CONTRACT WITH THE LONGEST PERIOD OF PERFORMANCE SHOULD BE USED IF NO CONTRACTS APPLY AN APPROPRIATE NOT TO EXCEED DATE SHOULD BE NOTED OR N A IF INDEFINITE ACCESS IS REQUIRED Approving Official The immediate supervisor of the Requesting Official must sign and complete the Approving Official block For Medicare Contractors l ntermediaries Carriers the Consortium Contractor Management Staff member assigned as Contractor Manager for the company must sign and complete the Approving Official block The RACF Group Administrator should note the preferred group for UserlD assignment in Section 1 They must also sign and complete the signature block where noted These responsibilities cannot be delegated J uly 2001 1002 Bu noddy se ubis jeniyo JO sOSIAJEdNS 3521 dde Jou 5 UOISIAIG UBUM x V9 OH v9 Jeuoiba y 40 OH v9 40 OH v9 Jeuoiba y 40 OH v9 Jeuoiba y JO OH V9 OH v9 Jeuoibau JO OH V9 v9 euoibey v9 euoibey v9 Jeuoiba y 40 OH Jo3eJjsiumupy 45v UOISIAIG UOISIAIG amp 40peoJIq UOISIAIG 1 UOISIAIG JOP34IG UOISIAIG
48. The eligible organization agrees to the following provisions for submitting Medicare risk adjustment data electronically to The Centers for Medicare amp Medicaid Services CMS or to CMS s contractors A 1 The Eligible Organization Agrees That it will be responsible for all Medicare risk adjustment data submitted to CMS by itself its employees or its agents That it will not disclose any information concerning a Medicare beneficiary to any other person or organization except CMS and or its contractors without the express written permission of the Medicare beneficiary or his her parent or legal guardian or where required for the care and treatment of a beneficiary who is unable to provide written consent or to bill insurance primary or supplementary to Medicare or as required by State or Federal law That it will ensure that every electronic entry can be readily associated and identified with an original source document Each source document must reflect the following information Beneficiary s name Beneficiary s health insurance claim number Date s of service Diagnosis nature of illness That the Secretary of Health and Human Services or his her designee and or the contractor has the right to audit and confirm information submitted by the eligible organization and shall have access to all original source documents and medical records related to the eligible organization s submissions including the beneficiary s auth
49. Transplant payment should be calculated for the beneficiary If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Adjusted Transplant ESRD Risk Portion of Factor Ratebook mm Beneficiary Payment source Source is the RAS Fu file i defined 4 5 7 593 RA Operational Specification Page 35 of 54 December 3 2003 4 3 15 Default for New Enrollee Transplant Payment A Default for New Enrollee Transplant payment is made when no RAF is available for a beneficiary and the beneficiary has had a transplant within the previous three months NOTE Paragraph 4 3 14 lists several specific guidelines for transplant factor payments of these guidelines also apply to the Default for New Enrolleee Transplant Payment The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a Default for New Enrollee Transplant payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is in the transplant period amp e The beneficiary does not have a transplant factor Appendix C provides a key between the rules above and the
50. UT FOOT 177 V4974 STATUS AMPUT ANKLE 177 V4975 STATUS AMPUT BELOW KNEE 177 V4976 STATUS AMPUT ABOVE KNEE 177 V4977 STATUS AMPUT HIP 177 V521 FITTING ARTIFICIAL LEG 177 Aspen Systems Corporation 50 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE V CODES CONTI NUED I CD 9 CM CODE SHORT DESCRI PTI ON OF I CD 9 CODE DISEASE GROUP V55 ATTEN TO ARTIFICIAL OPEN 176 V550 ATTEN TO TRACHEOSTOMY 77 V551 ATTEN TO GASTROSTOMY 176 V552 ATTEN TO ILEOSTOMY 176 V553 ATTEN TO COLOSTOMY 176 V554 ATTEN TO ENTEROSTOMY NEC 176 V555 ATTEN TO CYSTOSTOMY 176 V556 ATTEN TO URI NOSTOMY NEC 176 V558 ATTN TO ARTIF OPEN NEC 176 V559 ATTN TO ARTIF OPEN NOS 176 V56 DIALYSIS ENCOUNTER 130 V560 RENAL DIALYSIS ENCOUNTER 130 V561 FT ADJ XTRCORP DIAL CATH 130 V562 FIT ADJ PERIT DIAL CATH 130 V563 DIALYSIS 130 V5631 HEMODIALYSIS TESTING 130 V5632 PERITONEAL DIALYSIS TEST 130 V568 DIALYSIS ENCOUNTER NEC 130 Aspen Systems Corporation 51 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE NEOPLASM GUI DELI NES If the treatment is directed at the malignancy designate the malignancy as the principal diagnosis When a patient is admitted because of a primary neoplasm
51. WALK RECORD FIELD FIELD NAME FIELD POSITION ANSI POSITION ANSI SEGMENT ID TYPE NO LENGTH NUMBER AAA 1 0 RECORD ID X 3 1 3 AAA 2 0 SUBMITTER ID X 6 4 9 1 020 NM109 AAA 3 0 FILE ID X 10 10 19 1010 BGNO02 AAA 4 0 TRANS DATE 9 8 20 27 BGNO3 AAA 5 0 PROD TEST IND X 4 28 31 0010 ISA15 BBB 1 0 RECORD ID X 3 1 3 BBB 2 0 SEQ NO 9 7 4 10 3 0 5 11 15 2 005 1C ZZ 1 0 RECORD ID X 3 1 3 2 0 9 7 4 10 3 0 SEQ ERROR CODE X 3 11 13 4 0 PATIENT CONTROL NO X 40 14 53 2 130 CLMO01 5 0 25 54 78 2 325 B 2 095 109 1 109 6 0 HIC ERROR CODE X 3 79 81 CCC 7 0 PATIENT DOB 9 8 82 89 2115 DMGO02 D8 CCC 8 0 DOB ERROR CODE X 3 90 92 CCC 9 0 DIAGNOSIS CLUSTER 93 412 occurs 10 times CCC 9 1 PROVIDER TYPE X 2 93 94 CCC 9 2 FROM DATE 9 8 95 102 2 455 472 9 3 THRU DATE 9 8 103 110 2 455 472 9 4 DELETE IND X 1 111 9 5 DIAGNOSIS CODE X 5 112 116 2 231 HI01 02 BR 02 02 HI04 02 BQ 9 6 DC FILLER X 2 117 118 9 7 DIAG CLUSTER ERROP 1 X 3 119 121 9 8 DIAG CLUSTER ERROR 2 X 3 122 124 YYY 1 0 RECORD ID X 3 1 3 YYY 2 0 SEQ NO 9 7 4 10 YYY 3 0 PLAN NO 5 11 15 2005 1C ZZ 4 0 CCC RECORD TOTAL 9 7 16 22 ZZZ 1 0 RECORD ID X 3 1 3 ZZZ 2 0 SUBMITTER ID 6 11 16 1 020 109 94 277 3
52. Y GAS NEC 55 E952 POISON GAS VAPOR NEC 55 E9520 POISON EXHAUST GAS 55 E9521 POISON CO NEC 55 E9528 POISON GAS VAPOR NEC 55 E9529 POISON GAS VAPOR NOS 55 E953 INJURY STRANGUL SUFFOC 55 E9530 INJURY HANGING 55 E9531 INJURY SUFF W PLAS BAG 55 E9538 INJURY STRANG SUFF NEC 55 E9539 INJURY STRANG SUFF NOS 55 E954 INJURY SUBMERSI ON 55 E955 INJ URY FI REARM EXPLOSI V 55 E9550 INJURY HANDGUN 55 E9551 INJURY SHOTGUN 55 E9552 INJ URY HUNTI NG RIFLE 55 E9553 INJ URY MI LI TARY FIREARM 55 E9554 INJURY FI REARM NEC 55 E9555 INJURY EXPLOSI VES 55 E9556 SELF INFLICT ACC AIR GUN 55 E9557 SELF INJ PAI NTBALL GUN 55 E9559 INJURY FIREARM EXPL NOS 55 E956 INJURY CUT INSTRUMENT 55 Aspen Systems Corporation 48 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE E CODES CONTI NUED I CD 9 CM CODE SHORT DESCRIPTION OF ICD 9 CODE DISEASE GROUP E957 INJU J UMP FROM HI PLACE 55 E9570 INJURY J UMP FM RESIDENCE 55 E9571 INJ URY J UMP FM STRUC NEC 55 E9572 INJURY J UMP FM NATUR SIT 55 E9579 INJ URY J UMP NEC 55 E958 INJURY SELF INJ NEC NOS 55 E9580 INJURY MOVING ECT 55 E9581 INJURY BURN FIRE 55 E9582 INJURY SCALD 55 E9583 INJ URY EXTREME COLD 55 E9584 INJURY ELECTROCUTI ON 55 E9585 INJURY MOTOR VEH CRASH 55 E9586 INJURY AI RCRAFT CRASH 55 E9587 INJ URY CAUSTIC SUBSTANCE 55
53. a that is submitted in September 2002 and finalized in October 2002 Please note that the deadline for submitting data for 2003 risk adjustment is September 6 2002 and the 2002 reconciliation data submission deadline will be September 27 2002 M C organizations may submit reconciliation data for 2003 after the October 1 2002 implementation of RAPS Reconciliation data will be run through the PIP DCG model All reconciliation data must be submitted utilizing a full UB 92 the encounter version of the UB 92 or the ANSI X12 837 to ensure the accuracy of the PIP DCG model organizations should submit only the 111 or 117 bill types data will be converted at the FERAS into the RAPS format and sent through the normal RAPS processing The returned report will be in the RAPS format rather than the encounter data report formats The transaction will be stored as one set of diagnosis clusters to maintain the integrity of the original transaction organizations shall not submit adjustment transactions for 2003 reconciliation data after October 1 2002 Any data submitted after that date should be submitted as a 111 117 bill type When organizations need to correct a previously submitted transaction organizations shall send a new 111 or 117 with the corrected information In the same manner as CMS handled the original abbreviated hospital inpatient encounter data CMS will check the from and through dates to identify duplica
54. age is impacted in the mid year run by the addition of the non lag RAFs The non lag RAFs will be loaded into MMCS such that they will only replace the RAFs for beneficiaries in Contracts H that are designated to receive the non lag RAF Therefore not all of the initial lag RAFS for January will be replaced 6 3 Final Reconciliation Run A history of all RAFs that are used for payments must be maintained on the beneficiary payment profile archive 7 Reports TBD RA Operational Specification Page 48 of 54 December 3 2003 Appendix A Glossary ESRD End Stage Renal Disease Lag RAF RAF based on lag data The timing of the lag data is defined in Section 3 MSP Non Lag RAF RAF based on non lag data The timing of the non lag data is defined in Section 3 Working Aged RA Operational Specification Page 49 of 54 December 3 2003 Appendix B Fu File Format RISK ADJUSTMENT DOWNLOAD RECORD FOR CY2004 44 next to field number denotes change from previous version START FORMAT COMMENTS POSITION l e Internal CMS Format 9 position CAN 2 position unequated BIC SSA Not missing e Unique within file e Variable by which file is sorted 12 e Original SSN e All numeric e May be missing e Not unique within file Beneficiary s last name First position alphabetic Not missing FIELD NAME Beneficiary Health Insurance Claim Number 2 Social Security Number 4 33 e First position alphabetic e N
55. and not within either MMCS or GHP In general in order to calculate the above payments GHP and MMCS use corresponding Risk Adjustment Factors RAF as shown in Table 1 below RA Operational Specification Page 6 of 54 December 3 2003 Table 1 Payment RAFs and Sources Payment Type Corresponding Model Tool System RAF Housing Model Tool Hospice Non Risk Not applicable Not applicable Adjusted Payment New Enrollee New Enrollee CMS HCC RAS Factor New Enrollee Plus New Enrollee CMS HCC RAS Frailty Frailty Factor CBC Provided GHP MMCS Table Default for New Default for New New Enrollee GHP MMCS Enrollee Enrollee Factor Base Default Table Default for New Default for New New Enrollee GHP MMCS Enrollee Plus Enrollee Factor Base Default Frailty Table 2004 Contract Level Payment File GHP MMCS Frailty Factor Record Type F Frailty Factor Community Community Factor CMS HCC RAS Community Plus Community CMS HCC RAS Frailty Frailty Factor 2004 Contract GHP MMCS Level Payment File Record Type F Frailty Factor Institutional Institutional CMS HCC RAS Factor Demographic Non Risk Not applicable Not applicable ESRD Adjusted Payment PACE WPP Non Risk Not applicable Not applicable Demographic Adjusted Payment ESRD New Enrollee New Enrollee ESRD RAS Dialysis Dialysis Factor Default for New Default for New New Enrollee GHP MMCS Enrollee D
56. art follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for any of the scenarios are true then the payment calculation should be for a Community Factor payment For 2004 either a b 9 Scenario 5 Scenario The beneficiary is not a The beneficiary is not a The beneficiary is in hospice amp in hospice amp not in hospice amp The beneficiary is not b The beneficiary is not b The beneficiary is in ESRD amp in ESRD amp not in ESRD amp There is a RAF for the c There is a RAF for the c There is a RAF for beneficiary on the beneficiary on the the beneficiary on Fu RAS File amp Fu RAS File amp the Fu RAS File amp The beneficiary is d The beneficiary is not d The beneficiary is enrolled in an enrolled in an not enrolled in an Institutional Mixed Institutional Mixed Institutional Mixed Plan Plan amp Plan amp The beneficiary does e The beneficiary is not e The beneficiary is not have an MDS flag enrolled in a Frailty enrolled in a Frailty amp Plan Plan amp The beneficiary is not f The beneficiary is enrolled in a Frailty under age 55 Plan Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adj
57. ary is not in ESRD amp b The beneficiary is not in ESRD amp c There is not a Community or c There is not a Community or Institutional RAF Institutional RAF for the beneficiary beneficiary on the Fu RAS File amp on the Fu RAS File amp d There is not a New Enrollee Factor d There is not a New Enrollee Factor for the beneficiary on the Fu RAS for the beneficiary on the Fu RAS File amp File amp e The beneficiary is not enrolled in a e The beneficiary is enrolled in a Frailty Plan Frailty Plan amp f The beneficiary is under age 55 Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Default for Risk Risk Adjusted Adjustment Portion of New Enrollee X Blend Factor Family of Beneficiary Ratebooks Payment Source is the Source Defined in defined Base Default 45 3 f Table defined 593 45 5 x RA Operational Specification Page 21 of 54 December 3 2003 4 3 5 Default for New Enrollee Plus Frailty Payment A Default for New Enrollee Plus Frailty Factor payment is made when no RAF is available for a beneficiary and the beneficiary is in a Frailty Plan The chart below follows the decision diagram in Figure 1 and lays out the rules for choo
58. ata should be differentiated based on whether it is received from within or outside of the M C organization s provider network Because the Code of Federal Regulations CFR requires that all organization network hospitals have a Medicare provider agreement see 42CFR422 204 a 3 i by extension a network provider should have a Medicare provider billing number for a hospital inpatient facility If a facility does not have a hospital inpatient Medicare provider number the M C organization Aspen Systems Corporation 10 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE shall not submit diagnoses from that facility as hospital inpatient data Table 1 at the end of these instructions gives the list of valid provider number ranges for hospital inpatient facilities Please note that it is not necessary for organizations to receive the Medicare provider number from the hospital on incoming transactions i e the organization may utilize its own provider identifications system Regardless of how organizations identify their facilities M C organizations must be able to distinguish diagnoses submitted by facilities that qualify as Medicare hospital inpatient facilities from diagnoses submitted by non qualifying facilities For diagnoses received from non network facilities the M C organization should first check whether the
59. ates for Calendar Year CY 2004 January 16 2004 http cms hhs gov healthplans rates 2004ma cover pdf Advance Notice of Methodological Changes for Calendar Year CY 2005 Medicare Advantage MA Payment Rates 45 Day Notice http cms hhs gov healthplans rates 2005 45day pdf Advance Notice of Methodological Changes for Calendar Year CY 2006 Medicare Advantage MA Payment Rates 45 Day Notice http www cms hhs gov healthplans rates 2006 45 day pdf Announcement of Calendar Year CY 2006 Medicare Advantage Payment Rates April 4 2005 http www cms hhs gov healthplans rates 2006 cover pdf Medicare Managed Care Manual http cms hhs gov manuals 116_mmc mc86toc asp Rate Book Information http cms hhs gov healthplans rates Risk Adjustment Models http cms hhs gov healthplans rates Healthplans Page http www cms hhs gov healthplans Risk Adjustment Page http www cms hhs gov healthplans riskadj Aspen Systems Corporation 6 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Health I nsurance Portability and Accountability Act HI PAA Page http www cms hhs gov hipaa Quarterly Provider Updates http www cms hhs gov providerupdate main asp Operational Policy Letters http cms hhs gov healthplans opl Official Meeting Notices http cms hhs gov providerupdate notices asp Medicare Bene
60. ation Page 5 of 54 December 3 2003 Paragraph 2 RA Payment Types This section is a brief introduction to the different types of payments and RAFs Paragraph 3 RAFTiming This section captures the timing issues associated with the creation of RAFs It does not define when the RAF is used that is defined in paragraph 4 Paragraph 4 Payment Rules This section captures both 1 the decisions on how to choose a RAF for payment and 2 the formula for calculating the Risk Adjusted Payment Paragraph 5 Sources This section describes the sources for the data that GHP and MMCS will use to calculate the Risk Adjusted payment 2 Payment Types The GHP and MMCS payment systems will calculate the following types of payments e Hospice e New Enrollee Dialysis New Enrollee e Default for New Enrollee Dialysis e New Enrollee Frailty e Dialysis e Default for New e Transplant e Default for New Enrollee Frailty e Default for New Enrollee Transplant e Community e New Enrollee Post Transplant e Community Frailty e Default for New Enrollee Post e Institutional Transplant e Demographic ESRD e Community Post Transplant e PACE Demographic ESRD e Institutional Post Transplant Please note that Working Aged MSP and MSP for ESRD will be implemented in 2004 However they are not addressed in this document These payments are based upon multipliers that will be applied at the Contract level This will happen within APPS
61. ation of the principal diagnosis The remaining diagnoses from a hospital inpatient stay shall be coded as Provider Type 02 Other Hospital Inpatient The guidance for coding other conditions appears in Official ICD 9 CM Guidelines for Coding and Reporting as well as in the section of these instructions titled Coexisting Conditions Aspen Systems Corporation 11 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Outpatient Hospital Data Hospital outpatient data includes any diagnoses from a hospital outpatient department excluding diagnoses that are derived only from claims or encounters for laboratory services ambulance or durable medical equipment prosthetics orthotics and supplies Hospital outpatient departments include all provider types listed on Table 2 at the end of these instructions Along with the provider types in the table Table 2 also lists the valid Medicare provider number ranges for those provider types The XX in the first two positions of every range represents the state code component of the Medicare provider number Because Medicare has multiple number ranges for many provider types and continuous number ranges feature multiple provider types a simplified list with the continuous valid Medicare provider number ranges for hospital outpatient facilities is provided in Table 3 CMS has included Federally Qualifie
62. bled ndicator CN 192192 192 sayments adluctments 4 193 193 Encounter data used to calculate RA factor ex payment year by 6 months 45 Segment ID 3 194 196 Identification number of the segment of the PBP Blank if there are no segments Aspen Systems Corporation 23 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE MMR FLAT FILE LAYOUT CONTI NUED Field Len Pos Description The source of the enrollment Values are A Auto enrolled by CMS B Beneficiary election i SEEN SOUS 1 d C Facilitated enrollment by CMS D Systematic enrollment by CMS rollover group member is not in an employer group The premium amount for determining the MA payment attributable to Part A It is subtracted 48 js 199 206 from the MA plan payment for plans that bid mount above the benchmark 99 The premium amount for determining the MA payment attributable to Part B It is subtracted 49 ME C Paaie Prernikin Span 207 214 from the MA plan payment for plans that bid mount above the benchmark 99 The amount of the rebate allocated to reducing the member s Part A cost sharing This amount 50 215 222 is added to the MA plan payment for plans that eduction bid below the benchmark 99 The amount of the rebate allocated to reducing the member s Par
63. chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration the principal or first listed diagnosis is V58 0 Encounter for radiotherapy or V58 1 Encounter for chemotherapy When the reason for admission encounter is to determine the extent of the malignancy or for a procedure such as paracentesis or thoracentesis the primary malignancy or appropriate metastatic site is designated as the principal or first listed diagnosis even though chemotherapy or radiotherapy is administered Symptoms signs and ill defined conditions listed in Chapter 16 characteristic of or associated with an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first listed diagnosis regardless of the number of admissions or encounters for treatment and care of the neoplasm Aspen Systems Corporation 52 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RISK ADJ USTMENT PROCESSI NG SYSTEM CROSSWALKS Aspen Systems Corporation 53 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ANSI NSF 3051 RISK ADJUSTMENT PROCESSING SYSTEM ANSI X12 3051B CROSS
64. continued diagnosis clusters from this record were stored In FERAS this error code 1s edited on the first and the last CCC record only Internet Aspen Systems Corporation 30 2005 Risk Adjustment Data Basic Training CIs For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Training Guides and Updates http csscoperations com new usergroup traininginfo html Zi Training Microsoft Internet Explorer File Edit View Favorites Tools Help ay E D i i 2S B LJ 3 Back x Search Favorites Meda c ew 2 Address http www mcoservice com new usergroup traininginfo html Home Page Hot Topics System Status RAPS References User Group Training Qs Site Map Site Search Training Information Please click on the circle to go to the desired topic To go to all other pages use wef at the top of the page Aspen Systems Training Center Register for 2005 Regional Training Introduction Letter amp List of Change Pages for Revisions Revision 11 24 03 Participant Guide Revision 11 24 03 Presentation Slides Revision 11 24 03 RAPS 2003 Regional Training Resource Guide Revision 11 24 03 June 2003 RA Regional Training Q amp As RO Contacts 2003 Regional RA Training Materials Delivery Status Introduction Lette
65. cord Type F Frailty Factor The frailty factor will be calculated as an add on to the beneficiaries payment This will only apply to beneficiaries within Contracts that are designated as frailty Contracts For each frailty Contract the frailty factor will be based upon the information on beneficiaries within that Contract The table will provide Frailty Factors by Contract H The file format for the records is as follows FIELD NAME LENGTH START FORMAT COMMENTS POSITION Record Type 1 1 Frailty Factors Contract 5 2 HXXXX Number Effective 8 7 YYYYMMDD Start Date Effective 8 15 YYYYMMDD End Date Frailty Factor 7 23 NN DDDD 5 9 2 Record Type G Non Community MCO Indicator This file indicates what percentage of Institutional Mixed beneficiaries are enrolled in each Contract The file format for the records is as follows FIELD NAME LENGTH START FORMAT COMMENTS POSITION Record Type 1 1 G Non Community MCOs Contract 5 2 HXXXX Number 1 Assume that all contracts not on this file are Community MCOs RA Operational Specification December 3 2003 Page 46 of 54 Effective 8 7 YYYYMMDD Start Date Effective 8 15 YYYYMMDD End Date 5 9 3 Record Type H Non 70 30 Blend MCOs The payments to are blended using Demographic payments and Risk Adjusted payments For determining payments the system wi
66. ct subsidy payment for the 68 Part D Direct Subsidy Payment 10 349 358 member Amount 99 Applies to all members Aspen Systems Corporation 25 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE MMR FLAT FI LE LAYOUT CONTI NUED Field Name Len Pos Description The amount of the reinsurance subsidy included 69 Reinsurance Subsidy Amount 359 368 the payment 99 Applies to all members Cost The amount of the low income subsidy cost 70 Sharing Amount 369 378 sharing amount included the payment 9 99 Applies to LIS members The total Part D payment for the member 71 Total Part D Payment eee 379 389 5 99 72 Number of payment adjustment 390 391 Total number of months covered by the months Part D payment adjustment 99 73 PACE Premium Add On 392 401 2 PACE Premium Add on amount 74 PACE Cost Sharing Add On 402 411 Total Part D PACE Cost Sharing Add on amount 99 Aspen Systems Corporation 26 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CSSC WEB RESOURCES Aspen Systems Corporation 27 2005 Risk Adjustment Data Basic Training CIWS For Medicare Advantage Organizations CENTERS for MEDICA
67. d aii eb 12 RA Operational Specification Page 4 of 54 December 3 2003 Risk Adjustment 2004 Operational Specification 1 Introduction The purpose of this document is to coordinate the Risk Adjustment Factor RAF information between the following parties CBC DMCS MMCS and their contractor CSC DMCS RAS and their contractor and GHP This document is in an interim state The intent of the document is to capture information as it unfolds This document will be maintained by DMCS Contact either Wendy Couch 410 786 6933 or Laquia Marks 410 786 312 to request changes There is a log with a synopsis of the changes for each release on the second page of the document distribution of this document is DMCS CBC OTHER CMS Wendy Couch Jane Andrews Mel Ingber ORDI Robin Geronimo Sean Creighton Matthew Leipold OCSQ Laquia Marks Jeff Grant Roger Milam OCSQ George Manaras Ed Howard Sol Mussey OACT Mary Sincavage Janice Keys Priscilla Waldman Marla Kilbourne Kim Miegel Cynthia Tudor OTHER NON CMS Dave Freund Fu Terry Gallagher IBM Phyllis Kay CSC Please note that MMCS and GHP are used interchangeably in this document unless stated otherwise This document is divided into 5 parts as follows Paragraph 1 Introduction This section introduces the purpose of the document document maintenance and the flow of the content within the document RA Operational Specific
68. d This is not a risk adjusted payment therefore no formula is provided This payment is made using the traditional ESRD payment methodology RA Operational Specification Page 29 of 54 December 3 2003 4 3 10 PACE WPP ESRD Demographic A PACE WPP ESRD Demographic payment is made for PACE WPP beneficiaries who have ESRD status The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for any of the scenarios are true then the payment calculation should be for a PACE WPP ESRD Demographic Factor payment This payment should be made when all of the following rules are met a The beneficiary is not in hospice amp b The beneficiary is in ESRD status amp c The beneficiary is not in an ESRD Demonstration amp d The beneficiary is in PACE WPP Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers Note In 2005 and beyond all ESRD beneficiaries will be risk adjusted This is not a risk adjusted payment therefore no formula is provided This payment is made using the traditional PACE ESRD payment methodology RA Operational Specification Page 30 of 54 December 3 2003 4 3 11 New Enrollee Dialysis Payment A New Enrollee Dialysis Factor payment is made when a beneficiary is on dialysis but has been in Medicare for less than one year and therefore not
69. d Health Centers Community Mental Health Centers and Rural Health clinics in the list of outpatient facilities to ensure organizations are allowed to submit complete physician data These three facility types utilize a composite bill that covers both the physician and the facility component of the services and services rendered in these facilities do not result in an independent physician claim organizations should determine which providers qualify as hospital outpatient facilities in a similar manner as they determine which providers qualify as hospital inpatient facilities As with hospital inpatient data diagnoses collected from network providers are differentiated from diagnoses collected from non network providers Because all organization network hospitals must have a provider agreement all network hospital outpatient facilities must have a Medicare provider number within the range of valid hospital outpatient provider numbers see Table 3 below If a facility does not have a hospital outpatient Medicare provider number the M C organization shall not submit diagnoses from that facility as hospital outpatient data It is not necessary that M C organizations receive the Medicare provider number on incoming risk adjustment transactions even if the transactions are electronic encounters or claims However organizations must be able to distinguish diagnoses submitted by providers that qualify as hospital outpatient facilit
70. der Number Ranges Type of I npatient Hospital Facility Number Range Short term General and Specialty Hospitals XX0001 XX0899 XXS001 XX5899 XXT001 XXT899 Medical Assistance Facilities Critical Access Hospitals XX1225 XX1399 Religious Non Medical Health Care Institutions formerly Christian Science Sanatoria XX1990 XX1999 Long term Hospitals XX2000 XX2299 Rehabilitation Hospitals XX3025 XX3099 Children s Hospitals XX3300 XX3399 Psychiatric Hospitals XX4000 XX4499 Table 2 Facility Types Acceptable for Hospital Outpatient Risk Adjustment Data Submission and Associated Valid Medicare Provider Number Ranges Type of Outpatient Hospital Facility Number Range Short term General and Specialty Hospitals XX0001 XX0899 XXS001 XX5899 XXT001 XXT899 Medical Assistance Facilities Critical Access Hospitals XX1225 XX1399 Community Mental Health Centers XX1400 XX1499 XX4600 XX4799 XX4900 XX4999 Federally Qualified Health Centers Religious Non Medical Health Care Institutions formerly Christian Science Sanatoria XX1800 XX1999 Long term Hospitals XX2000 XX2299 Rehabilitation Hospitals XX3025 XX3099 Children s Hospitals XX3300 XX3399 Rural Health Clinic Freestanding and Provider Based XX3400 XX3499 XX3800 XX3999 XX8500 XX8999 Psychiatric Hospitals XX4000 XX4499 Table 3 Continuous Valid Medicare Provider N
71. e This table is utilized by MMCS GHP to calculate 1 new enrollee RAFs when none exists for a managed care enrollee and 2 post transplant RAFs when none exists for an ESRD enrollee in post transplant status The format for 2004 is different from 2003 detailed layout is in May 127 notice In general the format will include Two columns Base Factor and Drug Add On Post Graft Four sets of columns d Base b Medicaid c Originally Disabled d Medicaid and Originally Disabled Each set of rows is divided into Male and Female subsections each of which is subdivided by age groups The sex and age division is the same as in the current Default Risk Adjustment Base Factors Table for New Enrollees See 12 13 02 RAS MMCS ICD Appendix D RA Operational Specification Page 44 of 54 December 3 2003 5 6 New Enrollee ESRD Default Table This table provides both the dialysis and the graft information For Graft status the table provides a single factor there are no bump ups This is one table that provides both dialysis and graft information and not two separate tables For dialysis the detailed layout is TBD In general the format will include Dialysis factors are divided into four sets of columns d Base b Medicaid c Previously Disabled d Medicaid and Previously Disabled Each set of columns is divided into Male and Female subsections each of which is subdivided by age groups It is not certain whether the
72. e Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CMS OPERATI ONS SPECI FI CATI ONS Aspen Systems Corporation 59 CATS Risk Adjustment 2004 Operations Specification December 3 2003 Change History Date Changed b Description 17 Jun 2003 Wendy Couch Initial Version 20 Aug 2003 Wendy Couch Changes from 14 Jul 2003 meeting 28 Aug 2003 Wendy Couch Revised process flow and impact to the text enhanced front summa 29 Aug 2003 Wendy Couch Minor changes suggested in RA Ops Spec Meeting 2 Sep 2003 Wendy Couch Revised Process flow and reorganize paragraph 4 8 Se 2003 Wendy Couch Incorporated C Tudor s comments from previous meeting 12 2003 Wendy Couch Incorporated J Grant s comments 15 Sep 2003 Wendy Couch Revised Process flow and reorganize paragraph 4 03 Oct 2003 Group Incorporate answers to questions 31 Oct 2003 Jeff amp Wend Incorporate Jeff s comments 14 Nov 2003 Jeff amp Wendy Incorporate Comments from various parties mostly clarifications and removing duplicate information 01 Dec 2003 Group Baseline Document 03 Dec 2003 Jeff amp Wendy For transplant payments to beneficiaries changing to an ESRD Demonstration change the percentage portion from 15 to 1 3 RA Operational Specification Page 2 of 54 December 3 2003 Table of Contents 1 ode eite ced cei 5 2 Payment
73. e Risk Adjustment Ratebook the Phase I Demonstration Risk Ratebook or the Phase II Demonstration Risk Ratebook RA Operational Specification Page 43 of 54 December 3 2003 5 3 1 Risk Adjustment Ratebook This is a county level table of Risk Adjusted base rates This ratebook should generally not change during the payment year however the system should be flexible enough to handle the odd exception 5 3 2 Phase Demonstration Risk Ratebook This is county level table of Risk Adjusted base rates It is similar to the base risk adjustment rate book but is adjusted for each specific plan to a plan negotiated rate This ratebook should generally not change during the payment year however the system should be flexible enough to handle the odd exception 5 3 3 Phase Demonstration Risk Ratebook This is a county level table of Risk Adjusted base rates This ratebook has all the features of the risk adjustment ratebook but the rates are the higher of the risk adjustment ratebook and a 9996 fee for service risk adjustment ratebook This ratebook should generally not change during the payment year however the system should be flexible enough to handle the odd exception 5 4 ESRD Risk Ratebook This is a State level table of ESRD base rates This ratebook should generally not change during the payment year however the system should be flexible enough to handle the odd exception 5 5 New Enrollee Base Default Tabl
74. e beneficiary is enrolled in a Institutional Mixed Plan The beneficiary does not have an MDS flag The beneficiary is age 55 or over Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula RA Operational Specification December 3 2003 Page 19 of 54 Enrollee Factor Source is defined in 7 5 1 Frailty Factor Source defined in qf 5 9 1 Risk X Adjustment Ratebook Defined 75 3 1 Risk Adjusted X Blend Portion of Beneficiary Payment Source defined in 9 5 9 3 RA Operational Specification December 3 2003 Page 20 of 54 4 3 4 Default for New Enrollee Payment A Default for New Enrollee payment is made when no RAF is available for a beneficiary and the beneficiary does not fall into any other special category e g Frailty or ESRD The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true for any one of the scenarios then the payment calculation shoud be for a Default for New Enrollee For 2004 either Scenario A Or Scenario a The beneficiary is not in hospice amp a The beneficiary is not in hospice amp b The benefici
75. eneficiary is not enrolled in a Frailty Plan a b d e 5 Scenario The beneficiary is not in hospice amp The beneficiary is not in ESRD amp There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp There is a New Enrollee Factor for the beneficiary on the Fu RAS File amp The beneficiary is enrolled in a Frailty Plan amp The beneficiary is enrolled in an Institutional Mixed Plan amp The beneficiary has an MDS flag a b d e 5 Scenario The beneficiary is not in hospice amp The beneficiary is not in ESRD amp There 15 not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp There is a New Enrollee Factor for the beneficiary on the Fu RAS File amp The beneficiary is enrolled in a Frailty Plan amp The beneficiary is not enrolled in an Institutional Mixed Plan amp The beneficiary is under age 55 Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula RA Operational Specification December 3 2003 Page 17 of 54 Risk Risk Adjusted New Enrollee Adjustment E Portion of Factor Family of E Ble
76. est COMPLETE FOR ALL REQUESTS Check one box indicating type of request enter name and current CMS UserlD in blocks indicated if using one A separate form must be submitted for each action desired Section 2 User Information COMPLETE FOR NEW CHANGE AND RECERTIFY REQUESTS Check employee type and complete blocks a through h CM S Employees Blocks e g and h may be left blank If not stationed at CMS Central Office provide a complete mailing address in block b and leave block c blank Non CM S Employees Block c may be left blank if not stationed at CMS Central Office For block h if your contract number is unknown obtain it from your Project Officer or your CMS contact person Section 3 Type of Access Required COMPLETE FOR NEW CHANGE AND RECERTIFY REQUESTS For NEW Requests Check each type of access required List the names of all CMS applications you require access to i e OSCAR CROWD CAFM CLIA in block a Application s For each application check the appropriate columns to indicate the environment s access is needed in and if remote access is required DO NOT USE THIS BLOCK TO ENTER SOFTWARE THAT IS PART OF THE STANDARD CMS WORKSTATION CONFIGURATION SEE BLOCK D Use block b Subsystems to request access not specific to particular applications This block is used to note accesses such as native TSO commands usually required by system developers If Other is checked be sure specify here and in Sectio
77. ew Enrollee Post transplant RAF Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula New Enrollee Risk 2 Post transplant X Adjustment X Blend Benefici Factor Ratebook Payment Source iog Defined in defined RAS Fu file 5 3 1 defined 4 5 7 593 RA Operational Specification Page 37 of 54 December 3 2003 4 3 17 Default for New Enrollee Post Transplant Payment A Default for New Enrollee Post Transplant payment is made when the beneficiary has a functioning graft that is past the initial 3 month transplant period however no RAF is available for a beneficiary The chart to the right follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a Default for New Enrollee Post Transplant payment should be calculated for the beneficiary a b c d e f 5 This payment should be made when all of the following rules are met The beneficiary is not in hospice The beneficiary is in ESRD status The beneficiary is in an ESRD Demonstration The beneficiary is not in the transplant period amp The beneficiary is not on dialysis amp The beneficiary does not have a Community or Institutional
78. ficiary Database User s Manual http cms hhs gov healthplans systems mcouserguide pdf Official Coding Guidelines on Centers for Disease Control amp Prevention Website http www cdc gov nchs data icd9 icdguide pdf Risk Adjustment Model Output Report Letter http csscoperations com new references cmsinstructions html Aspen Systems Corporation 7 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CMS REFERENCE DOCUMENTS Aspen Systems Corporation 8 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Health Plan Management System HPMS HPMS is a CMS information system created specifically for the Medicare Advantage program that provides MA organization level information Accessing HPMS e Access to HPMS is accomplished via the Medicare Data Communications Network MDCN e A User ID is required for HPMS access If you do not currently have access complete the Access to CMS Computer Systems form available at http cms hhs gov mdcn hdcidform asp or at the end of this Resource Guide e If MA organizations experience difficulty logging into HPMS please contact Don Freeburger dfreeburger cms hhs gov 410 786 4586 or Neetu Balani nbalani cms hhs gov 410 786 2548 Aspen Systems Corporation 9 2005 Risk Adjustment Data
79. he indication that the beneficiary is long term institutional will be on the beneficiary level risk adjuster record in the FU file The field long term institutional flag will equal Y to indicate the beneficiary has long term institutional The beneficiary does not have an MDS flag For 2004 if the long term institutional flag on the beneficiary level risk adjuster record in the FU file is spaces then the beneficiary does not have long term RA Operational Specification December 3 2003 Page 53 of 54 institutional The beneficiary is under age 55 On MBD use the birth date to calculate the beneficiary s age The beneficiary is age 55 or over On MBD use the birth date to calculate the beneficiary s age There is a New Enrollee Factor for the beneficiary on the Fu RAS File The New Enrollee Factor for the beneficiary exists on the Fu RAS File There is not a New Enrollee Factor for the beneficiary on the Fu RAS File The New Enrollee Factor for the beneficiary does not exist on the Fu RAS File The beneficiary is in an ESRD Demonstration PICS will provide the Payment Bill Option 12 and Demo Type code TBD to determine if the beneficiary is in an ESRD Demonstration For MMCS this data will be stored in the MCO tables The beneficiary is not in an ESRD Demonstration The contract number the beneficiary is enrolled in is not the corresponding Payment Bill
80. hodology for the new plan effective the month of the enrollment change 4 1 3 Changes in Contract during the Payment Year For 2004 a contract should not change from a Community organization to an Institutional Mixed organization within the contract year or vice versa However the system should be flexible enough to handle the odd exception RA Operational Specification Page 10 of 54 December 3 2003 4 2 Overview of Choosing the RA Payment The decision tree in Figure 1 is a graphical representation of the logic behind choosing the RA payment calculation to be applied to each beneficiary RA Operational Specification Page 11 of 54 December 3 2003 Hospice Yes Risk Adjustment Payment Type Selection for 2004 version dated 9 15 03 Figure 1 RA Decision Diagram New enrollee enrollee No enrollee pos gratt factor Yes factor exists Enrolled In Fralty Han Erolled In Mixed New Errollee See 4 3 3 y y y A PACE WPP ESRD Default for New TS New Enrollee Default for New Institutional Post Community Post New Enrollee Default for New p Community Factor Derogspne Demographic Errollee Transplant Diss Didyss amp rollee Didyds Tranglent Tranglent Pos Trangant Gnrollee
81. hologist Multispecialty clinic or group practice Peripheral vascular disease Vascular surgery Cardiac surgery Addiction medicine Licensed clinical social worker Critical care intensivists Hematology Hematology oncology Preventative medicine Maxillofacial surgery Neuropsychiatry Certified clinical nurse specialist Medical oncology Surgical oncology Radiation oncology Emergency medicine Interventional radiology Physician assistant Gynecologist oncologist Unknown physician specialty Aspen Systems Corporation 20 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE MONTHLY MEMBERSHI P REPORT MMR MMR FLAT FILE LAYOUT Field Len Pos Description 1 Contract Number The organization s Contract Number 2 Run Date of the File YYYYMMDD 4 HIC Number 12 20 31 Member s HIC 5 Surname 7 32 38 6 First Initial 1 39 39 1 Sex 40 40 M Male Female 8 Date of Birth EN 41 48 YYYYMMDD BBEE 49 52 BB Beginning Age EE Ending Age State amp County Code 53 57 Y Out of Contract level service area Out of Area Indicator 58 58 Always Spaces on Adjustment Part A Entitlement EE 59 59 Entitled to Part A m P Age Group rH I m N he 13 Part B Entitlement 1 60 60 Y Entitled to Part B 14 Hospice 1 61 61 Y Hospice 15 ESRD 1 62 62 Y
82. ialysis Enrollee Dialysis ESRD Default Factor Table Dialysis Dialysis Factor ESRD RAS RA Operational Specification Page 7 of 54 December 3 2003 Payment Corresponding Model Tool System RAF Housing Model Tool Transplant Transplant Factor ESRD RAS Default for New Default for New New Enrollee GHP MMCS Enrollee Enrollee ESRD Default Transplant Transplant Factor Table New Enrollee Post New Enrollee ESRD RAS Transplant Post Transplant Factor Default for New Default for New New Enrollee GHP MMCS Enrollee Post Enrollee Post Base Default Transplant Transplant Factor Table Community Post Community Post ESRD RAS Transplant Transplant Factor Institutional Post Institutional Post ESRD RAS Transplant Transplant Factor 3 RAF Timing The detailed schedule for implementing the new systems and decommissioning the legacy systems will be addressed in a separate MSProject source The purpose of this section is to define a typical cyclical basis upon which RAS will run RAFs The following two charts represent payment years 2004 and 2005 CMS HCC Model Runs Regular Cycle For Payment Year 2004 Name of Run Data Data RAF Payment Made from RAF Collection Submission Transmitted Period Deadline to MMCS Initial RAF 07 01 02 09 30 03 11 15 03 2004 Payments made between Calculation 06 30 03 1 1 04 6 30 04 2004 Mid Year 01 01 03 03 31 04 5
83. ication Plan Number Hnnnn Plan Name Address Fax Number Operations Contact Person E Mail address Phone Number Technical Contact Person E Mail address Phone Number What format do you plan to use to submit Risk Adjustment Data RAPS Format M4 CO NSF Format UB 92 version 6 0 ANSI 837 4010 Aspen Systems Corporation 42 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE What Connection Type is established via the Medicare Data Communications Network MDCN Lease Line IP NDM Dial up Modem Please list any additional Plan numbers your organization will submit data for Plan Plan Plan Plan Plan Plan Plan Plan Plan Please return the completed submitter application EDI Agreement and NDM specifications to CSSC Operations at the address below 1 877 534 55 WWW csscoperations com FAX 1 803 935 0171 Aspen Systems Corporation 43 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Risk Adjustment NDM Specifications The NDM Node connection is defined as follows NET ID SCA NODE ID A7ONDM MC APPLID A70NDMMC AGNS ID PGBA PLEASE ENTER YOUR NDM INFORMATION Required NET ID NODE ID APPLID ID Your NDM User ID and pa
84. ice and Support Center Cerebrovascular Disease Common Working File Calendar Year Data Collection Period Direct Data Entry Department of Health amp Human Services Diabetes Mellitus Durable Medical Equipment Date of Birth Department of Defense Dates of Service Diagnosis Related Group Diagnosis Electronic Data Interchange End Stage Renal Disease Eastern Time Front End Risk Adjustment System Fee for Service Federally Qualified Health Center File Transfer Protocol Group Health Plan Payment System GHP Group Output User Communication Help System Graphical User Interface MA Organization CMS Contract Number Hierarchical Condition Category Medicare Part B Claim Filing Form Healthcare Common Procedure Coding System Health Plan Employer Data Information Set Aspen Systems Corporation 2 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE ACRONYM HHS C HI PAA HMO HOS HPMS I CD 9 CM I CN IP JCAHO MA MA PD MBD organization MCCOY MDCN MDS MMA MMCS MMR MnDHO MOR MSA MSG MSHO NCH NCPDP NCQA NDM NMUD NSF OIG OREC Palmetto GBA PACE PCN PHS PI P DCG PPO QIO RAPS RAPS Database RAS RHC RRB RPT RT RxHCC SAS SH S HMO SNF TERM Department of Health and Human Services Health Insurance Claim Number Beneficiary Medicare ID Health Insurance Portability and
85. ies from diagnoses submitted by non qualifying providers For diagnoses received from non network facilities the M C organization should first check whether the hospital is a Medicare certified hospital outpatient facility If the provider is a Medicare certified hospital outpatient facility the organization should submit the diagnoses from this facility If the hospital is not Medicare certified but is a VA or DOD facility the M C organization must verify that it is a legitimate outpatient facility by contacting the CSSC prior to submitting data from that facility If the hospital is not Medicare certified or VA DOD the organization should contact CMS to verify that the facility qualifies as a hospital outpatient facility prior to submitting any diagnoses from that facility As with hospital inpatient facilities if the facility s Medicare provider number is unknown the organization may verify the provider number by contacting facility s billing department Aspen Systems Corporation 12 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Physician Data For purposes of risk adjustment data physicians are defined by the specialty list in Table 4 This list includes certain non physician practitioners who for purposes of risk adjustment data will be covered under the broad definition of physicians This list also incl
86. ion Submission Methods Data submission to CMS may be accomplished through any of the following methods 1 full or abbreviated UB 92 Version 6 0 2 full or abbreviated National Standard Format NSF Version 3 1 3 ANSI X12 837 Version 30 51 only for those submitters currently utilizing this version 4 ANSI X12 837 Version 40 10 5 the new RAPS format and 6 on line direct data entry DDE available through Palmetto Government Benefits Administrators Regardless of the method of submission that a organization selects all transactions will be subject to the same edits The Front End Risk Adjustment System FERAS will automatically format all DDE transactions in the RAPS format Transactions that are submitted in claim or encounter formats will be converted to the RAPS format prior to going through any editing The mapping from each claim or encounter transaction to the RAPS format is on the CSSC web site at www csscoperations com Each M C organization should select the most efficient method for data submission taking into account the unique nature of its data systems organizations may elect to utilize more than one submission method All transactions will be submitted using the same network connectivity that M C organizations currently utilize for encounter data submission For assistance in utilizing any of the submission methods please contact the Customer Service and Support Center CSSC at 1 877 534 2772 Aspen Sy
87. ion d The beneficiary is not in the transplant period amp e The beneficiary is not on dialysis amp f The beneficiary has Community and Institutional Post transplant RAFs amp 6 The beneficiary is not enrolled in an Institutional Mixed Plan a b d e 5 h Scenario The beneficiary is not in hospice The beneficiary is in ESRD status The beneficiary is in an ESRD Demonstration The beneficiary is not in the transplant period amp The beneficiary is not on dialysis amp The beneficiary has Community and Institutional Post transplant RAFs amp The beneficiary is enrolled in an Institutional Mixed Plan amp The beneficiary does not have an MDS flag Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula RA Operational Specification December 3 2003 Page 39 of 54 Risk Adjusted Community Risk Portion of Post transplant X Adjustment X Blend Benefici Factor Ratebook TEES Payment ie Defined in defined RAS Fu file 531 defined 4 5 7 593 RA Operational Specification Page 40 of 54 December 3 2003 4 3 19 Institutional Post Transplant An Institutional Post Transplant Factor payment is made when a beneficiary
88. itle 5 U S Code Section 552a e 10 This information is used for assigning controlling tracking and reporting authorized access to and use of CMS s formerly H CFA s computerized information and resources The Privacy Act prohibits disclosure of informati on from records protected by the statute except in limited circumstances The information you furnish on this form will be maintained in the Individuals Authorized Access to the Centers for Medicare amp Medicaid CMS Data Center Systems of Records and may be disclosed as a routine use disdosure under the routine uses established for this system as published at 59 FED REG 41329 08 11 94 and as CMS may establish in the future by publication in the Federal Register Collection of the Social Security Number SSN is authorized by Executive Order 9397 Furnishing the information on this form induding your Social Security Number is voluntary but failure to do so may result in delaying the processing of this request SECURITY REQUIREMENTS FOR USERS OF CMS s COMPUTER SYSTEMS CMS formerly HCFA uses computer systems that contain sensitive information to carry out its mission Sensitive information is any information which the loss misuse or unauthorized access to or modification of could adversely affect the national interest or the conduct of Federal programs or the privacy to which individuals are entitled under the Privacy Ac To ensure the security and privacy of sensitive informati
89. ll refer to Record Type H of the 2004 Contract Level Payment File to determine the blend for the Contract The file format for the records is as follows FIELD NAME LENGTH START FORMAT COMMENTS POSITION Record Type 1 1 Non 70 30 Blend types Contract 5 2 HXXXX lt TBD gt Number Blend 1 7 1 90DEMOG 10 RA 2 100RA 3 100 DEMOG Effective Start 8 8 YYYYMMDD Date Effective End 8 16 YYYYMMDD Date Generally the Blend ratio for a contract should not change during a payment year However the system should be flexible enough to handle the odd exception 5 9 4 MCOs Using the Lag Factor The file format for the records is as follows 2 Assume that all contract types not on this file are 70 30 RA Operational Specification December 3 2003 Page 47 of 54 6 Rules for Storing RAFs 6 1 Initial Run In November 2003 MMCS will receive a set of lag RAFS from RAS for January 2004 payments MMCS will need to recreate payments so MMCS must know what RAFS were used for calculating payments The RAF used for calculating the beneficiary level payment is stored on the beneficiary payment profile 6 2 Mid Year Run The Mid year run will result in additional RAFS that MMCS must store in the event a retroactive adjustment is required to be calculated based on a change to the beneficiary s status The Mid year run will result in both lag and non lag RAFs Temporary stor
90. mber 3 2003 Table 3 RAS RAFs for Each Beneficiary Type Beneficiaries ESRD Beneficiaries Existing New Existing New Beneficiary Beneficiary New Factor Community Factor Institutional Factor Products of CMS HCC Model RA Operational Specification December 3 2003 Page 14 of 54 In general the payment calculations described in paragraph 4 3 multiply the RAF by a Ratebook Table 4 below provides a high level view of the ratebooks applied to each RAF in the payment calculation Table 4 Ratebooks and RAFs RAF Ratebook Hospice Not Applicable New Enrollee Factor Risk Adjustment Family of Ratebooks New Enrollee Frailty Factor Risk Adjustment Ratebook Default for New Enrollee Risk Adjustment Family of Ratebooks Default for New Enrollee Frailty Risk Adjustment Ratebook Factor Community Factor Risk Adjustment Family of Ratebooks Community Factor Frailty Factor Risk Adjustment Ratebook Institutional Factor Risk Adjustment Family of Ratebooks Demographic ESRD State ESRD Demographic Ratebook PACE WPP ESRD State ESRD Demographic Ratebook New Enrollee Dialysis Factor ESRD Risk Ratebook Default for New Enrollee Dialysis ESRD Risk Ratebook Dialysis Factor ESRD Risk Ratebook Transplant Factor ESRD Risk Ratebook Default for New Enrollee Transplant ESRD Risk Ratebook Ne
91. mp Frailty Plan amp f The beneficiary is enrolled in f The beneficiary is age 55 or older Frailty Plan amp 2 The beneficiary is age 55 or older Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula RA Operational Specification Page 26 of 54 December 3 2003 Risk Risk Adjusted Comum Prou X Adjustment X Blend Pohon of Factor Factor Ratebook Beneficiary Payment Source is Source Defined Seme the defined in in 5 3 1 ee RAS Fu 9 5 9 1 in file defined 0 3 in 45 7 RA Operational Specification Page 27 of 54 December 3 2003 4 3 8 Institutional Mixed Payment An Institutional Factor payment is made when a beneficiary is in an Institutional Plan and has an MDS flag The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria below are true then the payment calculation should be for a Institutional Factor payment This payment should be made when all of the following rules are met a The beneficiary is not in hospice amp b The beneficiary is not in ESRD amp c There is a Community or Institutional RAF for the beneficiary on the Fu RAS File amp d The beneficiary is e
92. mt 9 135 143 99 Aspen Systems Corporation 22 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE MMR FLAT FI LE LAYOUT CONTI NUED Field Len Pos Description 35 FILLER 144 171 SPACES BBEE 36 Risk Adjuster Age Group RAAG 172 175 BB Beginning Age EE Ending Age NN DDDD 37 Previous Disable Ratio PRDIB 7 176 182 Percentage of Year in months for Previous Disable Add On Only on pre 2004 adjustments 38 FILLER mig 183 184 5 5 185 187 Pen Benefit Package Id 39 Plan Benefit Plan Benefit Packaged Id 3 105 187 187 FORMAT 999 Format X Values 0 Unknown 1 White 40 Race Code 188 188 2 Black 3 Other 4 Asian 5 Hispanic 6 N American Native Type of factors in use see Fields 24 25 C Community Community Post Graft ESRD C2 Community Post Graft ESRD D Dialysis ESRD E New Enrollee ED New Enrollee Dialysis ESRD a RA Factor Type Code 189 190 E1 New Enrollee Post Graft ESRD E2 New Enrollee Post Graft 11 ESRD G1 Graft ESRD G2 Graft ESRD Institutional 11 Institutional Post Graft ESRD 12 Institutional Post Graft 11 ESRD 42 Frailty Indicator 2 2000 22 191 191 MCO level Frailty Factor Included Previously Disabled Only on post 2003 43 Previously Disabled Indicator Disa
93. n 4 Reason for Request Non CM S employees should complete block c Expected Frequency of Use If access to a CMS desktop or LAN is required check your location in block d CMS Standard Desktop Software LAN Checking this box will ensure you have access to all software available on the standard CMS workstation i e Word E xcel GroupWise etc For CHANGE Requests If access needs have changed enter an to add or a D to delete for each type of access requiring a change Most changes in job duties or organizational placement require a change access needs If Other is checked be sure to specify here and in Section 4 Reason for Request For name changes only leave this block blank and go to Section 4 For RECERTIFY Requests Check each type of access required to perform your job duties If additional accesses are required submit a separate change request Those accesses currently held but not checked will be lost If Other is checked in block 3 b Subsystems or block 3 d CMS Standard Desktop Software LAN be sure to specify here and in Section 4 Reason for Request Section 4 Reason for Request COMPLETE AS REQUIRED For NEW Requests Provide an explanation of what job duties require you to access a CMS computer system Include applicable project non CMS only accounting numbers If Other is checked in block 3 b Subsystems or block 3 d CMS Standard Desktop Software LAN specify here
94. n hospice On MBD there is a Hospice Coverage Period for the given payment month The beneficiary is not in hospice Absence of Hospice Coverage period for the given payment month on MBD The beneficiary is in ESRD On MBD is there an ESRD Coverage Period for the given payment month The beneficiary is not in ESRD Absence of ESRD coverage period for the given payment month There is a Community or Institutional RAF for the beneficiary on the Fu RAS File Community or Institutional RAF exists for the beneficiary the Fu RAS File There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File Absence of the Community or Institutional RAF for the beneficiary on the Fu RAS file The beneficiary is enrolled in an Institutional Mixed Plan The Institutional Mixed Plan is identified on the contract file record type which indicates non community The beneficiary is not enrolled in an Institutional Mixed Plan The contract number is not on the contract file record type therefore assume the contract is not an Institutional Mixed Plan The beneficiary is enrolled in a Frailty Plan The beneficiary is not enrolled in a Frailty Plan The beneficiary has an MDS flag The Frailty Plan is identified on the contract file record type F The contract number is not on the contract file under record type F For 2004 t
95. nd Beneficiary Ratebooks Payment Defined RAS Fu file 15 3 in defined in 4 5 5 593 RA Operational Specification Page 18 of 54 December 3 2003 4 3 3 New Enrollee Plus Frailty Payment A New Enrollee Plus Frailty Factor payment is made when the beneficiary has less than one year of Part B data and they are enrolled in a Frailty Plan The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a New Enrollee Plus Frailty payment should be calculated for the beneficiary Scenario a The beneficiary is not in hospice amp b The beneficiary is not in ESRD amp c There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp d There is a New Enrollee Factor for the beneficiary on the Fu RAS File amp e The beneficiary is enrolled in a frailty plan amp f The beneficiary is not enrolled in a Institutional Mixed Plan 6 The beneficiary is age 55 or over Or a b d e f 5 h Scenario B The beneficiary is not in hospice amp The beneficiary is not in ESRD amp There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp There is a New Enrollee Factor for the beneficiary on the Fu RAS File amp The beneficiary is enrolled in a frailty plan amp Th
96. ng chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for any of the scenarios are true then the payment calculation should not be risk adjusted for the beneficiary This payment should be made when the following rule is met The beneficiary is in hospice Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will not apply any risk adjustment factor or blend to determine the beneficiary s payment RA Operational Specification Page 16 of 54 December 3 2003 4 3 2 New Payment A New Enrollee payment is made when a beneficiary has less than 12 months of Part B data and does not fall into a special category e g ESRD or Institutional The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true for any one of the scenarios then the payment calculation should be for a New Enrollee Factor payment For 2004 either a b d e Scenario The beneficiary is not in hospice amp The beneficiary is not in ESRD amp There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp There is a New Enrollee Factor for the beneficiary on the Fu RAS File amp The b
97. nrolled in an Institutional Mixed Plan amp e The beneficiary has an MDS flag Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Risk Adjusted Institutional Adjustment Portion of Factor Family of Ex Beneficiary Ratebooks Payment BMC Defined RAS Fu file 15 3 defined 4 5 7 593 RA Operational Specification Page 28 of 54 December 3 2003 4 3 9 Demographic ESRD A Demographic ESRD payment is made for non Demonstration beneficiaries who have ESRD status The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for any of the scenarios are true then the payment calculation should be for a Demographic ESRD Factor payment This payment should be made when all of the following rules are met a The beneficiary is not in hospice amp b The beneficiary is in ESRD status amp c The beneficiary is not in an ESRD Demonstration amp d The beneficiary is not in PACE WPP Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers Note In 2005 and beyond all ESRD beneficiaries will be risk adjuste
98. odel CMS has provided a list of the minimal ICD 9 codes required to group diagnoses for risk adjustment In all cases coding to the highest degree of specificity provides the most accurate coding and ensures appropriate grouping in the risk adjustment model For the complete list of diagnoses used in the risk adjustment model as well as the list of diagnoses with the minimum specificity required to group for the model see web links at the end of these instructions organizations must apply the following guidelines when collecting data from their provider networks If the M C organization utilizes an abbreviated method of collecting diagnoses such as a superbill the diagnoses may be coded to the highest level of specificity or to the level of specificity necessary to group the diagnosis appropriately for risk adjusted payments If the organization collects data using an encounter or claim format the codes should already be at the highest level of specificity CMS encourages organizations to utilize the full level of specificity in submitting risk adjustment data Regardless of the level of specificity of submitted diagnoses a medical record must substantiate all diagnostic information provided to CMS The Official ICD 9 CM Guidelines for Coding and Reporting see web links at end of instructions provides guidance on diagnosis coding This document provides guidelines for hospital inpatient hospital outpatient and physician service
99. okup Risk Adjustment System Reports ORAPS System Reports Revised 07 15 04 RAPS FERAS Reports Report Naming Conventions Submission Timetable Risk Adjustment Submission Timetable Revised 08 27 04 Contact Us Please note electronic mail is not necessarily secure against interception If your communication is very sensitive or includes personal information you may want to send it by 1 4 Aspen Systems Corporation 29 2005 Risk Adjustment Data Basic Training CIWS For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RAPS FERAS Error Code Lookup http www csscoperations com servlets ErrorCodeLookup Error Code Return Microsoft Internet Explorer Q sxx 7 po Search Favorites QI ei ty Y lay 33 _ Address http www csscaperations com servlets ErrarCodeLookup Be RAPS FERAS Error Code Lookup Instructions To perform an action on an error code for RAPS or FERAS enter the code then click the lt Search gt button Enter Error Code Code 310 Description MISSING INVALID HIC NO ON RECORD Suggestions In a CCC Record Field 5 Poistion 54 through 78 is either missing the Medicare HIC Number or is an invalid Medicare HIC Number The 300 Series RAPS Error Codes a record level error The record was bypassed and all editing was dis
100. on in Federal computer systems the Computer Security Act of 1987 requires agencies to identify sensitive computer systems conduct computer security training and develop computer security plans CMS maintains a system of records for use in assigning controlling tracking and reporting authorized access to and use of CM S s computerized information and resources CMS records all access to its computer systems and conducts routine reviews for unauthorized access to and or illegal activity Anyone with access to CMS Computer Systems containing sensitive information must abide by the following e Donot disclose or lend your IDENTIFICATION NUMBER AND OR PASSWORD to someone else They are for your use only and serve as your electronic signature This means that you may be held responsible for the con sequences of unauthorized or illegal transactions browse or use CMS data files for unauthorized or illegal purposes Dono use CMS data files for private gain or to misrepresent yourself or CMS e Donot make any disclosure of CMS data that is not specifically authorized e Donot duplicate CMS data files create subfiles of such records remove or transmit data unless you have been specifically authorized to do so e Donot change delete or otherwise alter CMS data files unless you have been specifically authorized to do so e Donot make copies of data files with identifiable data or data that would allow individual identities to be
101. on those claims and encounters organizations shall not utilize superbill or the minimum risk adjustment data set to obtain diagnoses from providers who submit electronic claims or encounters except when correcting erroneous diagnoses or supplementing incomplete diagnoses Regardless of the method s that the M C organization utilizes to collect data from providers any M C organization may utilize any submission method accepted by CMS UB 92 NSF ANSI risk adjustment data format or direct data entry Aspen Systems Corporation 13 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Diagnostic Coding Medicare utilizes I CD 9 CM as the official diagnosis code set for all lines of business accordance with this policy CMS will utilize ICD 9 diagnosis codes the determination of risk adjustment factors organizations must submit for each beneficiary all relevant ICD 9 codes that are utilized in the risk adjustment model M C organizations must submit each relevant diagnosis at least once during a risk adjustment data reporting period with the first period being J 1 2002 June 30 2003 Future risk adjustment data reporting periods will be announced January 15 2003 At a minimum the submitted ICD 9 codes must be sufficiently specific to allow appropriate grouping of the diagnoses the risk adjustment m
102. orization and signature Based on best knowledge information and belief that it will submit risk adjustment data that are accurate complete and truthful That it will retain all original source documentation and medical records pertaining to any such particular Medicare risk adjustment data for a period of at least 6 years 3 months after the risk adjustment data is received and processed That it will affix the CMS assigned unique identifier number of the eligible organization on each risk adjustment data electronically transmitted to the contractor That the CMS assigned unique identifier number constitutes the eligible organization s legal electronic signature Aspen Systems Corporation 39 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE 9 That it will use sufficient security procedures to ensure that all transmissions of documents authorized and protect all beneficiary specific data from improper access 10 That it will establish and maintain procedures and controls so that information concerning Medicare beneficiaries or any information obtained from CMS or its contractor shall not be used by agents officers or employees of the billing service except as provided by the contractor in accordance with 1106 a of the Act 11 That it will research and correct risk adjustment data discrepancies 12 That it
103. ot missing 40 Alphabetic e missing 41 e CCYYMMDD format e Not missing 21 3 0 1 9 Y or missing 50 1 52 5 Middle Initial D Date of Birth Previously Disabled Y previously entitled to Medicare due to disability Y or missing Y Medicaid Status Applicable to Risk Adjustment Factors Medicaid Flag 9 New Enrollee Flag e Yormissing e Y New Enrollee Factor used Long Term e Yormissing Institutional Flag e Y MDS as L T Institutional RA Operational Specification Page 50 of 54 December 3 2003 RISK ADJUSTMENT DOWNLOAD RECORD FOR CY2004 next to field number denotes change from previous version FIELD NAME START POSITION Start Date End Date Community Factor Institutional Factor New Enrollee Dialysis Factor New Enrollee Post Transplant Factor Dialysis Factor 16 New Enrollee Factor FORMAT COMMENTS CCYYMMDD format Not missing values are 20040101 CCYYMMDD format Not missing values are 20041231 NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 00 0010 and 99 9990 Present only if new enrollee flag is set to Y NN DDDD format Leading N may be left blank Rounded to 3 decimal places with trailing Zero Values between 0
104. ource including who will provide them 4 1 Payment Rules for All Payments The following general rules apply to all beneficiary level payment calculations regardless of RAF 4 1 1 Lag Non Lag Lag Non Lag This rule only applies to selecting the factor created in the Mid year RAF calculation MMCS and GHP will know if all beneficiaries are lag or Non lag based upon the MCO contract they are in as defined in the 2004 Contract Level Payment File see Section 5 9 Record type I in the 2004 Contract Level Payment File will list MCOs that have opted to use the lag factor versus the non lag factor e All beneficiaries enrolled in MCOs listed in the 2004 Contract Level Payment File will have their payment based upon the lag factor through the payment year In March of the following year MMCS will adjust 2004 payments retroactively to reflect the difference between the lagged and non lagged factor e All beneficiaries in MCOs which are not listed in the 2004 Contract Level Payment File see Section 5 9 2 will have their payment based upon the non lag factor For the non lagged contracts an adjustment to the beneficiary payments for the year will be calculated from January to the current payment month in which the file is processed This is not calculated for the lag contracts 4 1 2 Changes in Plan Enrollment during the Payment Year If a beneficiary changes in plan enrollment during a payment year use the appropriate factor payment met
105. payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is not in the transplant period amp e The beneficiary is on dialysis amp f The beneficiary has a dialysis RAF Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Risk Adjusted 2 ESRD Risk Portion of Dialysis Factor X Ratebook X Blend Beneficiary Payment Source is the RAS Fu file E defined in 4 5 7 593 RA Operational Specification Page 33 of 54 December 3 2003 4 3 14 Transplant Payment A Transplant Payment is made for a beneficiary during the first three months after having a graft In 2004 MMCS and GHP will handle the timing of the transplant payments as follows o If the transplant takes place on the 1 then the three month transplant period starts in that month and payment for that month will be based on the transplant factor and o If the transplant takes place any date other than 1 of the month the three month transplant payment period starts the month after the transplant takes place The Transplant Factor is a national factor
106. r to Medicare Compliance Officer Risk Adjustment Data Physician s Introduction Letter to Physicians Training Physician CD Instructions Physician CD Labels Avery Software Version 1 16 Physician CD Labels Avery Design Pro Software Version 4 0 Regional Training Q amp A s 2004 Special Training Session Introduction Letter amp List of Change Pages for Revisions Revision 03 02 05 Participant Guide Revision 03 02 05 maa RAPS 2004 Regional Training Aspen Systems Corporation 31 CMTS CENTERS for MEDICARE amp MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE User Group nformation http www csscoperations com new usergroup usergroupinfo html User Group Information Microsoft Internet Explorer File Edit View Favorites Tools X 2 ix a P Search 472 Favorites A r E 3 http www csscoperations com new usergroup usergroupinfo html i Address User Group Information Home Page Hot Topics System Status RAPS References 4 User Group Training Please click on the circle to to the desired topic go to all other pages use the blue menu bar at the top of the page User Group Registration Registration Form O Monthly User Group Meeting Contact User Group Meetings Schedule Date
107. recorded based on a visit to one of the three provider types covered by the risk adjustment data collection requirements The first data collection period will cover all diagnoses submitted for dates of service from July 1 2002 through June 30 2003 CMS will utilize the through date of a particular diagnosis when determining the date of service for purposes of risk adjustment i e all diagnoses that have a through date that falls within the data collection year will be utilized in the risk adjustment model For hospital inpatient diagnoses the through date should be the date of discharge All hospital inpatient diagnoses shall have a through date For physician and hospital outpatient diagnoses the through date should represent either the Aspen Systems Corporation 15 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE exact date of a patient visit or the last visit date for a series of services For outpatient and physician diagnoses that correspond to a single date of service organizations have the option of submitting only the from date leaving the through date blank When a organization submits a from date and no through date the Risk Adjustment Processing System RAPS will automatically copy the from date into the through date field The returned file provided to the organization will con
108. reported to CMS is recorded in the beneficiary s medical record for the data collection period or that the medical record documents the clinical evidence of that specific diagnosis for the data collection period For example prescription of an ACE inhibitor alone would not be considered as sufficient the sole data source of clinical evidence of CHF instead the medical record would need to document an appropriate clinician s diagnosis of congestive heart failure during the data collection period e g where an appropriate clinician is a physician nurse practitioner physician assistant A laboratory test showing one reading of high blood sugar would also not be considered to be sufficient clinical evidence of diabetes the medical record would need to document a clinician s diagnosis of diabetes during the data collection period Diagnosis Submission For each enrolled beneficiary organizations shall submit each relevant diagnosis at least once during a data collection period A relevant diagnosis is one that meets three criteria 1 the diagnosis is utilized in the model 2 the diagnosis was received from one of the three provider types covered by the risk adjustment requirements and 3 the diagnosis was collected according to the risk adjustment data collection instructions organizations may elect to submit a diagnosis more than once during a data collection period for any given beneficiary as long as that diagnosis was
109. rt Risk Adjustment within the required schedule Table 6 below provides a summary list The table is followed by detailed explanations in the subsequent paragraphs Table 6 Schedule For Receipt of Software Tables and Ratebooks Item Who No Later than Date Paragraph Described In Below to be used in payment calculations CMS HCC Model Final version From ORDI Mel Ingber Through Cynthia Tudor To DMCS George Manaras and Fu June 2003 54 ESRD Model From ORDI Mel Ingber Through Cynthia Tudor To DMCS George Manaras and Fu Draft Final 9 2 Risk Adjustment Ratebook From OACT Mel Ingber Through Cynthia Tudor To MMCS Mary Sincavage and GHP Kim Miegel October 2003 5 3 ESRD Risk Ratebook From ORDI Mel Ingber Through Cynthia Tudor To MMCS Mary Sincavage and GHP Kim Miegel New Enrollee Base Default Table From ORDI Mel Ingber Through Cynthia Tudor To MMCS Mary Sincavage and GHP Kim Miegel May 2003 Table New Enrollee Dialysis Default From ORDI Mel Ingber Through Cynthia Tudor To MMCS Mary Sincavage and GHP Kim Miegel Fu File RAS File to GHP MMCS From Fu and RAS George Manaras Through Cynthia Tudor To MMCS Mary Sincavage and GHP Kim Miegel Fu Oct 03 RAS RA Operational Specification December 3 2003 Page 42 of 54 NoLater Paragraph than Described I
110. s 9 codes are updated on an annual basis Physicians and providers must begin using the ICD 9 CM codes as updated in October 2001 for risk adjustment data submitted on or after July 1 2002 It is very important that physicians and providers use the most recent version of the ICD 9 CM coding book Failure to use the proper codes will result in diagnoses being rejected in the Risk Adjustment Processing System Information regarding CD 9 CM codes is available on the Internet at http cms hhs gov Coexisting Conditions Physicians and providers should use the Official ICD 9 CM Guidelines for Coding and Reporting and Medicare fee for service rules when submitting risk adjustment data to organizations The official guidelines that govern those coexisting conditions that may be coded and reported by hospital inpatient hospital outpatient and physician providers are summarized below The guidelines for inpatient hospital stays are as follows conditions that coexist at the time of admission that develop subsequently or that affect the treatment received and or length of stay Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded The guidelines for coexisting conditions that should be coded for hospital outpatient and physician services are as follows Aspen Systems Corporation 14 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage
111. s 2002 User Group Meeting Information Q amp A s Notes Slides 2003 User Group Meeting Information Q amp A s Notes Slides 2004 User Group Meeting Information O Q amp A s Notes Slides 2005 User Group Meeting Information Notes Slides Risk Adjustment User Group Connections Quarterly Bulletin for the User Group Community January 2004 O June 2004 O September 2004 Aspen Systems Corporation 32 Go FAQs Site Map Site Search lt 2005 Risk Adjustment Data Basic Training CIs For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Frequently Asked Questions FAQs http www csscoperations com new fags radfags html FAQs Microsoft Internet Explorer File Edit Favorites Tools ay c x 7 i a A NA E 3 Back lt 2 ix a Search Favorites H LJ 2 Address http www mcoservice com new Fags radfags html 8 Go Links Risk Adjustment Data FAQs The FAQs page provides the questions and the answers to our most Frequently Asked Questions Select the category most closely related to your area of inquiry and click on the circle to go to the desired topic to review what has been asked by others experiencing a same or similar situation To go to all other pages use the blue menu bar at the
112. s no further treatment directed to that site and there is no evidence of any existing primary malignancy a code from category V10 Personal history of malignant neoplasm should be used to indicate the former site of the malignancy Any mention of extension invasion or metastasis to another site is coded as a secondary malignant neoplasm to that site The secondary site may be the principal or first listed with the 10 code used as a secondary code Admissions Encounters involving chemotherapy and radiation therapy 1 When an episode of care involves the surgical removal of a neoplasm primary or secondary site followed by chemotherapy or radiation treatment the neoplasm code should be assigned as principal or first listed diagnosis When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy code the malignancy as the principal or first listed diagnosis using codes in the 140 198 series or where appropriate in the 200 203 series 2 f patient admission encounter is solely for the administration of chemotherapy or radiation therapy code V58 0 Encounter for radiation therapy or V58 1 Encounter for chemotherapy should be the first listed or principal diagnosis If a patient receives both chemotherapy and radiation therapy both codes should be listed in either order of sequence 3 When a patient is admitted for the purpose of radiotherapy or
113. sing this payment type If all the criteria are true then a Default for New Enrollee Plus Frailty payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a The beneficiary is not in hospice amp b The beneficiary is not in ESRD amp c There is not a Community or Institutional RAF for the beneficiary on the Fu RAS File amp d There is not a New Enrollee Factor for the beneficiary on the Fu RAS File amp e The beneficiary is enrolled in a Frailty Plan amp f The beneficiary is age 55 or over Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula RA Operational Specification Page 22 of 54 December 3 2003 Default for New Enrollee Factor Source is the Frailty Factor Source defined in qf 5 9 1 Risk X Adjustment Ratebook Defined 75 3 1 Risk Adjusted X Blend Portion of Beneficiary Payment Source defined in 9 5 9 3 RA Operational Specification December 3 2003 Page 23 of 54 4 3 6 Community Payment A Community Factor payment is made when a beneficiary is not in an Institutional Plan is not in a Frailty Plan and is under age 55 The following ch
114. specific criteria to be applied by the system developers If this payment type is chosen then MMCS and GHP will calculate the risk adjusted portion of the beneficiary s payment using the following formula Default for Risk Adjusted New Enrollee ESRD Risk Portion of Transplant Ratebook E Blend Beneficiary Factor Payment Source is the source New Enrollee ESRD Default defined in defined 40 7 Table defined 593 in 45 6 ai RA Operational Specification Page 36 of 54 December 3 2003 4 3 16 New Enrollee Post Transplant Payment A New Enrollee Post Transplant Factor payment is made when a beneficiary has functioning graft but has been in Medicare Part B for less than one year and therefore not enough data is available to determine a regular RAF The chart below follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a New Enrollee Post Transplant payment should be calculated for the beneficiary This payment should be made when all of the following rules are met a beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is not in the transplant period amp e The beneficiary is not on dialysis amp f The beneficiary does not have a Community or Institutional Post transplant RAF amp g The beneficiary has a N
115. ssword if datasets are racf protected User ID Password RAPS Transaction Submission DSN MAB PROD NDM RAPS PROD submitter id 41 DISP NEW CATLG DELETE UNIT SYSDG SPACE CYL 75 10 RLSE DCB RECFM FB LRECL 512 BLKSIZE 27648 Note For testing use MAB PROD NDM RAPS TEST submitter 14 1 Please note that the test prod indicator in the file AAA 6 must also indicate TEST or PROD depending on the type of file being submitted Report Retrieval enter names We will return reports to you in the following DSN s These datasets need to be GDGs to allow multiple files to be sent without manual intervention or overwriting of existing files Front End FERAS Response Report Frequency Daily Report DSN DCB DSORG PS LRECL 80 RECFM FB BLKSIZE 27920 Aspen Systems Corporation 44 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE RAPS Return File Frequency Daily Flat DSN DCB DSORG PS LRECL 512 RECFM FB BLKSIZE 27648 RAPS Error Report Frequency Daily Report DSN DCB DSORG PS LRECL 133 RECFM FB BLKSIZE 27930 RAPS Summary Report Frequency Daily Report DSN DCB DSORG PS LRECL 133 RECFM FB BLKSIZE 27930 RAPS DUPLICATE DIAGNOSIS CLUSTER REPORT 502 Error Report Frequency Daily Report DSN DCB DSORG PS LRECL 133 RECFM FB BLKSIZE 27930 RAPS Monthly Summary Report Frequency Monthly Repor
116. stems Corporation 16 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Deleting Diagnoses The RAPS will not perform adjustment processing In place of the current adjustment process there will be a diagnosis delete function available that will serve the same purpose Each diagnosis cluster diagnosis code from and through date s and provider type will be stored separately as a unique cluster associated with a person s HIC number If a diagnosis was submitted in error and needs to be corrected the original diagnosis cluster must be resubmitted with a delete indicator in the appropriate field The correct diagnosis may be sent as a normal transaction Delete transactions may only be submitted using the RAPS format or the DDE function When a delete record is received CMS will maintain the original diagnosis cluster on file and add to it a delete indicator and the date of the deletion 2003 Hospital I npatient Data organizations should submit as much 2003 data as possible through the existing encounter data processing system 2003 data is defined as hospital inpatient data for dates of discharge from July 1 2001 though June 30 2002 Any data submitted on or before September 27 2002 will be processed through the existing systems and will be reported back to the M C organizations in the existing report formats This includes all dat
117. t cost sharing This amount 51 2 Part B Lost sharing 223 230 is added to the MA plan payment for plans that eduction bid below the benchmark 99 The amount of the rebate allocated to providing Rebate for Other Part A Part A supplemental benefits This amount is 52 Mandatory Supplemental 231 238 added to the MA plan payment for plans that Benefits bid below the benchmark 99 The amount of the rebate allocated to providing Rebate for Other Part B Part B supplemental benefits This amount is 53 Mandatory Supplemental 239 246 added to the MA plan payment for plans that Benefits bid below the benchmark 99 The Part A amount of the rebate allocated to reducing the member s Part B premium This 54 Rebate for Part B Premium 8 247 254 amount is retained by CMS for ESRD Reduction Part A Amount members and it is subtracted from ESRD member s payments 99 Aspen Systems Corporation 24 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE MMR FLAT FILE LAYOUT CONTI NUED Field Name Len Pos Description The Part B amount of the rebate allocated to reducing the member s Part B premium This 55 Rebate for Part B Premium 8 255 262 amount is retained by CMS for ESRD Reduction Part B Amount members and it is subtracted from ESRD member s payments 99 Par
118. t A Amount of the rebate allocated to 56 ee 263 270 providing Part D supplemental benefits Benefits Part A Amount 565 99 Part B Amount of the rebate allocated to 57 Renale tOr Pare 0 Sapplemental 271 278 providing Part D supplemental benefits Benefits Part B Amount 565 99 58 Total Part MA Payment 100 279 288 279 288 A MA payment 289 The total Part B MA payment 59 Total Part B MA Payment CENE ND 99 The total MA A B payment including MMA 11 adjustments This also includes the Rebate 9d Amount for Part D Supplemental Benefits 99 The member s Part D risk adjustment factor 61 Part D RA Factor 7 310 316 NN DDDD An indicator to identify if the Part D Low Income multiplier is included in the Part D B 1 aL payment Values are 1 subset 1 2 subset 2 or blank fa The member s low income multiplier 63 Part D Low Income Multiplier 318 324 NN DDDD An indicator to identify if the Part D Long Term 64 Part D Long Term Institutional 1 325 Institutional multiplier is included in the Part D Indicator payment Values are A aged D disabled or blank Part D Long Term Institutional 1 The member s long term institutional multiplier 2 Amount of the rebate allocated to reducing the 333 340 member s basic Part D premium Reduction 99 67 Part D Basic Premium Amount 341 348 S Part D premium amount The total Part D Dire
119. t DSN DCB DSORG PS LRECL 133 RECFM FB BLKSIZE 27930 RAPS Monthly Cumulative Report Frequency Monthly Report DSN DCB DSORG PS LRECL 133 RECFM FB BLKSIZE 27930 NOTE If you submit the UB92 NSF or ANSI file format you may submit to the DSNs below However with these file formats it is necessary to identify to the front end the data is being submitted for translation to the RAPS format and data for risk adjustment processing by using the appropriate receiver ID as designated below Institutional Data UB 92 80884 01 6 Professional Data NSF 80883 0 17 0 Institutional 80884 and Professional 80883 ANSI 4010 18A08 9503 NM109 1000B Aspen Systems Corporation 45 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE NSF Format Submission DSN MAB PROD NDM EDS CLM NSF submitter id 1 DISP NEW CATLG DELETE UNIT SYSDG SPACE CYL 75 10 RLSE DCB RECFM FB LRECL 320 BLKSIZE 27840 Note For testing use MAB PROD NDM EDS TCLM NSF submitter id 1 UB92 Format Submission DSN MAB PROD NDM EDS CLM UBF submitter id 1 DISP NEW CATLG DELETE UNIT SYSDG SPACE CYL 75 10 RLSE DCB RECFM FB LRECL 192 BLKSIZE 27840 Note For testing use DSN MAB PROD NDM EDS TCLM UBF submitter id 1 837 Format Submission DSN MAB PROD NDM EDS CLMA UBF submitter 1 DISP NEW CATLG DELETE UNIT SYSDG
120. tain both a from date and through date for every diagnosis Date Span Date span is the number of days between the from date and through date on a diagnosis For inpatient diagnoses the from date and through date should always represent the admission and discharge dates respectively Therefore the date span should never be greater than the length of the inpatient stay For physician and hospital outpatient data the date span shall not exceed 30 days Submission Frequency organizations shall submit at least once per calendar quarter Each quarter s submission should represent approximately one quarter of the data that the organization will submit over the course of the year The amount of records and diagnoses to which this corresponds depends upon the type of submission a M C organization selects If a M C organization elects to use a claim or encounter submission the ratio of records and diagnoses to enrollees will be much higher than if a organization elects to use a quarterly summary transaction CMS will monitor submissions to ensure that all organizations meet the quarterly submission requirements For organizations that do not receive a regular submission of superbills claims or encounter data from their providers CMS strongly recommends that these organizations request new diagnoses from all network providers on a quarterly basis at a minimum to ensure accurate complete and timely data submiss
121. te inpatient transactions determine which of the duplicate transactions was submitted most recently and utilize the most recent transaction for calculating the risk adjustment factor Electronic Data nterchange EDI Agreements All M C organizations should have EDI agreements on file at Palmetto GBA the front end recipient of all encounter data The language in encounter data EDI agreements has been updated to reflect the change from encounter data submission to risk adjustment data submission All M C organizations must complete a new EDI agreement prior to submitting to the new system This change does not in any way change the network connectivity organizations currently utilize but merely aligns the language in the agreement with the new data rules Use of Third Party Submitters organizations may continue to utilize third party vendors to submit risk adjustment data Regardless who submits the data CMS holds the M C organization accountable for the content of the submission Aspen Systems Corporation 17 2005 Risk Adjustment Data Basic Training Ay For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Data Validation A sample of risk adjustment data used for making payments may be validated against hospital inpatient hospital outpatient and physician medical records to ensure the accuracy of medical information Risk adjustment data will be validated to the e
122. tem Who Date In Below Demonstration Ratebooks From OACT October 5 8 To GHP MMCS 2004 Contract Level Payment From Cynthia Tudor October 5 9 File To MMCS Mary Sincavage and GHP Kim Miegel 5 1 CMS HCC Model The CMS HCC Model is a SAS model developed by CMS ORDI to calculate the non ESRD RAFs The RAFs produced by the CMS HCC model are listed in Section 2 In Section 2 Table 2 lists the RAFs produced by CMS HCC model The model has two components each of which uses unique and independent logic when calculating RAFs The main component runs community and institutional risk adjustment factors for beneficiaries with 12 months of Part B Medicare eligibility during the data collection period This component utilizes demographic and diagnosis information in calculating the factors e The new enrollee component calculates risk adjustment factors for beneficiaries with less than 12 months of Part B Medicare eligibility during the data collection period This component uses only demographic data when calculating factors Beneficiaries will receive only 1 the community and institutional RAF or 2 the new enrollee RAF 5 2 ESRD Model The ESRD Model is a SAS model developed by CMS ORDI to calculate the ESRD RAFs The ESRD RAFs are listed in Section 2 In Section 2 Table 2 lists the RAFs produced by the ESRD model 5 3 Risk Adjustment Family of Ratebooks Risk Adjustment Family of Ratebooks refers to th
123. that remains constant for each of the three months A beneficiary is paid for all three months regardless of whether or not the transplant was successful A beneficiary is not paid for all three months if the beneficiary dies or dis enrolls during the transplant period In 2004 GHP MMCS will only pay for a transplant that occurs on or after the date of enrollment in the ESRD demonstration When a beneficiary receives a transplant prior to enrollment in an ESRD Demonstration the beneficiary will be allowed to enroll during the three month transplant period Since the ESRD demonstration did not pay the initial cost of the transplant MMCS GHP will pay one third 1 3 the transplant rate during the transplant period for any beneficiaries who enroll in an ESRD demonstration after receiving a transplant For example if a beneficiary receives a transplant on April 15 2004 and enrolls in the ESRD demonstration effective May 1 2004 the May June and July payments for that beneficiary will be at one third 1 3 the transplant rate If that beneficiary enrolls effective June 1 2004 the June and July payments will be at one third 1 3 the transplant rate This rule will be handled as a post implementation release to MMCS The enrollments can be forced using the on line The payment for those beneficiaries will be calculated at the full transplant rate The payments will be adjusted to the correct rate during the 2004 reconciliation If a beneficiar
124. tive when signed by the eligible organization The responsibilities and obligations contained in this document will remain in effect as long as Medicare risk adjustment data are submitted to CMS or the contractor Either party may terminate this arrangement by giving the other party 30 days written notice of its intent to terminate In the event that the notice is mailed the written notice of termination shall be deemed to have been given upon the date of mailing as established by the postmark or other appropriate evidence of transmittal Aspen Systems Corporation 40 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Signature I am authorized to sign this document on behalf of the indicated party and I have read and agree to the foregoing provisions and acknowledge same by signing below Eligible Organization s Name Title Address City State ZIP By Title Date cc Regional Offices Please retain a copy of all forms submitted for your records Complete and mail this form with original signature to M CO EDI Enrollment P O Box 100275 AG 570 Columbia SC 29202 3275 Aspen Systems Corporation 41 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE CSSC Risk Adjustment Data Submitter Appl
125. top of the page I Risk Adjustment Process Go to FAQs II File Layout Format Go to FAQs Diagnosis Go to FAQs IV Data Submission Connectivity Reports Go to FAQs V Miscellaneous Go to FAQs CMS Go to FAQs VII Data Validation Go to FAQs i Contact Us Aspen Systems Corporation 33 2005 Risk Adjustment Data Basic Training CANIS For Medicare Advantage Organizations CENTERS for MEDICARE amp MEDICAID SERVICES RESOURCE GUI DE Register for Email Service http www mcoservice com new registration_home htm Registration Home Page Microsoft Internet Explorer File Edt View Favorites Tools Help Q sax c x a po Search she Favorites media O B P H 33 Addi http www mcoservice com new registration home htm Go Links Welcome to the Medicare Advantage Information Registration System For all new registrants there are 3 separate email lists you can subscribe to for information RAPS only PART D only BOTH RAPS amp PART D If you wish to be placed on or more of the mailing lists for email notification of informational updates please click on the New Registrations Only button to be added to the registration systern Registration involves a two step process after you click on New Registrations Only In Step 1 you will be taken to a page where you will need to complete a
126. udes multi specialty groups and clinics This inclusion is solely intended to allow M C organizations to submit data based on claims received from groups and clinics that bill M C organizations on behalf of individual practitioners covered on the specialty list Physician risk adjustment data is defined as diagnoses that are noted as a result of a face to face visit by a patient to a physician as defined above for medical services Pathology and radiology services represent the only allowable exceptions to the face to face visit requirement since pathologists do not routinely see patients and radiologists are not required to see patients to perform their services Medicare fee for service coverage and payment rules do not apply to risk adjustment data therefore organizations may submit diagnoses noted by a physician even when the services rendered on the visit are not Medicare covered services The diagnoses should be coded in accordance with the diagnosis coding guidelines in these instructions Data Collection organizations have several options for collecting data to support the risk adjustment submission When organizations collect data from providers they may choose to utilize 1 the standard claim or encounter formats 2 a superbill or 3 the minimum data set i e the format used to report risk adjustment data to CMS Standard claim and encounter formats currently include the UB 92 the National Standard Format NSF
127. umber Ranges For Hospital Outpatient Facilities 0001 0899 also includes 5001 5899 and XXT001 XXT899 XX1225 XX1499 XX1800 XX2299 XX3025 XX3099 XX3300 XX3499 XX3800 XX3999 XX4000 XX4499 XX4600 XX4799 XX4900 XX4999 XX8500 XX8999 Aspen Systems Corporation 19 CMTS CENTERS for MEDICARE amp MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE Table 4 Specialties Acceptable for Physician Risk Adjustment Data Submission and Associated Medicare Specialty Numbers General Practice General Surgery Allergy Immunology Otolaryngology Anesthesiology Cardiology Dermatology Family Practice Gastroenterology Internal medicine Osteopathic manipulative therapy Neurology Neurosurgery Obstetrics gynecology Ophthalmology Oral Surgery Dentists only Orthopedic surgery Pathology Plastic and reconstructive surgery Physical medicine and rehabilitation Psychiatry Colorectal surgery Pulmonary disease Diagnostic radiology Thoracic surgery Urology Chiropractic Nuclear medicine Pediatric medicine Geriatric medicine Nephrology Hand surgery Optometry specifically means optometrist Certified Nurse Midwife Certified Registered Nurse Anesthetist Infectious disease Endocrinology Podiatry Nurse practitioner Psychologist Audiologist Physical therapist Rheumatology Occupational therapist Clinical psyc
128. usted portion of the beneficiary s payment using the following formula RA Operational Specification Page 24 of 54 December 3 2003 Risk Risk Adjusted Community Adjustment E Portion of Factor Family of E Blend Beneficiary Ratebooks Payment i source ie defined in defined RAS Fu file 453 defined 4 5 7 593 RA Operational Specification Page 25 of 54 December 3 2003 4 3 7 Community Plus Frailty Payment A Community Plus Frailty payment is made when a beneficiary is in a Frailty Plan and follows the rules below The following chart follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria for either of the scenarios are true then the payment calculation should be for a Community Plus Frailty Factor payment For 2004 either Scenario A Or Scenario a The beneficiary is not in hospice amp a The beneficiary is not in hospice amp b The beneficiary is not in ESRD amp b The beneficiary is not in ESRD amp c There is a Community or c There is a Community or Institutional Institutional RAF for the RAF for the beneficiary on the beneficiary on the Fu RAS File amp Fu RAS File amp d The beneficiary is enrolled in an d The beneficiary is not enrolled in an Institutional Mixed Plan amp Institutional Mixed Plan amp e The beneficiary does not have an e The beneficiary is enrolled in a MDS flag a
129. w Enrollee Post Transplant Factor Risk Adjustment Ratebook Default for New Enrollee Post Risk Adjustment Ratebook Transplant Community Post Transplant Factor Risk Adjustment Ratebook Institutional Post Transplant Factor Risk Adjustment Ratebook NOTE The Risk Adjustment Family of Ratebooks is defined in paragraph 5 3 In general the payment calculations to MCOs are blended using Demographic payments and Risk Adjusted payments Table 5 below provides a high level summary of the types of Contracts and their blends for 2004 RA Operational Specification Page 15 of 54 December 3 2003 Table 5 Anticipated Blends Payment Demographic Risk Adjusted Payment 9o M CO 70 30 PACE 90 10 EVERCARE 70 30 PHASE 1 DEMONSTRATIONS 70 30 PHASE II DEMONSTRATIONS 70 30 MASS DUAL ELIBIBLE 90 10 DEMONSTRATION CDM DEMONSTRATION 0 100 ESRD DEMONSTRATION 0 100 new ESRD DEMONSTRATION old 100 0 MNSHO 90 10 WPP 90 10 SHMO 90 10 MNDHO 90 10 If there is a conflict between Table 5 and the blend provided in the 2004 Contract Level Payment File Section 5 9 3 the 2004 Contract Level Payment File will prevail The detailed views of the payment calculations by RAF are as follows 4 3 Details for Each Payment Type 4 3 1 Hospice A hospice payment is made for beneficiaries who have a current hospice election on file The followi
130. will notify the contractor or CMS within 2 business days if any transmitted data are received in an unintelligible or garbled form B The Centers for Medicare amp Medicaid Services Agrees To 1 Transmit to the eligible organization an acknowledgment of risk adjustment data receipt 2 Affix the intermediary carrier number as its electronic signature on each response report sent to the eligible organization 3 Ensure that no contractor may require the eligible organization to purchase any or all electronic services from the contractor or from any subsidiary of the contractor or from any company for which the contractor has an interest 4 contractor will make alternative means available to any electronic biller to obtain such services 5 Ensure that all Medicare electronic transmitters have equal access to any services that CMS requires Medicare contractors to make available to eligible organizations or their billing services regardless of the electronic billing technique or service they choose Equal access will be granted to any services the contractor sells directly indirectly or by arrangement 6 Notify the provider within 2 business days if any transmitted data are received in an unintelligible or garbled form NOTICE Federal law shall govern both the interpretation of this document and the appropriate jurisdiction and venue for appealing any final decision made by CMS under this document This document shall become effec
131. with metastasis and treatment is directed toward the secondary site only the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines 1 When admission encounter is for management of an anemia associated with the malignancy and the treatment is only for anemia the anemia is designated at the principal diagnosis and is followed by the appropriate code s for the malignancy 2 When the admission encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia the anemia is sequenced first followed by the appropriate code s for the malignancy 3 When the admission encounter is for management of dehydration due to the malignancy or the therapy or a combination of both and only the dehydration is being treated intravenous rehydration the dehydration is sequenced first followed by the code s for the malignancy 4 When the admission encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy designate the complication as the principal or first listed diagnosis if treatment is directed at resolving the complication When a primary malignancy has been previously excised or eradicated from its site and there i
132. xtent that the diagnostic information justifies appropriate payment under the risk adjustment model M C organizations will be provided with additional information as the process for these reviews is developed M C organizations must submit risk adjustment data that are substantiated by the physician or provider s full medical record M C organizations must maintain sufficient information to trace the submitted diagnosis back to the hospital or physician that originally reported the diagnosis Since M C organizations may submit summary level transactions without a link to a specific encounter or claim establishing an appropriate audit trail to the original source of the data requires diligent information management on the part of the organization Web Links The following web links contain information cited within these instructions RAPS format mapping and edits www csscoperations com ICD 9 CM Public Use Files http cms hhs gov paymentsystems icd9 default asp CD 9 CM Coding Guidelines http www cdc gov nchs datawh ftpserv ftpicd9 ftpicd9 htm Diagnosis Codes for Risk Adjustment http cms hhs gov healthplans riskadj Aspen Systems Corporation 18 CENTERS for MEDICARE 8 MEDICAID SERVICES 2005 Risk Adjustment Data Basic Training For Medicare Advantage Organizations RESOURCE GUI DE Table 1 Hospital I npatient Facility Types Acceptable for Risk Adjustment Data Submission and Associated Valid Medicare Provi
133. y is in Dialysis status and converts to Transplant status and MMCS GHP are not aware of the change and Dialysis payments are made then MMCS GHP will make the corrections to the payments retroactively back to the date of the change A beneficiary will be paid for multiple transplants as follows RA Operational Specification Page 34 of 54 December 3 2003 e Ifthe additional transplant occurs after the three month window for transplant payments ends then a new three month transplant period begins or e Ifthe additional transplant occurs during the three month window for transplant payments then a new transplant period begins on the month of the most recent transplant Therefore it is possible for a beneficiary to be paid up to two months for the first transplant receive an additional transplant and start a new period of three months of transplant payments This payment should be made when all of the following rules are met a The beneficiary is not in hospice b The beneficiary is in ESRD status c The beneficiary is in an ESRD Demonstration d The beneficiary is in the transplant period amp e The beneficiary has a transplant factor Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers The chart to the right follows the decision diagram in Figure 1 and lays out the rules for choosing this payment type If all the criteria are true then a

RESOURCE GUIDE

Contents

Download Pdf Manuals

Related Search

Related Contents