RISK ADJUSTMENT CRC 2026/2027 QUESTIONS AND
SOLUTIONS RATED A+
✔✔CMS center for beneficiary choices - ✔✔develops and implements ra payment
methodology for MM program. monitors plans to improve data quality
✔✔CMS regional office - ✔✔provide assistance to ra organization and beneficiaris
✔✔palmetto government benefits admin (palmetto gba) - ✔✔manages front-end ra
system (FERAS) and customer service and support center (CSSC)
✔✔RAPS - ✔✔risk adjustment processing system
✔✔multiple chronic diseases - ✔✔risk adjusted payment based on assignment of dx to
disease groups, HCC. most influenced by medicare costs associated with chronic
diseases
✔✔interactions - ✔✔allow for additive factors based on chronic conditions and disabled
status to increase payment accuracy
✔✔hierarchies - ✔✔allow for payment based on most serious conditions when less
serious conditions exist
✔✔new enrollee - ✔✔CMS uses medicare FFS up to 12 months of data collected within
collection period to calculate risk score. If data is submitted via RAPS, CMS uses those
too.
✔✔risk score (5 demographic factors) - ✔✔calculate risk score: age, sex, medicaid
status, disability and original reason for medicare entitlement
✔✔disease interactions - ✔✔6 in community model; 5 in institutional model
✔✔disable interactions - ✔✔5 in community; 4 institutional
✔✔FERAS - ✔✔front-end risk adjustment system; ra submitters sends data to palmetto
through FERAS
✔✔RAPS - ✔✔risk adjustment processing system; process ra data
✔✔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
SOLUTIONS RATED A+
✔✔CMS center for beneficiary choices - ✔✔develops and implements ra payment
methodology for MM program. monitors plans to improve data quality
✔✔CMS regional office - ✔✔provide assistance to ra organization and beneficiaris
✔✔palmetto government benefits admin (palmetto gba) - ✔✔manages front-end ra
system (FERAS) and customer service and support center (CSSC)
✔✔RAPS - ✔✔risk adjustment processing system
✔✔multiple chronic diseases - ✔✔risk adjusted payment based on assignment of dx to
disease groups, HCC. most influenced by medicare costs associated with chronic
diseases
✔✔interactions - ✔✔allow for additive factors based on chronic conditions and disabled
status to increase payment accuracy
✔✔hierarchies - ✔✔allow for payment based on most serious conditions when less
serious conditions exist
✔✔new enrollee - ✔✔CMS uses medicare FFS up to 12 months of data collected within
collection period to calculate risk score. If data is submitted via RAPS, CMS uses those
too.
✔✔risk score (5 demographic factors) - ✔✔calculate risk score: age, sex, medicaid
status, disability and original reason for medicare entitlement
✔✔disease interactions - ✔✔6 in community model; 5 in institutional model
✔✔disable interactions - ✔✔5 in community; 4 institutional
✔✔FERAS - ✔✔front-end risk adjustment system; ra submitters sends data to palmetto
through FERAS
✔✔RAPS - ✔✔risk adjustment processing system; process ra data
✔✔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
