RISK ADJUSTMENT CRC EXAM SCRIPT 2026/2027
QUESTIONS AND SOLUTIONS RATED A+
✔✔RAS - ✔✔risk adjustment system; calculates risk score
✔✔common UI - ✔✔maintains medicare beneficiary eligibility data
✔✔HPMS - ✔✔health plan management system; CMS MA information system that
contains health plan-level data
✔✔required diagnosis - ✔✔diagnosis codes required to be submitted for the CMS-HCC
model and future model development
✔✔ra data - ✔✔ra data must be submitted at least quarterly; processed through RAPS
✔✔ra data requirements - ✔✔health insurance claim (HIC) #, diagnosis code, service
date from, service date through, provider type
✔✔ra data requirements diagnosis - ✔✔diagnosis codes must be reported at least once
per enrollee within data collection period
✔✔ra data flow - ✔✔**hospital/physician submits data to MA organization
**MA organization submits data at least quarterly to Palmetto GBA
**MA organization submits data via Direct Data Entry or in RAPS format
**data sent to FERAS for processing where file-level data, batch-level data, and first
and last detail records are checked
**any data rejected, report on FERAS Response Report
**passing FERAS checks, file submitted to RAPS where detail editing performed
**RAPS return file is returned daily ; shows approved and errors
**RAPS transaction error report displays records on errors
**RAPS distributed monthly and quarterly
**RAPS database stores all finalized diagnosis clusters
**RAS calculates RAF by executing the CMS-HCC model
✔✔ra data processing time - ✔✔1 to 2 days
✔✔dx codes importance to ra - ✔✔drives risk scores, which drives ra reimbursement
from CMS to MA organizations
✔✔outpatient and physicians dos - ✔✔from date and through date may be the same
✔✔inpatient dos - ✔✔from date and through date must be different; reflects dates of
admission to and discharge from a facility
, ✔✔date span - ✔✔ra; it is important to determine if reported dx cluster falls within data
reporting period
✔✔FFS - ✔✔fee for service; physician pay based on specific services provided to each
patient
✔✔capitated - ✔✔physician pay is fixed amount per patient per month, regardless of
types of services provided
✔✔staff model - ✔✔physician are paid employees managed care plan; phyisicans
generally provide services in clinic setting
✔✔mixed services model - ✔✔managed care org. use a combination of contractual
arrangements
✔✔authoratative - ✔✔conservative, official, and factual; perfect grammar, spelling, and
punctuation.
✔✔current communication - ✔✔recent
✔✔timely - ✔✔provide information when needed and meeting deadlines
✔✔consistent - ✔✔consistent messages, right the first time and every time
✔✔practical relevant and well organized communication - ✔✔no background noise,
clear and easy to read/understand
✔✔accessible communication - ✔✔easy accessibility
✔✔accurate reimbursement contains - ✔✔ICD 9 CM & ICD 10 CM basis of ra models
accurate dx codes are a result of clear, consistent, and complete documentation
CMS verifies accuracy
✔✔exclude notes - ✔✔informs coder which dx codes are not included in code selection
✔✔use additional code - ✔✔informs coder that more than one code is needed to fully
described condition
✔✔not otherwise specified (NOS) - ✔✔"unspecified"
✔✔not elsewhere classified (NEC) - ✔✔used when medical record documents a
condition to a level of specificity not identified by specific ICD 9 or ICD 10 code.
QUESTIONS AND SOLUTIONS RATED A+
✔✔RAS - ✔✔risk adjustment system; calculates risk score
✔✔common UI - ✔✔maintains medicare beneficiary eligibility data
✔✔HPMS - ✔✔health plan management system; CMS MA information system that
contains health plan-level data
✔✔required diagnosis - ✔✔diagnosis codes required to be submitted for the CMS-HCC
model and future model development
✔✔ra data - ✔✔ra data must be submitted at least quarterly; processed through RAPS
✔✔ra data requirements - ✔✔health insurance claim (HIC) #, diagnosis code, service
date from, service date through, provider type
✔✔ra data requirements diagnosis - ✔✔diagnosis codes must be reported at least once
per enrollee within data collection period
✔✔ra data flow - ✔✔**hospital/physician submits data to MA organization
**MA organization submits data at least quarterly to Palmetto GBA
**MA organization submits data via Direct Data Entry or in RAPS format
**data sent to FERAS for processing where file-level data, batch-level data, and first
and last detail records are checked
**any data rejected, report on FERAS Response Report
**passing FERAS checks, file submitted to RAPS where detail editing performed
**RAPS return file is returned daily ; shows approved and errors
**RAPS transaction error report displays records on errors
**RAPS distributed monthly and quarterly
**RAPS database stores all finalized diagnosis clusters
**RAS calculates RAF by executing the CMS-HCC model
✔✔ra data processing time - ✔✔1 to 2 days
✔✔dx codes importance to ra - ✔✔drives risk scores, which drives ra reimbursement
from CMS to MA organizations
✔✔outpatient and physicians dos - ✔✔from date and through date may be the same
✔✔inpatient dos - ✔✔from date and through date must be different; reflects dates of
admission to and discharge from a facility
, ✔✔date span - ✔✔ra; it is important to determine if reported dx cluster falls within data
reporting period
✔✔FFS - ✔✔fee for service; physician pay based on specific services provided to each
patient
✔✔capitated - ✔✔physician pay is fixed amount per patient per month, regardless of
types of services provided
✔✔staff model - ✔✔physician are paid employees managed care plan; phyisicans
generally provide services in clinic setting
✔✔mixed services model - ✔✔managed care org. use a combination of contractual
arrangements
✔✔authoratative - ✔✔conservative, official, and factual; perfect grammar, spelling, and
punctuation.
✔✔current communication - ✔✔recent
✔✔timely - ✔✔provide information when needed and meeting deadlines
✔✔consistent - ✔✔consistent messages, right the first time and every time
✔✔practical relevant and well organized communication - ✔✔no background noise,
clear and easy to read/understand
✔✔accessible communication - ✔✔easy accessibility
✔✔accurate reimbursement contains - ✔✔ICD 9 CM & ICD 10 CM basis of ra models
accurate dx codes are a result of clear, consistent, and complete documentation
CMS verifies accuracy
✔✔exclude notes - ✔✔informs coder which dx codes are not included in code selection
✔✔use additional code - ✔✔informs coder that more than one code is needed to fully
described condition
✔✔not otherwise specified (NOS) - ✔✔"unspecified"
✔✔not elsewhere classified (NEC) - ✔✔used when medical record documents a
condition to a level of specificity not identified by specific ICD 9 or ICD 10 code.
