Frequently Asked Questions

MAOs may resubmit data for all historical dates of service to the extent that they find its prior submissions were affected by the deactivated edit.

MAOs and other entities can submit questions regarding missing MAO-004 Reports to RiskAdjustmentOperations@cms.hhs.gov. If asking about specific records versus whole reports, please include the contract ID and related Internal Control Numbers (ICNs) of the encounter(s) in question. Prior to submitting questions, please verify that reports are not in your established File Transfer Protocol (FTP) mailbox or are not available through the Medicare Advantage Prescription Drug User Interface (MARx UI). Review Accessing Archived Reports using MARx UI CBT. 

If you believe an Encounter Data Record (EDR) is missing from the MAO-004, please check to make sure the EDR meets the criteria below.

• Does the data in question have a date of service of January 2014 or later?

• Is the encounter data record accepted at the header level by Encounter Data System (EDS), as reported on the MAO-002 report?

• Does the encounter data record pass the CMS published filtering logic for each specific encounter type under consideration– Professional, Outpatient, Inpatient?

If an encounter data record meets these criteria, all diagnoses on the record will be indicated as either allowed or disallowed and will also be designated as add, delete, or blank. Diagnoses marked as allowed and either add or blank are considered eligible for risk adjustment, however, not all eligible diagnoses map to an Hierarchical Condition Category (HCC) in the risk adjustment models.

Source: User Group Q&A Documentation from January 19, 2017 and the Plan Communication User Guide

Diagnosis codes on an accepted encounter data record will not be on the MAO-004 report if the encounter data record does not meet the Phase IV Version 0 MAO-004 production criteria stated in the July 21,2020 Health Plan Management System (HPMS) memo with subject line “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version”.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

The MAO-002 report indicates whether an encounter data record has been “Accepted” or “Rejected.” The Phase IV Version 0 MAO-004 report includes diagnoses from almost all of the Encounter Data System (EDS) accepted records. The MAO-004 indicates whether the diagnoses are “Allowed” or “Disallowed” depending on whether they pass the CMS filtering logic. To pass the filtering logic, the diagnosis must be submitted on an encounter data record with an acceptable type of bill and/or Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS) code, depending on the type of submission.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

Yes, the MAO-004 report will indicate diagnoses that do not pass the CMS filtering logic with a “D”, in the allowed/disallowed flag field, meaning the diagnoses were reported but are disallowed for risk adjustment. The allowed/disallowed flag field is included to help MAOs or other entities determine which records accepted on the MAO-002 report passed the CMS filtering logic as reported on the MAO-004 report.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

The MAO-004 report will identify diagnoses as “allowed” or “disallowed” to indicate whether or not they are risk adjustment eligible. If diagnoses pass the CMS filtering logic, they are “allowed.” Allowed diagnoses are considered eligible for risk adjustment since these are the diagnoses that are run through the model when calculating risk scores. Not all diagnoses that are run through the model will be included in the risk score calculation, since not all diagnoses map to the Hierarchical Condition Category (HCC) in the model. Please refer to the December 20, 2017 CMS Health Plan Management System (HPMS) Memo with subject line, “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version”.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-issuing of Historical MAO-004 Reports in the New Version”. (July 21, 2020)

Yes. Durable Medical Equipment (DME) records (payer code 80887) are reported on the MAO-004 report and are filtered in the same way as professional records. If at least one of the accepted lines on the record has a Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code that is on the list of acceptable CPT/HCPCS codes for filtering, then these records will be reported with an Allowed status and the diagnoses on the record will be considered for risk adjustment.

Source: Help Desk Inquiry answered in June 2018.

Field #25 (Allowed/Disallowed Flag) will be “A” if field #27 (Allowed/Disallowed Reason Codes) is “Q”. ‘Q’= the diagnoses on the current encounter are now allowed due to Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS) quarterly update. This value is only applicable to reprocessed outpatient and professional and Durable Medical Equipment (DME) encounters, not to inpatient encounters.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-Issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

Diagnoses reported in field #35 as add, delete or “blank” reference the diagnoses reported on the submitted encounter (#9). For replacements, voids, and linked chart review deletes, field #35 will also report diagnoses deleted from the prior record that the encounter or chart review is linked to, the Internal Control Number (ICN) listed in field (#13).

Source: User Group Q&A Documentation from March 23, 2017

Field #35 has 38 slots because the MAO-004 will report diagnoses deleted from a prior Internal Control Number (ICN). If, for example, an institutional record was submitted with 25 diagnoses and then replaced with 25 new, unique diagnoses, field #35 would report the 25 diagnoses on the current record as add and the 25 diagnoses removed from the prior record as delete. Since only 38 slots are available, the additional diagnoses would be reported on a second line in the report, with all fields identical to the first line except for the diagnoses and add/delete indicators.

Source: User Group Q&A Documentation from March 23, 2017

For the diagnoses reported only on the replacement but not on the original, the MAO-004 will indicate these records as “Add” in the add/delete indicator. All diagnoses reported on both the replacement and the original encounter data record will be reported with a “blank” for the add/delete indicator, signifying that those diagnoses have been reported as “add” within that family before, and all diagnoses on the original encounter data record, but not on the replacement record, will be noted as “Delete” in the add/delete indicator.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-Issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

Yes, linked and unlinked chart review records used to report supplemental diagnosis codes are reported on the MAO-004 report. Chart review records that delete diagnosis codes are also reported on the MAO-004 report.

Source: User Group Q&A Documentation from January 19, 2017

To access the MAO-004 reports use the following steps:

1. In Medicare Advantage Prescription Drug User Interface (MARx UI) go to the ‘Reports’ menu

2. Select ‘Monthly’ frequency, the ‘Start Month/Year’ and the ‘End Month/Year’

3. On the ‘Report/Data File’ dropdown select ‘Risk Adjustment Eligible Diagnosis Report’

4. Add your ‘Contract ID’ and hit find

5. Do not specify the file type.

The archived reports will populate and become available for download approximately 10-15 minutes after requestors log out and log back into MARx.

Please contact the MAPD Help Desk at MAPDhelp@cms.hhs.gov or 1-800-927-8069 for any issues with the MARx UI.

Source: User Group Q&A Documentation from January 19, 2017

CMS reports almost all MAO-002 accepted records on the Phase IV Version 0 MAO-004 reports. The very few submissions that are not processed are the instances when CMS cannot determine the intention of the submitter. Diagnoses on these records are also not included in the model run processes.

Source: CMS HPMS Memo with subject “Updated Version of MAO-004 Reports (Phase IV Version 0) and Re-Issuing of Historical MAO-004 Reports in the New Version” (July 21, 2020)

There are a number of reasons why the Hierarchical Condition Category (HCC) for a diagnosis reported as accepted and allowed on the MAO-004 report would not appear on the Initial payment Model Output Report (MOR). A diagnosis code that is added and allowed is considered for risk adjustment and will appear on the MOR. While the MAO-004 reports all diagnosis codes submitted on accepted encounters not all diagnosis codes reported map to a payment HCC. In addition, it is possible that there is a diagnosis that maps to a payment HCC that is higher in a hierarchy and thus a lower severity HCC in the same hierarchy would not be included in the risk score for payment. The MOR reports HCCs after the hierarchies are applied, therefore the lower severity HCC that was excluded for payment will not be reported on the MOR. Please also ensure that the diagnosis was submitted on an encounter with dates of service within the submission window for the [payment year’s] Initial and was not deleted by a subsequent replacement or chart review delete.

Source: User Group Webinar on February 21, 2019

The Monthly Membership Report (MMR) contains payment information for the reported month; the Medicaid data fields on the MMR represent the beneficiary's Medicaid status used to determine dual status for that month. The Monthly Medicaid Status Report provides information on dual status that may be more current than the anchor months in the MMR that are used for payment. The Monthly Medicaid Status Report gives plans a more complete picture of a beneficiary’s Medicaid status, which can assist with predicting revenue.
Source: User Group Q&A Documentation from April 27, 2017

Prior to final reconciliation for a payment year, the Medicaid status on the Monthly Membership Report (MMR) reflects the rolling anchor month’s status used in prospective payment, while the monthly Medicaid Status file identifies the most recent monthly Medicaid status information CMS has for the beneficiary. MAOs and other entities can also use the Medicare Advantage Prescription Drug User Interface (MARx UI) to identify a beneficiary’s most recent dual status. At final reconciliation, CMS uses the most recent information about a beneficiary’s dual status from each payment month and makes payments adjustments if the dual status is updated.

Source: User Group Webinar on April 19, 2018

Yes, Encounter Data System (EDS) will accept service lines with “S” and “G” procedure codes. There is a link on the Customer Service and Support Center (CSSC) Operations website that provides a list of the procedure codes that are acceptable for Encounter Data Processing. Under Medicare Advantage Encounter Data and Risk Adjustment Processing System (RAPS) Data click on Edits, and then click on Reference Code Tool. https://www.csscoperations.com/internet/csscw3.nsf/DID/D2AMI3Y7X6

Source: User Group Q&A Documentation from January 19, 2017

An edit is triggered if an anesthesia modifier (AA, AD, QK, QS, QX, QY or QZ) is submitted with Procedure Code 01996. If 01996 is submitted with one of these modifiers, the edit states the units or basis of measurement code must be ‘MJ’. In order to avoid this edit, MAOs and other entities should not submit anesthesia modifiers with procedure code 01996.

Source: User Group Webinar on June 20, 2019

MAOs and other entities should only submit ancillary dental data incident to a physician (837-P) or institutional visit (837-I) in order for CMS to obtain the full beneficiary utilization. MAOs and other entities should not submit dental services that are not incident to a physician or institutional visit.

Source: MAO Help Desk Inquiry answered in November 2019

Please refer to the Medicare Claims Processing Manual, Chapter 18 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf) for information on annual wellness visits. To the extent that the MAO provides more than one annual wellness visit per year to a beneficiary, the MAO may submit the data to the Risk Adjustment Processing System (RAPS) and Encounter Data System (EDS).

Source: MAO Help Desk Inquiry answered in November 2019

No, MAOs and other entities may not submit information on behalf of dialysis centers. CMS obtains information regarding the start of dialysis and transplant status from reports that dialysis facilities directly submit to CMS.

Source: User Group Q&A Documentation from October 26, 2017

The list of eligible Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) codes used for filtering diagnoses from encounter data records for each service year is available at https://www.cms.gov/medicare/fraud-and-abuse/physicianselfreferral/list_of_codes.html. A full list of Level II alphanumeric HCPCS procedure and modifier codes and their long and short descriptions can be accessed at https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html. CMS does not control Level I codes. In addition, risk adjustment information, including evaluation of the CMS-HCC Risk Adjustment Model, model diagnosis codes, Risk Adjustment model software (HCC, RxHCC, ESRD) and information for the relevant payment year, is available at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.

The blended risk score equation is listed in the Health Plan Management System (HPMS) memos announcing the deadlines for submitting risk adjustment data in upcoming payment years. For payment year 2019, CMS will calculate risk scores by adding 25% of the risk score using encounter data and Fee-for-Service (FFS) diagnoses with 75% of the risk score using Risk Adjustment Processing System (RAPS) and FFS diagnoses. For Payment Year 2020, CMS will calculate risk scores by adding 50% of the risk score using encounter data and FFS diagnoses with 50% of the risk score using RAPS and FFS diagnoses.

Source: CMS HPMS Memo with subject "Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2019, 2020, and 2021" (January 15, 2021)

Yes, risk adjustment filtering logic includes diagnoses captured from atypical provider service records (as indicated by the default atypical National Provider Identifier). All risk adjustment filtering logic and requirements remain in effect for atypical providers.

Source: MAO Help Desk Inquiry answered in November 2019

Please refer to the December 22, 2015 CMS Health Plan Management System (HPMS) memo entitled "Final Encounter Data Diagnosis Filtering Logic" related to how CMS will extract risk adjustment eligible diagnoses.

Source: User Group Q&A Documentation from February 16, 2017

All diagnoses on the header of the encounter data record are considered for risk adjustment, if the diagnoses pass the CMS filtering logic.

Source: User Group Q&A Documentation from March 23, 2017

The ICD-9 and ICD-10 mappings of diagnoses to model the Hierarchical Condition Category (HCC) and the model software are available on the CMS Risk Adjustment website (https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html). CMS has also posted the PY2020 initial mappings and model software on that website.

Source: User Group Webinar on June 20, 2019

No, the filtering rules are the same for Programs of All-Inclusive Care for the Elderly (PACE) and Medicare Advantage plans.

Source: User Group Q&A Documentation from June 20, 2019

All risk adjustment data (Risk Adjustment Processing System Data and Encounter Data System Data) that will be included in risk score runs need to be submitted by 8pm ET of the deadline for submission date that is relevant to the specific risk score run. For example, for the payment year 2019 final risk score run, the deadline for submission was January 31, 2020, and all risk adjustment data should be submitted by 8:00 PM ET on January 31, 2020. The deadlines for the risk score runs are announced via Health Plan Management System (HPMS) memo on a periodic basis.

Source: CMS HPMS Memo with subject “Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2019, 2020, and 2021” (January 15, 2021)

Submission deadlines are released through the Health Plan Management System (HPMS) Memo distribution system. Historically, the submission deadline memos are released periodically throughout the year and can be located by searching the HPMS memo system using the terms “Deadline for Submitting Risk Adjustment Data”. Payment dates are announced monthly through HPMS in the Medicare Advantage Prescription Drug (MARx) Plan Payment Letter.

Source: User Group Q&A Documentation from April 27, 2017

The submission deadlines for MAOs and Program of All-Inclusive Care for the Elderly (PACE) are the same as for all MAOs. Submission deadlines are released through the Health Plan Management System (HPMS) Memo distribution system. Historically, the submission deadline memos are released periodically throughout the year and can be located by searching the HPMS memo system using the terms “Deadline for Submitting Risk Adjustment Data”. Payment dates are announced monthly through HPMS in the Medicare Advantage Prescription Drug (MARx) Plan Payment Letter.

Source: User Group Q&A Documentation from February 16, 2017

To access the CMS 5010 Claim Edits and Enhancement Module (CEM) Edits Spreadsheet, use the following steps:

1. Click on https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals

2. Key in ‘(EDI) Front End Updates’ in the ‘Filter On’ box

3. Select Transmittal #

• R1806OTN – Version EA20173V01 (Institutional)

• R1865OTN – Version EB20181V01 (Professional)

• R1947OTN – Version CE20182V01 (Durable Medical Equipment)

4. Click on the link(s) under ‘Downloads’ at the bottom of the page.

Source: Encounter Data Submission and Processing Guide

Common edit codes relating to sanctioned or precluded providers include: 01405 – Sanctioned Provider, 01440 – Precluded Billing Provider, 01445 – Precluded Rendering, 01450 - Precluded Referring Provider and 01455 – Precluded Ordering Provider. Edit 01405 will be posted on Institutional, Professional and DME encounters when the header “from” date of service is within the billing provider sanction effective date and the sanction termination date received from the Medicare Exclusion Database (MED File). This edit will be posted on Institutional, Professional and DME encounters when the header/line “from” date of service is within the billing provider or rendering provider’s (header and line) sanction effective date and the sanction termination date received from the MED File. The edit will be bypassed if the header/line “from” date of service is within the Billing (header level) and Rendering (header and line level) provider’s waiver effective date and waiver termination date received from MED Waiver file. Edits 01440, 01445, 01450, and 01455 are informational edits that check the Billing (header), Rendering (both header and line), Referring (both header and line), and Ordering (only at line on Professional/DME encounters) Provider’s National Provider Identifier (NPI) at the header/line level on Professional, Institutional, and Durable Medical Equipment (DME) records against the latest Preclusion List. If the Provider NPI is on the Preclusion List, this edit will check the ‘Claim Rejection Date’ field. If the ‘From Date of Service’ on the header/line is on or after the ‘Claim Rejection Date’ for the Billing Provider NPI and the ‘Reinstatement Date’ field is null the edit will post. The edit will also post on the header/line if the ‘From Date of Service’ is on or after the ‘Claim Rejection Date’ and prior to the ‘Reinstatement Date.’ For more information about the Preclusion list, please see the Preclusion List FAQ memo at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Preclusion_List_FAQs.pdf

Source: User Group Q&A Documentation from April 27, 2017; and CMS HPMS Memo with subject “Announcement of the March 2020 Encounter Data Software Release Updates” (March 19, 2020)

For Institutional records, Encounter Data Front End System (EDFES) edit 255 will not generate a rejection when the Principal Diagnosis code (qualifier ABK or BK) is duplicated in an Other Diagnosis code (qualifier ABF or BF) on the record. For Professional records, if the Principal Diagnosis code is duplicated on an Other Diagnosis code field, edit 255 does apply and will result in a rejection. When diagnosis codes are duplicated within the Other Diagnosis (ABF or BF) fields within a record, edit 255 does apply to both Institutional and Professional records.

Source: User Group Q&A Documentation from January 19, 2017

To pass Encounter Data Front End System (EDFES) edits, diagnoses codes must be valid codes for the respective date of service and should be coded to the highest level of specificity, meaning to the maximum number of digits available for the codes, in the valid code set. The edits used are similar to those used in Original Medicare, so you may refer to the CMS Medical Learning Network (MLN) Publications Medicare Billing: 837P and Form CMS-1500 (October 2016) and Medicare Billing: 837I and CMS Form 1450 (April 2016), which provide references to the relevant guidance in the “Medicare Claims Processing Manual” for guidance on coding specificity requirements.

Source: User Group Q&A Documentation from January 19, 2017

This edit applies to the header level on Professional records in the Encounter Data Front End System (EDFES). Given the current edit, CMS recommends splitting the Encounter Data Record (EDR) into two separate records. It is important to note that, in order to avoid a duplicate record rejection in the Encounter Data Processing System (EDPS), the submitter should also split the services (e.g., procedure code, modifier, etc.) along with the billed amount across multiple encounters. Assuming the services as well as the amounts are allocated across multiple EDRs, the duplicate edit will not be triggered since the data elements that are checked in the EDPS duplicate logic will differ across the EDRs.

Source: User Group Q&A Documentation from January 19, 2017

Special characters should be excluded when submitting data to Encounter Data System (EDS).

Source: User Group Q&A Documentation from January 19, 2017

CMS issued Medicare Beneficiary Identifier (MBI) Implementation Guidance on December 22, 2017. Please refer to the December 22, 2017 CMS Health Plan Management System (HPMS) memo, “Updates to the Encounter Data System and Risk Adjustment Suite of Systems to Accommodate the New Medicare Card Project” for guidance on how these systems implemented the MBI initiative. In addition, CMS released two additional HPMS memos on MBI implementation, the December 10, 2018, HPMS memo titled, “Updates to the Risk Adjustment Suite of Systems (RASS) for Delete Transactions using a Beneficiary Identifier” and the September 6, 2019 HPMS memo titled, “Risk Adjustment Suite of Systems (RASS) MBI Related Enhancements.”

Source: User Group Q&A Documentation from October 26, 2017

No, CMS does not provide default procedure codes for MAOs and other entities to use when submitting unlinked chart reviews.

Source: User Group Q&A Documentation from March 23, 2017

Yes, at this time, all records with default procedure codes and/or a default National Provider Identifier (NPI), and that have diagnoses that pass the CMS filtering logic, are eligible for risk adjustment.

Source: User Group Q&A Documentation from March 23, 2017

Yes, CMS does consider diagnosis codes for the risk score calculation that are submitted via unlinked chart reviews, provided the codes pass the filtering logic.

Source: User Group Webinar on January 17, 2019

Yes, however, MAOs should include only the diagnosis codes they want to delete on linked chart review delete records. The primary diagnosis on a chart review is not required to match the primary diagnosis on the encounter it is associated with.

Source: User Group Webinar on April 19, 2018

The Encounter Data Processing System (EDPS) has no restrictions related the number of chart review delete records submitted to the Encounter Data System (EDS). Please note that chart review delete records must include the Internal Control Number (ICN) of the record from which the delete chart review is deleting diagnoses, or it will be rejected.

Source: User Group Q&A Documentation from January 19, 2017

The Chart Review Record (CRR) will not be considered a duplicate of a previously accepted Encounter Data Record (EDR). If the CRR is a copy of previously accepted CRR, then the CRR will be considered a duplicate. Please refer to the ED and Risk Adjustment Processing System (RAPS) Webinar Topics Index (user group topics index) for more information on duplicate record processing from prior user group calls.

Source: User Group Webinar on August 15, 2019

No, the diagnoses on the Chart Review Record (CRR) Add will not be linked to the replacement Encounter Data Record (EDR). However, the diagnoses on the CRR Add will still be considered for risk adjustment if they pass the CMS filtering logic. The information on a Linked CRR Add is still retained in CMS’ filtering process, even if the record that the CRR Add is linked to is voided or replaced.

Source: User Group Webinar on February 21, 2019 and User Group Webinar on August 27, 2020

MAOs and other entities should submit a replacement Encounter Data Record (EDR) using the Internal Control Number (ICN) from the most recently accepted submission for the record. In the example provided in the question, the subsequent replacement EDR should reference the ICN of the previously accepted replacement EDR.

Source: User Group Q&A Documentation from January 19, 2017

Encounter Data System (EDS) cannot process Encounter Data Records (EDRs) that were rejected by the EDFES. If EDRs were rejected because of the inclusion of codes that are not yet valid, then the MAO would need to resubmit these records. When the EDS validates incoming data using reference data, the EDS applies the effective data range business rules that were in effect at the time of service.

Source: User Group Q&A Documentation from January 19, 2017.

If one of the key fields is different from the original record submitted, MAOs should void the originally accepted record and re-submit as an original record.

Source: User Group Webinar on April 18 2019