Risk Adjustment Services

The Vendor is required to provide risk adjustment services for include:
- Population analytics
•    Integrate data from a variety of sources and in a variety of formats for commercial (qualified health plan), Medicare advantage and Medicaid, health and recovery plan (HARP), essential plan and child health plus (CHP) lines of business:
o    Member demographic and enrollment data
o    Pharmacy claims data
o    Medical claims data
o    Provider demographic data
o    Encounter platform response and summary files
o    Supplemental diagnosis code files
o    Occasional ad-hoc supplemental data (including data in non-standard formats)
•    Ingest data into a comprehensive (cumulative) database of all agency members, enrollment spans, medical claims, pharmacy claims, and supplemental diagnosis data. 
•    Use aforementioned database to identify risk adjustment-eligible data and calculate accurate risk scores for all members using the appropriate risk score model for that population 
•    Maintain and continuously update all relevant risk score models based on updates and notifications from the organization or agency responsible for updating each model 
•    Calculate risk scores at various levels of aggregation, i.e. Plan-level, eligibility group level, metal level, plan year, PCP, etc. 
•    Maintain accurate risk scores at both member and aggregated levels over multiple years, using the relevant parameters and data for each calendar year. 
•    Maintain a portal that displays imported member, provider and plan-level data, including calculated risk scores, risk score categories risk score gaps by plan year. 
•    Use current-year claims data, historic claims data as well as predictive analytics to generate prospective risk scores, risk gaps and potential risk score categories. 
•    Generate target lists of members with actual or imputed risk score gaps on both a retrospective or prospective basis.
•    Generate custom retrospective and prospective target lists using claims data, including provider locations for “chart chase” lists. 
•    Generate additional custom data as requested. 
•    Where available, calculate risk-adjusted premium revenue using available data sources. 
•    Integrate supplemental diagnosis code data into risk score calculations and link supplemental diagnosis codes to claims with the same member, provider and date or service. 
•    Linking must be completed using claim number or encounter system identifier, as required by encounter submission system. 
•    Generate custom data extracts, including extracts of supplemental diagnosis codes linked to existing medical claims and encounters.
- Medical record retrieval and coding
•    Ingest retrospective target lists of members to retrieve medical records for at specific provider offices. 
•    Analyze target lists to identify the best way to group record requests by provider office location. 
•    Conduct outreach to provider office using phone, fax, mail, electronic communication and direct EHR access, where permitted. 
•    Allow providers to submit records using a variety of methods including, at a minimum, direct EHR access, copy service, electronic drop-box or SFTP, fax and e-fax, mail, and onsite retrieval. 
•    Triage issues with non-compliant sites, including by making additional retrieval attempts, providing sites with additional information, finding additional points of contact, and offering multiple retrieval methods. 
•    Convert physical medical records into digital format. 
•    Extract diagnosis codes from medical records using the latest medical record documentation standards, including from CMS, aha and AMA, as appropriate. 
•    Ensure that all icd-10 codes are captured in a medical record, including “status codes” that map to risk adjustable conditions in the appropriate risk adjustment model. 
•    Ability to extract specific icd-10 codes as required by agency. 
•    Ability to extract all conditions on all dates of service may be required. 
•    All diagnosis codes in a medical record must be confirmed by a human onshore certified medical record coder. 
•    Report extracted diagnosis codes in a data format that includes diagnosis code, date of service, member details, provider details, and setting (inpatient or outpatient). 
•    Achieve 95% coding accuracy on annual joint quality audits led by agency and conducted using latest medical coding standards.
•    Deliver images of all coded medical records to agency. 
•    Provide comprehensive and frequent reporting on retrieval and coding, to include coding and retrieval status for each chart, as well as retrieval percentage by project and by site as well as details on problems encountered at non-retrieval sites.
- Prospective in-home health assessments
•    Conduct clinically valid, comprehensive health assessments of members by professionals licensed to diagnose and treat health conditions in state and who can submit claims as the rendering provider for Medicare, commercial (QHP) and Medicaid. 
•    Comprehensive assessments must include at least medical history review, medication review, review of systems, vital signs and physical exam, cognitive and mental health screens as well as social needs screenings. 
•    Social needs and depression screenings must use clinically valid standardized surveys as agreed upon by agency. 
•    Correctly document all parts of assessment, including using all diagnosis codes and service codes that represent conditions addressed and services provided. 
•    Transmit accurate 837 claims to agency from an entity licensed to submit claims for agency, commercial and Medicaid patients in state. 
•    Ensure data on 837 accurately matches medical documentation. 
•    Provide accurate and timely reporting on project status, including detailed member outreach and visit status, indicating which members have been contacted and which have had visits completed. 
•    Ingest member data (including demographic data, chronic condition history, and claims history and member PCP data) in order to generate a member outreach list. 
•    Outreach members using mail, telephone, and e-mail and text message and manage all scheduling of provider appointments. 
•    Identify high-risk clinical situations and establish a protocol to address these, including escalating to agency, emergency services or the member’s PCP. 
•    Provide comprehensive visit summary to each member, agency and the member’s PCP following each appointment. 
•    Achieve 95% icd-10 and CPT coding accuracy on agency -initiated joint quality audits. 
•    Provide agency with full medical records for all visits conducted. 
•    Conduct in-home lab tests as requested by agency, including for diabetes, colorectal cancer and bone density.
- Customer service
•    Provide ongoing and timely customer support with a dedicated account manager. 
•    Proactively identify project execution issues and provide timely guidance on error resolution. 
•    Continually refine and improve processes to ensure they follow clinical, coding and regulatory standards as required for the appropriate line of business.