Suite 1300
Salt Lake City, UT 84111
Block-1 3rd Floor, Perungudi Bypass Rd, Perungudi,
Chennai - 600096
MGR Main Rd,
Perungudi, Chennai - 600096
Villupuram,
Tamil Nadu – 605602
HCC Risk Adjustment Coding Services
Risk Scores and Quality Metrics Drive Revenue: We Optimize Both
Prospective HCC coding · Retrospective chart review · HEDIS abstraction · RADV defense · RAF analytics
Risk adjustment and HEDIS are revenue programs
AnnexMed’s Risk Adjustment & HEDIS Programs service delivers an integrated clinical data program covering prospective HCC coding, retrospective chart review, HEDIS abstraction, Star Rating gap closure, RADV audit defense, and analytics, so every documented condition is coded, every care gap is closed, and every code survives audit review.
Trusted by 100+ healthcare providers | AAPC, AHIMA & AAHAM Certified | SOC 2 Type II
The RAF Score Revenue Equation
The Three Sources of RAF Score Leakage
- Coding gaps: Documented chronic conditions not fully coded or submitted to CMS
- Specificity gaps: Conditions coded at a lower level than the medical record supports.
- Annual recapture failures: Previously coded HCC conditions not resubmitted in the current benefit year.
The Star Rating Bonus Revenue Equation
The Three Sources of HEDIS Rate Shortfall
- Data completeness gaps: Care delivered but not captured in claims or supplemental data feeds.
- Care gaps: Members who have not received required preventive or chronic care services
- Attribution gaps: Members linked to providers who do not generate HEDIS-relevant documentation.
Why both programs require an integrated approach?
- $43M+ annual revenue loss: for a 50,000-member MA plan with a 0.08 RAF gap from under-coded documented conditions.
- HEDIS cut-point risk: Measures just below 4-Star thresholds require thousands of gap closures before measurement year end.
- RADV exposure: Plans without internal validation risk RAF scores based on codes that may not survive CMS medical record review.
- Provider education alone is insufficient: Documented but uncoded conditions require structured retrospective chart review, not just training.
Six integrated service components
Prospective HCC Coding & Provider Education
What we do?
- AI HCC suspect lists identify members with likely undocumented or undercoded conditions using claims, pharmacy, and prior-year coding data.
- Provider HCC gap reports show PCPs and specialists attributed members with suspected undocumented conditions needing documentation.
- Annual wellness visit and chronic care management outreach: coordinating with plan care management to prioritize AWV scheduling for high-gap members
- Provider education on ICD-10-CM specificity: targeted education on the specific coding patterns generating RAF score leakage in each provider's panel
- Condition-specific coding guidance supports accurate HCC capture for diabetes complications, COPD severity, CKD stage, and CHF specificity.
- Real-time coding feedback integration: HCC performance feedback delivered to providers through the plan's provider portal or direct reporting
- Care gap and HCC gap co-presentation: presenting HCC coding opportunities alongside HEDIS care gap data to enable single-encounter resolution of both
- In-person and virtual provider education sessions for high-volume PCP and specialist groups
- RAF score contribution tracking by provider: showing each provider their attributed population's RAF score trend and HCC capture rate
- Prospective program calendar management: annual HCC outreach cycle coordinated with the plan's benefit year and CMS submission deadlines
Why it matters?
Prospective coding programs deliver high ROI because they capture conditions at the point of care without chart review costs. Their success depends on timing. Suspect lists sent months after a visit are not useful. Lists delivered before a scheduled visit, highlighting prior-year conditions to review, help providers document and code accurately during the encounter.
Measurable Outcome
HCC capture rates improve year over year when providers receive timely, specific gap reports instead of generic coding education. Targeted outreach increases Annual Wellness Visit completion for high-gap members. As prospective programs mature, RAF scores improve each plan year, compounding gains from consistent, accurate condition capture and documentation.
Retrospective Chart Review & HCC Reconciliation
What we do?
- Retrospective chart review targeting members with the highest RAF gap potential using Annex AI suspect scoring and claims data analysis.
- Vendor-neutral chart retrieval from provider offices, EHR systems, and hospital medical records departments for complete documentation access.
- Certified risk adjustment coder review with HCC-certified coders evaluating charts for all CMS-eligible diagnosis codes supported by documentation.
- ICD-10-CM code assignment maximizing specificity for each applicable HCC hierarchy supported by clinical documentation.
- Condition validation confirming coded diagnoses meet CMS risk adjustment model rules, including required encounters.
- New condition identification for chronic diagnoses documented in records but never submitted for risk adjustment.
- Recapture of lapsed chronic conditions coded in prior years but not captured in the current year despite ongoing documentation.
- Addendum and clarification request management for documentation gaps requiring provider confirmation.
- Submission-ready encounter data with reconciled HCC codes formatted for CMS RAPS or EDPS submission.
- Post-review RAF score impact measurement comparing review results against the baseline RAF score.
Why it matters?
Retrospective chart review recovers conditions missed by prospective coding using the same documentation standards CMS applies in RADV audits. Each code must be supported by a face-to-face encounter and clinical diagnosis in the medical record. Coding only what the chart supports ensures submitted HCC codes are accurate, defensible, and able to withstand CMS audit review.
Measurable Outcome
RAF score improvement is measured for each review cohort, showing additional capitation revenue from condition recapture and coding specificity. New condition identification rates track charts with diagnoses not previously submitted for risk adjustment. A controlled submission pipeline ensures validated codes are submitted within the CMS risk adjustment submission window.
HEDIS Measure Abstraction
What we do?
- Full HEDIS measure set coverage: all applicable NCQA measures for the plan's product lines: Commercial, Medicare, and Medicaid
- Administrative data abstraction: claims-based measure rate calculation from the plan's administrative data feed
- Hybrid measure medical record review: supplemental record retrieval and abstraction for hybrid measures where administrative data is insufficient
- Electronic clinical data system (ECDS) integration: integrating EHR-sourced clinical data for measures with ECDS specifications
- Supplemental data collection: collecting structured clinical data from provider offices and health systems for measures not fully capturable from claims
- Denominator identification accuracy: identifying eligible members for each measure using current NCQA technical specifications
- Numerator documentation review: confirming that care delivered meets the numerator criteria for each measure per NCQA specifications
- Exclusion application: applying all valid denominator exclusions to avoid inflating the denominator with ineligible members
- Measure rate calculation and benchmarking: calculating each measure rate against NCQA national percentiles and CMS Star Rating cut points
- HEDIS Compliance Audit support: documentation and workpapers for HEDIC-certified auditor review
Why it matters?
Administrative-only HEDIS rates understate care because not all services generate claimable data. A mammogram done at a radiology center may not appear in plan claims. Supplemental data from provider EMRs captures these results. Adding this data can increase HEDIS rates by 5–15 percentage points, reflecting care already delivered but not counted previously.
Measurable Outcome
HEDIS measure rates reflect actual care delivery rather than limits of administrative claims data. Supplemental data from provider EMRs captures services not found in claims. Contribution of this data is tracked by measure and source to show rate improvement. Measures are calculated using current NCQA technical specifications to prevent disallowances from compliance errors.
Star Rating Gap Closure & Care Gap Analytics
What we do?
- Real-time HEDIS measure rate dashboard: current-year measure rates updated as supplemental data is received, benchmarked against Star Rating cut points
- Care gap velocity analytics: the rate of gap closure per month vs. the rate required to cross the next Star Rating threshold by measurement year end
- Member-level care gap lists: open gaps by measure, member demographic, attributed PCP, last outreach date, and gap closure probability
- PCP-level performance reporting: measure compliance rates by attributed provider with gap lists formatted for direct use by provider care teams
- Care management integration: high-priority gap lists delivered to the plan's care management team for outreach coordination
- Outreach campaign management: member contact for priority measures including scheduling assistance and transportation coordination
- Community health worker deployment support: gap lists formatted for CHW outreach programs in high-gap member segments
- CAHPS survey performance analytics: patient experience measure trend analysis connected to inquiry program and care access metrics
- Part D medication adherence gap identification: statin use, diabetes medication adherence, and hypertension medication adherence gaps for MA-PD plans
- Star Rating bonus payment modeling: projecting the quality bonus revenue at each possible Star Rating outcome to quantify the financial stakes of each threshold
Why it matters?
The gap between a 3.5-Star and 4.0-Star rating is often just a 2–4 percentage point improvement on a few measures near the CMS cut point. Plans that identify early which measures and members have open gaps can close them before the measurement year ends. Plans that learn their rates late, from preliminary NCQA data, have no opportunity left to improve performance in that year.
Measurable Outcome
Star Rating improvements are achieved through targeted, analytics-driven care gap closure rather than broad outreach. Quality bonus revenue is protected and increased, with the financial value of each Star Rating point quantified against program investment. Care gap closure rates by measure are tracked monthly, providing real-time visibility into program performance and progress.
What we do?
- RADV universe development: identifying the plan's submitted HCC codes and their associated encounter records for potential RADV sample selection
- Pre-RADV internal chart review: validating a sample of submitted HCC codes against the underlying medical records before CMS selects the audit sample
- Documentation gap identification flags HCC codes submitted without adequate face-to-face encounter or clinical diagnosis support required by CMS.
- Addendum and correction management: clinically appropriate documentation corrections and provider addendum requests for records with identified gaps
- RADV response coordination: organizing and submitting medical records to CMS within the required response timeframe when a RADV sample is received
- CMS contractor interface: coordinating with CMS's RADV contractor for record submission, clarification requests, and preliminary findings review
- Preliminary findings dispute support: reviewing CMS preliminary RADV findings for administrative or clinical errors warranting dispute
- Error rate extrapolation management: understanding the financial implications of identified error rates under CMS's RADV payment adjustment methodology
- Post-RADV corrective action program: process improvements addressing the documentation and coding gaps identified in audit findings
- Annual RADV readiness assessment: ongoing program review to ensure submitted codes maintain audit-ready documentation support
Why it matters?
CMS RADV audits validate submitted HCC codes against medical records. Codes lacking documentation are removed, reducing RAF scores and triggering payment adjustments across the plan population. Plans that validate codes internally before RADV audits ensure documentation fully meets CMS standards and avoid costly recoupments from unsupported diagnoses.
Measurable Outcome
Timely filing expiration rates are tracked monthly with a target of zero preventable write-offs. Claims within 30 days of the filing deadline are placed in a high-priority follow-up queue to ensure proper, timely submission before expiration. Exception requests are submitted when payer processing delays or documentation support eligibility for timely filing extensions under applicable payer policies and rules.
Encounter Data & Submission Quality Management
Making sure every code that was validated in the chart actually reaches CMS in the correct format, on time, and error-free.
What we do?
- Encounter data completeness review: verifying that all RAPS and EDPS submissions contain required data elements for each submitted encounter
- ICD-10-CM code validity verification: confirming all submitted diagnosis codes are valid for the submission date and risk adjustment model year
- HCC mapping validation: confirming that submitted ICD-10-CM codes map to the intended HCC categories under the applicable CMS model version
- Duplicate submission identification: detecting and resolving duplicate encounter records before submission creates scoring anomalies
- Deletion and correction workflow: managing deletions and corrections for invalid or erroneous submitted records
- CMS RAPS and EDPS submission cycle management: coordinating submission timing to maximize data in each CMS sweep
- Mid-year submission strategy: identifying and submitting high-value HCC codes early in the submission cycle to accelerate RAF score improvement
- Final submission reconciliation: confirming final submitted data reflects all validated codes before CMS closes the submission window
- Submission error report management: reviewing and resolving CMS error reports for rejected records
- Year-over-year submission trend analysis: tracking RAF score trajectory and HCC mix changes across submission cycles
Why it matters?
Encounter data quality failures can reduce RAF scores even when coding is correct. Codes identified in chart review may not count if encounter records are rejected by CMS, submitted after a sweep, or mapped incorrectly under the model year. Strong submission quality management ensures all validated codes are successfully accepted and included in RAF score calculations.
Measurable Outcome
Submission error rate minimized; rejected encounter records resolved and resubmitted within the correction window. Final RAF score reflects all validated codes; no codes lost to submission timing, data quality, or mapping errors. Submission cycle analytics show the RAF score trajectory across each CMS sweep, enabling proactive mid-year program performance course correction.
What sets AnnexMed apart?
Integrated RA & HEDIS: One Program, Not Two
Most plans run risk adjustment and HEDIS through vendors, creating silos and duplicated work. AnnexMed integrates both programs so chart reviews, AWVs, and outreach close HCC and HEDIS gaps together, improving results with lower cost.
Financial Outcomes, Not Activity Metrics
AnnexMed reports risk adjustment and HEDIS performance in financial terms, RAF gains as capitation revenue, HEDIS rates vs. Star thresholds, and RADV exposure. Chart reviews become measurable financial management tools.
Annex AI Suspect Identification for RAF Capture
Annex AI identifies HCC suspects using MA and Medicaid claims models, ranking conditions by RAF impact, documentation probability, and feasibility. This targets gaps and focuses effort on highest-yield opportunities.
RADV-Ready Coding Standards From Day One
AnnexMed’s chart review and prospective coding follow CMS RADV standards, requiring face-to-face encounters and clinical documentation. Codes submitted are validated to withstand CMS medical record review and audit scrutiny.
Both Sides of the Clinical Data Relationship
AnnexMed improves risk adjustment through provider services that address why providers undercode. Patient-level feedback on specific documentation gaps changes coding behavior more effectively than generic HCC education.
Dedicated Program Manager: Single Owner
Each AnnexMed risk adjustment and HEDIS engagement is led by a dedicated Program Manager coordinating outreach, chart review, abstraction, gap closure, RADV defense, and analytics as the point of accountability.
Annex AI: HCC & HEDIS Insights
Machine learning models trained on Medicare Advantage and Medicaid claims generate condition-specific suspect scores, care gap probability rankings, and RAF trajectory projections, updated continuously as new encounter data flows in.
RAF & Star Rating Live Dashboard
Plan leaders access a live dashboard with RAF scores by segment, HEDIS rates vs Star cut points, care gap closure velocity, HCC capture by provider, and financial impact, updated with each CMS sweep and supplemental data batch.
Chart Review Workflow Platform
Retrospective review runs on a structured platform tracking record requests, retrieval, coder assignment, QA review, and submission status, with daily output reporting and RAF impact measurement for each completed cohort.
Integrated Data Platform
AnnexMed seamlessly integrates with plan claims systems, pharmacy data, clinical feeds, HEDIS abstraction tools, and CMS submission platforms via EDI, FHIR APIs, and secure file transfer protocols without modifying existing systems.
HIPAA-Compliant Infrastructure
All program infrastructure follows HIPAA Security Rule requirements with encryption, role-based access, and audit logging. AnnexMed’s platform is SOC 2 Type II and ISO compliant, with annual reviews and strict handling standards.
Coverage across all plan types
Plan Type
RA Model
Quality Program
AnnexMed Program Elements
Medicare
Advantage
CMS-HCC V28/V24 transition; RAPS & EDPS submission
CMS Star Ratings: HEDIS Medicare, CAHPS, HOS measures tracking and reporting
HCC prospective and retrospective review, RADV prep, HEDIS, Star gaps, RAF dashboard
Medicaid
MCO
CDPS or state-specific RA model; MMIS submission
State HEDIS Medicaid measures; quality incentive programs reporting requirements
State RA coding, HEDIS Medicaid abstraction, care gap closure, supplemental data collection
MA-PD (Part D)
plan
CMS-HCC risk model (Part C); RxHCC risk model (Part D)
Part D Star: PDC adherence, statin use, MTM program completion
Dual HCC/RxHCC coding; PDC adherence gap identification; MTM tracking; Star dashboard
D-SNP Dual Plan program
CMS-HCC model with FIDE/HIDE SNP complexity
D-SNP HEDIS measures; care coordination and quality outcomes
High-risk coding, FIDE/HIDE compliance, SNP HEDIS abstraction, and SDOH data integration
ACA Exchange
health plan
HHS-HCC (concurrent model); EDGE server submissions processing
NCQA HEDIS commercial measures; CAHPS surveys; state exchange reporting requirements
HHS-HCC coding, EDGE submission, HEDIS abstraction, and CAHPS supplemental data
Financial impact & performance results
+0.15
Avg RAF Lift per Population
95%+
HCC Documentation Accuracy Rate
+5–15%
HEDIS Rate Improvement via Data
<3%
RADV Unsupported Diagnosis Rate
Prospective program
Retrospective review
HEDIS abstraction
Star Rating gap closure
RADV defense
Submission quality
Frequently Asked Questions
Increase risk scores and close care gaps
Tell us your plan size, current RAF performance, HEDIS gaps, and RADV exposure.
AnnexMed will assess your program and quantify the financial opportunity.
Request a Free Risk Adjustment & HEDIS Assessment
Case Studies
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Discover how AnnexMed reduces denials, accelerates reimbursements, and strengthens financial performance. Backed by measurable outcomes and proven RCM expertise, we deliver operational excellence, revenue stability, and sustainable growth you can trust.
Client Voices
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Proven RCM expertise. delivered at scale.
For over 20 years, AnnexMed has delivered RCM solutions nationwide, combining expert billing, coding, and AR support to drive measurable results and growth.
- 20+ years of proven healthcare RCM experience
- 1,500+ professionals supporting billing, coding & AR
- 500+ certified coders across multiple specialties
- 99%+ compliance with HIPAA and security standards
- All 50 states served with consistent, scalable operations
