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Risk Adjustment Overview

Risk adjustment helps align payments to health plans based on the demographics (e.g., age and gender) and the health status of members.

Accurate risk adjustment relies on comprehensive, face-to-face health assessments of patients. The assessments result in appropriate medical record documentation and diagnosis coding. The diagnosis codes are then submitted to Horizon BCBSNJ and used to determine the level of risk associated with the patient.

Horizon BCBSNJ particiaptes in Commercial (Individual and Small Group), Medicaid and Medicare Advantage risk adjustment programs.

Visit Risk Adjustment In Depth or access our Provider FAQs for more information.

Key Resources

Risk Adjustment Overview

Risk Adjustment Coding Checklist

Complex Case Management Trigger Events

ICD-10-CM Clinical Documentation Improvement for Chronic Conditions

Care Management Programs

Horizon NJ Health Medicaid Risk Adjustment