Skip to Main Content

Risk Adjustment

What is Risk Adjustment?

Risk Adjustment is a statistical technique that calculates a relative risk score which can be accumulated to compare health risk of a population of Individuals enrolled in Medicare Advantage Plan, Commercial Health Plan, and/or Medicaid.

Risk Adjustment process is regulated by CMS (Centers for Medicare and Medicaid Services).  The CMS Risk Adjustment model measures the disease burden that includes the HCC categories (Hierarchical Condition of Categories, which are correlated or linked to corresponding ICD 10 diagnosis codes.

HCC coding is prospective in nature. Diagnosis codes reported on your claims determine a patient’s disease burden and risk score. Reporting the appropriate diagnosis code and complete clinical documentation by the provider increases the member’s risk score. The disease categories mainly represent chronic conditions that are likely to persist leading to additional medical expenses if not addressed.

The goal of any health plan is to have an accurate picture of the health status of their membership. Which according to CMS guidelines must be captured annually. Health Plans can support the best care for their members when they are informed about the member’s health status and the acuity of their conditions.

PA Health and Wellness (PHW) Risk Adjustment Department’s priority focus is to collaborate with all health care providers in support of Hierarchical Condition Category (HCC) risk adjustment efforts. There are various types of Risk Adjustment programs that are used by PHW to assist our providers: HCC Accuracy Program (Continuity of Care/COC), In Office Assessment (IOA), RADV (Risk Adjustment Data Validation), Chart Review, and In Home Assessment (IHA).

PA Health and Wellness Risk Adjustment Resources/Tools

For more information please reach out to

  • In Office Assessment (IOA): formerly known as Healthcare Quality Patient Assessment Form (HQPAF)
  • The intent of this program is to promote early detection and ongoing assessment of chronic conditions for PHW Medicare Advantage and Medicaid Managed Care Plan members.
  • Goal of the IOA program is to help ensure plan members receive a Comprehensive Annual Assessment.
  • Forms are mailed out to provider throughout the calendar year for which providers are incentivized to completed
  • Qualifying providers receive IOA forms for the assigned members who have chronic conditions or suspected conditions that have been identified based on claims, labs, and pharmacy data.

For more information please reach out to

  • RADV is the process of verifying diagnosis codes submitted to the health plan for payment with the support of medical record documentation. Accurate HCC diagnosis is crucial for RADV
  • CMS adjusts payments to Medicare Advantage plans/Marketplace (Affordable Care Act health plans) based on the health risks of the participants. For PA Health & Wellness this means the Allwell (Medicare) and Ambetter (ACA) health plans.
  •  A significant part of the RADV and Risk Adjustment process is the Medical Record Review/Chart Review. 
    • A vendor or plan employee may request a medical record/chart from the provider for select members included in: COC program RADV, and IOA.
    • This request is based on diagnosis data submitted to CMS as a result of services provided to Medicare beneficiaries and/or Marketplace
    • Not all diagnosis are always required per claim; however, that does not mean the condition was not evaluated.

For more information please reach out to

An in-home health assessment is an evaluation of the member’s overall health. The face-to-face visit takes place for an hour with the provider in the member’s home or HIPAA-compliant location.  The medical professional will go over the member’s personal and family health history. In addition to the history, the medical provider will also examine vital signs and screen for chronic conditions.

The medical provider may also collect speciments for lab tests for:

  • Hemoglobin A1C-Diabetes Monitoring Test
  • Microalbumin-Kidney Function Monitoring Test
  • iFit-Colorectal Cancer Screening

For more information please reach out to

For assistance with access to the provider portal please contact the Provider Relations Representative assigned to your practice or via email at

Or for additional information, please contact a member of the Risk Adjustment Team via email at

  • A major challenge with Risk Adjustment has to do with the medical documentation.  The motto is “Think Ink.”  If it wasn’t written in the medical record. It does not exist and in some cases, does not exist at the right specificity of the condition.
  • Our CDI efforts are two-fold. 
    • First, The CDI Team at Centene Corporate invites you to attend a Risk Adjustment Web-based training that will cover coding guidelines and best practices to promote quality documentation, accurate coding and regulatory compliance. 
    • Areas covered in these Webinars will include:
      • Broad Overview of Risk Adjustment
      • Documentation and Coding – It’s all in the details
      • Case Study Examples
      • Telehealth for Risk Adjustment
    • Who will benefit:
      • Coders, Billers, Auditors, Providers, Practice Administrators
    • Training Topics Include:
      • Leading Practices for HCC Documentation and Coding
      • HCC Coding & Documentation Trends to Avoid
      • Application of MEAT Criteria & Specificity in Coding
      • Practical Approaches to HCC Coding and Risk Adjustment
      • Commonly Missed and Miscoded Diagnosis Codes
      • And more! 
      • Please visit our Provider Training page for a full list of training topics, dates and registration links.
      • The latest schedule is listed below as well
    • Second,  If interested we could do a specialized review from the Risk Adjustment team here at PHW, where we coordinate with you on a review of medical records and Certified Risk Adjustment Coders go over CDI opportunities we notice within the documentation. 

  1. This is not my member but this person was added to the Appointment Agendas
    Our records show that s/he is assigned to your practice. Only the member can change their assigned provider through member services.  Also work with your provider relations representative to assist you with this matter.  Or contact your Provider Relations Representative:
  2. Why aren’t all the members enrolled in Continuity of Care?
    We are focusing on members with Chronic Conditions to assure the diagnosis are accurate. Not all members have conditions that require frequent oversight by the physician.
  3. Why do I have to go into the provider portal if you already have the diagnosis verified by a claim?
    The portal has diagnosis other than what you have already verified by claim.  We ask that you use the portal to address all diagnosis.  Even if the diagnosis is already confirmed by a claim, please make sure it is accurate, update and submit.
  4. Where did you get the list of diagnoses for Continuity of Care?
    As a fairly new plan, our historical data on members comes from various places.  Not all diagnoses listed in the Appointment Agenda are from your practice.  This is why we are asking you to verify the accuracy so we can update our records accordingly.
  5. What is the benefit of Risk Adjustment to the Providers?
    In today’s performance-based payment models, provider’s payments are closely tied to their patient’s health outcomes.  Without Risk Adjustment providers in disproportionately higher risk populated areas can receive payment reductions that may not accurately reflect the quality of care that was provided.  Therefore, Risk Adjustment allows for more accurate comparisons across providers by removing factors that affect measured outcomes not under the provider’s control.
  6. What are Hierarchical Condition Categories or HCCs?
    Risk Adjustment models use patient diagnoses and demographic information to predict medical spending.   The HHS-HCC Risk Adjustment model groups ICD 10-CM codes into smaller number of categories producing a diagnostic profile of each individual. The HCC diagnostic classification distinguish the low- cost individuals from the more medical complex individuals.
  7. What is Risk Adjustment?
    Risk Adjustment is a statistical technique that calculates a relative risk score which can be accumulated to compare health risk of a population of Individuals enrolled in.

For more information please reach out to