Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 13, 2020

Program Area: Risk Adjustment (RA)

Question: What stage of the Risk Adjustment (RA) claims selection process excludes orphaned claims from inclusion in RA calculations?

Answer: Accepted claims without a corresponding enrollee ID (orphan claim) are included in the RA claims selection process since the process occurs immediately after file ingest. The next step is risk score calculation and it is during this process that 'orphan' claims are excluded from risk score calculation. For additional information please refer to the RA Risk Scores Part One (1) Computer-based Training (CBT), located under the RA program area at https://www.regtap.info/reg_librarye.php?i=2141&type=v in the REGTAP Library.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.