Telemedicine and Risk Adjustment Programs
Telemedicine and Risk Adjustment Programs
Unconfirmed Diagnosis Code (UDC) Program
The UDC Program is a clinically based program that promotes Provider/Highmark collaboration to evaluate previously reported and/or suspected diagnosis conditions. These conditions require annual evaluation and/or treatment but may not have been reported to Highmark in the current year. This improves continuity, quality and timely coordination of care for chronic conditions.
2023
2022
UDC Engagement Webinar
Bi-monthly Engagement Webinar and Live Q&A session: This 30-minute bi-monthly series is held from 12:15 – 12:45 p.m.
2023
2022
*We are now offering video recordings of our webinars. If you experience an issue with the video, please contact resourcecenter@highmark.com.
2023 Risk Score Accuracy (RSA) Program
The goal of the RSA Program is to help ensure that quality health care is provided to Highmark Medicare Advantage and Inter-Plan Medicare Advantage members with complex chronic health conditions by assisting provider practices to accurately identify, treat, document, and report appropriate diagnosis codes to Highmark.
To support this, analytics are used to identify persistent and/or suspected diagnosis conditions of Members. Participants are asked to address these diagnosis conditions during office visits using an Electronic Medical Record ("EMR")-based or desktop-based, system-generated form ("RSA Tool"). Participants must respond to the RSA Tool, document the confirmed condition in the Member's medical record, and submit confirmed conditions on their claim as indicated in the instructions and Program Manual.
HHS Risk Adjustment Data Validation (HHS-RADV) Program
The HHS Risk Adjustment Data Validation (HHS-RADV) Program is in compliance with federal regulations that require Affordable Care Act (ACA) organizations and their providers and practitioners to submit medical records for the validation of risk adjustment data. Highmark requests medical records to ensure that diagnoses sent to the Centers for Medicare and Medicaid Services (CMS) are valid for the services provided to Medicare Advantage (MA) beneficiaries.
Part C Improper Payment Measure (IPM) Audit
The Part C Improper Payment Measure (IPM) audit is in compliance with federal regulations that require Medicare Advantage (MA) organizations and their providers to submit medical records for the validation of risk adjustment data. Highmark requests medical records to ensure that diagnoses sent to the Centers for Medicare and Medicaid Services (CMS) are valid for the services provided to MA beneficiaries.
Retrospective Chart Retrieval Program
The Retrospective Chart Retrieval Program supports a requirement of the Centers for Medicare & Medicaid Services (CMS) to ensure the accuracy and integrity of risk adjustment data submitted to CMS. Highmark works with vendors to retrieve charts for a predetermined list of Highmark members from providers.
Last updated on 9/11/2023 10:53:32 AM