Risk Adjustment Coding and HCC Guide

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Power up your Adjustment Coding and HCC Guide2018 Optum360, LLCiContentsIntroduction ........................................ ........................................ ........................................ ..... 1History and purpose of RAF ........................................ ........................................ ........................................ ...1Key Terms Definitions ........................................ ........................................ ........................................ .............3Acceptable provider types/SOS ........................................ ........................................ ....................................5The provider s role ........................................ ........................................ ........................................ ...................6Payment Methodology.

using the Hierarchical Condition Category (HCC)/risk adjustment model since 2004. The primary purpose of a risk adjustment model is to predict (on average) the future healthcare costs for specific consortiums enrolled in MA health plans. CMS is then able to provide capitation payments to these private health plans.

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