CRC Exam – Risk Adjustment | Latest Update
2026 | Exam Prep | Graded A+
Risk Adjustment Data Element - correct answerAge, Gende, Socioeconomic status,
Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such
as procedure codes, place of service codes, special patient-specific conditions hospice,
ESRD
RAF - correct answerRisk Adjustment Factor Scores
Three main types of reviews - correct answerRetrospective, Concurrent and prospective
Retrospective - correct answerreviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - correct answerperformed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - correct answerwill effect the next year and not the current year
where payment is concerned. They are used to forcast
Types of Risk Adjustment Models(HHS) - correct answerHHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Types of Risk Adjustment Modles(CDPS) - correct answerChronic Illness and Disability
payment systems(Medicaid)
Types of Risk Adjustment Models(HCC-C) - correct answerHierarchical Condition
Category, Part C
Types of Risk Adjustment model (DRG) - correct answerDiagnosis Related Group
(Inpatient)
Types of Risk Adjustment model (ACG) - correct answerAdjusted Clinical
Groups(Outpatient)
Prescription based program risk adjustment examples:UCSD - correct answerMedicaid
Rx(UCSD)
Prescription based program risk adjustment examples(Dxcg) - correct
answerRxGroups(DxCG)
,Prescription based program risk adjustment examples(HCC-D) - correct
answerHierarchical Condition Category, Part D(HCC-D
Trump List - correct answerFamilies or hierarchies set a value base on severity of
illness with more severe diagnoses carrying the overall risk score for that family.
Stage 1 Pressure Ulcer - correct answerPersistent focal erythema
stage 2 pressure ulcer - correct answerPartial thickness skin loss involving epidermis,
dermis, or both
Stage 3 pressure ulcer - correct answerFull Thickness skin loss extending through
subcutaneous tissue
Stage 4 Pressure ulcer - correct answerNecrosis of soft tissue extending to muscle and
bone
Unstageable Ulce - correct answeris covered in eschar or slough it cannot be determine
how deep
Pathologic Fractures - correct answerBroken bone that occures in an area of weakened
bone. The cause typically due to another disease such as neoplasm or osteoporosis
Stress Fractures - correct answerrepeated force or overuse. these fractures are
considered non-traumatic
malunion fracture - correct answera healed fracture in a undesirable position resulting in
a deformity or crooked limb.
nonunion fracture - correct answerfracture is not healing New bone tissure is not
growing to bridge the gap between the broken bones
FFS Normalization adjustment - correct answerCMS payments are based on a
population with an average risk score
Special population for normalization factores - correct answerPace Mode, ESRD and
Part D
History of CDPS - correct answerBegan using RA in 1996 utilizing claims from disabled
beneficiaries information from the disability payment system from Colorado, Michiganm
Missouri, New York, and Ohio
Star Ratings - correct answerMedicare Advantage plan would received a bonus if they
receive 4 or more stars in 5 star quality ratings
5 star - correct answerExcellent performance
,4 star - correct answerAbove Average Performance
3 star - correct answeraverage performance
2 star - correct answerBelow average performance
1 star - correct answerPoor Performance
Part C Plan - correct answerDomain 1 Staying Helathy Screenings, test, and vaccines
(7 measures
Domain 2 Managing Chronic (Long Term) Conditions (12Measures)
Domain 3 Member Experience with Health Plan (6 measures)
Domain 4: Member complaints, problems getting service and improvement in the Health
Plan's Performance (4 measures)
Domain 5 Health Plan customer service (3 measures
Part D Plans - correct answerDomain 1Drug plan customer service (3 measures)
Domain 2 Member Complaints, Problems Getting Services, and improvement in the
Drug Plan's Performance (4 measures)
Domain 3 Member Experience with Drug Plan (2 measures)
Domain 4 Patient afety and drug pricing (6measures)
Star Rating penalize - correct answerwhen plans are not obtaining four stars or better
PQRS - correct answerPhysician Quality Reporting System
PQRS 2 - correct answerA Reporting program using a combination of incentive
payments and payment adjustments to promote reporting of quality information by
eligible professionals (EP)
Valued-Based Payment Modifier Program - correct answerProvide Performance
information to physicians as part of Medicare's efforts to improve the quality and
efficiency of medical care
HEDIS - correct answerThe Healthcare Effectiveness Data and Information Set)
HEDIS 3 - correct answerTract year to year performance
81 HEDIS Measures DIVIDED into five domains of care - correct answer1.
Effectiveness of Care
2. Access/Availability of Care
3. Experience of Care
4. Utilization and relative resource use
5. Health Plan Descriptive Information
, Major Reason for RA - correct answerTo identify all current diagnoses to highest
specificity.
Annual RA Audits - correct answerCMS conducts audits of the risk adjustment data
submitted by or on behalf of health plans to ensure program integrity
Error in RA Audits - correct answeronce error determine will then be applied to the
premiums for the entire patient population for that health plan
RADV(Risk Adustment Data Validation) - correct answerCMS identifies a random
stratified sample of patients audit. Only Part C HCC'S are audited in a RADV
RADV submission - correct answermust submit up to five best recrods demonstrating
diagnoses as current in year being audited and support the HCC values
Two types of RADV audit - correct answerNational Radv audit and Targeted RADV
National RADV audit - correct answerSelection of patients using a stratfied sample
metholology, where a percentage of patients are selected randomly from high risk,
medium risk, and low risk based on HCC risk scores
Selection of MA plan and/or contracts is random
Targeted RADV audit - correct answerTargeted contract of those who have had
problematic past audit findings
plans with higher risk scores when compared to traditional FFS(Fee-For-Service
Medicare)
HHS RADV - correct answeridentifes a similar sample of patients, however the dos only
come from those that were submitted on claims through the edge servers
IVA - correct answerInitial Validation Auditor that reviews the sample to identify DOS
that support HCC'S(through diagnosis codes)
IVA process - correct answeris typicall summer and fall months winter and fall months
are SVA(Secondary Validation Auditor
Differences between the CMS RADV AND HHS HRADV - correct answercms RADV is
typically 2-3 years after payment, while HHS HRADV is typically 6 months after year
end
Differences between the CMS RADV and HHS HRADV - correct answerCMS RADV
allows for any face to face encounter by an approved provider to be subitted for audit
support while HHC HRADV only allows DOS that were submitted on t he edge server.
Accountable care Oganization three core principles - correct answer1. they are
provider=led organizations with a strong base of primary care that are collectively
2026 | Exam Prep | Graded A+
Risk Adjustment Data Element - correct answerAge, Gende, Socioeconomic status,
Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such
as procedure codes, place of service codes, special patient-specific conditions hospice,
ESRD
RAF - correct answerRisk Adjustment Factor Scores
Three main types of reviews - correct answerRetrospective, Concurrent and prospective
Retrospective - correct answerreviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - correct answerperformed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - correct answerwill effect the next year and not the current year
where payment is concerned. They are used to forcast
Types of Risk Adjustment Models(HHS) - correct answerHHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Types of Risk Adjustment Modles(CDPS) - correct answerChronic Illness and Disability
payment systems(Medicaid)
Types of Risk Adjustment Models(HCC-C) - correct answerHierarchical Condition
Category, Part C
Types of Risk Adjustment model (DRG) - correct answerDiagnosis Related Group
(Inpatient)
Types of Risk Adjustment model (ACG) - correct answerAdjusted Clinical
Groups(Outpatient)
Prescription based program risk adjustment examples:UCSD - correct answerMedicaid
Rx(UCSD)
Prescription based program risk adjustment examples(Dxcg) - correct
answerRxGroups(DxCG)
,Prescription based program risk adjustment examples(HCC-D) - correct
answerHierarchical Condition Category, Part D(HCC-D
Trump List - correct answerFamilies or hierarchies set a value base on severity of
illness with more severe diagnoses carrying the overall risk score for that family.
Stage 1 Pressure Ulcer - correct answerPersistent focal erythema
stage 2 pressure ulcer - correct answerPartial thickness skin loss involving epidermis,
dermis, or both
Stage 3 pressure ulcer - correct answerFull Thickness skin loss extending through
subcutaneous tissue
Stage 4 Pressure ulcer - correct answerNecrosis of soft tissue extending to muscle and
bone
Unstageable Ulce - correct answeris covered in eschar or slough it cannot be determine
how deep
Pathologic Fractures - correct answerBroken bone that occures in an area of weakened
bone. The cause typically due to another disease such as neoplasm or osteoporosis
Stress Fractures - correct answerrepeated force or overuse. these fractures are
considered non-traumatic
malunion fracture - correct answera healed fracture in a undesirable position resulting in
a deformity or crooked limb.
nonunion fracture - correct answerfracture is not healing New bone tissure is not
growing to bridge the gap between the broken bones
FFS Normalization adjustment - correct answerCMS payments are based on a
population with an average risk score
Special population for normalization factores - correct answerPace Mode, ESRD and
Part D
History of CDPS - correct answerBegan using RA in 1996 utilizing claims from disabled
beneficiaries information from the disability payment system from Colorado, Michiganm
Missouri, New York, and Ohio
Star Ratings - correct answerMedicare Advantage plan would received a bonus if they
receive 4 or more stars in 5 star quality ratings
5 star - correct answerExcellent performance
,4 star - correct answerAbove Average Performance
3 star - correct answeraverage performance
2 star - correct answerBelow average performance
1 star - correct answerPoor Performance
Part C Plan - correct answerDomain 1 Staying Helathy Screenings, test, and vaccines
(7 measures
Domain 2 Managing Chronic (Long Term) Conditions (12Measures)
Domain 3 Member Experience with Health Plan (6 measures)
Domain 4: Member complaints, problems getting service and improvement in the Health
Plan's Performance (4 measures)
Domain 5 Health Plan customer service (3 measures
Part D Plans - correct answerDomain 1Drug plan customer service (3 measures)
Domain 2 Member Complaints, Problems Getting Services, and improvement in the
Drug Plan's Performance (4 measures)
Domain 3 Member Experience with Drug Plan (2 measures)
Domain 4 Patient afety and drug pricing (6measures)
Star Rating penalize - correct answerwhen plans are not obtaining four stars or better
PQRS - correct answerPhysician Quality Reporting System
PQRS 2 - correct answerA Reporting program using a combination of incentive
payments and payment adjustments to promote reporting of quality information by
eligible professionals (EP)
Valued-Based Payment Modifier Program - correct answerProvide Performance
information to physicians as part of Medicare's efforts to improve the quality and
efficiency of medical care
HEDIS - correct answerThe Healthcare Effectiveness Data and Information Set)
HEDIS 3 - correct answerTract year to year performance
81 HEDIS Measures DIVIDED into five domains of care - correct answer1.
Effectiveness of Care
2. Access/Availability of Care
3. Experience of Care
4. Utilization and relative resource use
5. Health Plan Descriptive Information
, Major Reason for RA - correct answerTo identify all current diagnoses to highest
specificity.
Annual RA Audits - correct answerCMS conducts audits of the risk adjustment data
submitted by or on behalf of health plans to ensure program integrity
Error in RA Audits - correct answeronce error determine will then be applied to the
premiums for the entire patient population for that health plan
RADV(Risk Adustment Data Validation) - correct answerCMS identifies a random
stratified sample of patients audit. Only Part C HCC'S are audited in a RADV
RADV submission - correct answermust submit up to five best recrods demonstrating
diagnoses as current in year being audited and support the HCC values
Two types of RADV audit - correct answerNational Radv audit and Targeted RADV
National RADV audit - correct answerSelection of patients using a stratfied sample
metholology, where a percentage of patients are selected randomly from high risk,
medium risk, and low risk based on HCC risk scores
Selection of MA plan and/or contracts is random
Targeted RADV audit - correct answerTargeted contract of those who have had
problematic past audit findings
plans with higher risk scores when compared to traditional FFS(Fee-For-Service
Medicare)
HHS RADV - correct answeridentifes a similar sample of patients, however the dos only
come from those that were submitted on claims through the edge servers
IVA - correct answerInitial Validation Auditor that reviews the sample to identify DOS
that support HCC'S(through diagnosis codes)
IVA process - correct answeris typicall summer and fall months winter and fall months
are SVA(Secondary Validation Auditor
Differences between the CMS RADV AND HHS HRADV - correct answercms RADV is
typically 2-3 years after payment, while HHS HRADV is typically 6 months after year
end
Differences between the CMS RADV and HHS HRADV - correct answerCMS RADV
allows for any face to face encounter by an approved provider to be subitted for audit
support while HHC HRADV only allows DOS that were submitted on t he edge server.
Accountable care Oganization three core principles - correct answer1. they are
provider=led organizations with a strong base of primary care that are collectively
