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How Risk Adjustment Benefits You and Your Patients

Risk adjustment uses member demographics and health status to help control premium rates and protect patients. Successful risk adjustment programs can result in better health management for your patients and a decreased administrative burden for you.

We support risk adjustment programs for Commercial, Medicare Advantage and Medicaid members. These risk adjustment programs rely on accurately coded claims and medical records. That’s why it’s important to properly document your patients’ medical records and use codes to the highest level of specificity using ICD-10-CM.

Accurate and complete coding allows us to correctly identify patients who could benefit from our Chronic Care and Complex Case Management programs. These programs, offered free of charge, focus on education and improving the health of our members. You should code for any condition that is monitored, evaluated, assessed or treated (MEAT) during a patient’s visit.

These steps, performed at least annually, can decrease administrative burdens by reducing chart retrieval requests:

  • Thoroughly document all medical conditions (acute/chronic, status and history).
  • Accurately code to the highest level of specificity.
  • Report all coded conditions on the claim.

A patient’s medical record can provide more insight into existing conditions, which may not be found in claims. By reviewing charts every year, we can look for ways to improve clinical documentation and follow the Centers for Medicare & Medicaid Services (CMS) and ICD-10 guidelines.

Using unspecified codes may not identify disease correctly and as a result, patients may not be directed to certain services like our Chronic Care and Case Management Programs. Also, if unspecified codes are used, we may need you to submit medical records to appropriately identify a patient’s health status and recognize any risk. This causes more work for you and can delay claims payments.

To achieve consistency and ensure the highest level of care, physicians must “MEAT” patients with chronic conditions at least once per year.

Risk Adjustment Programs

There are a few types of Risk Adjustment Programs that we participate with.

Commercial Risk Adjustment (CRA) – is administered by us as a result of the Affordable Care Act (ACA) and is overseen by CMS. Risk adjustment helps patients get affordable coverage regardless of their health status. These are members insured through our small group and individual plans who purchase insurance on or off the Health Insurance Marketplace. This includes Horizon Advantage EPO and OMNIA℠ Health Plans, as well as HMO, Direct Access and Point-of-Service plans with a metallic identifier after the product name (e.g., Bronze, Silver, Gold). The risk is captured through a combination of ICD-10-CM codes submitted on claims and medical record reviews. The chronic conditions must be submitted annually.

Medicare Risk Adjustment – is administered by us and is overseen by CMS. The primary plans are Horizon Medicare Blue (PPO), Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Patient-Centered w/Rx (HMO), Braven℠ Health and Horizon NJ TotalCare (HMO D-SNP). Like CRA, Medicare risk is captured through a combination of ICD-10-CM codes submitted via claims and medical record reviews. Chronic conditions must be submitted annually.

Medicaid Risk Adjustment – is administered by Horizon NJ Health and is based on the state of New Jersey guidelines. Risk is captured solely by ICD-10-CM codes submitted via claims. Claims should be filed for every encounter, even if the service is capitated.

If you have questions about our adjustment programs, our Provider Educators can assist you: