What is “claims-based data” and how does RADV relate to it?

What is “claims-based data” and how does RADV relate to it?

• A. Claims-based data are hospital admission dates only; RADV ignores them.
• B. Claims-based data are diagnoses and procedures from submitted claims; RADV validates these diagnoses against chart documentation.
• C. Claims-based data are patient satisfaction ratings; RADV uses them to adjust payments.
• D. Claims-based data are only prescription data; RADV uses them to validate diagnoses.

Answer: (B)

Claims-based data are the diagnoses and procedures that appear on the claims submitted by providers to payers, and these codes determine a patient’s risk score in the risk-adjustment model. In RADV, auditors verify that those claimed diagnoses are actually supported by the patient’s medical records, ensuring the risk scores—and the resulting payments—are accurate. The other ideas miss the point: admissions dates alone don’t capture the full set of diagnoses/procedures on claims, patient satisfaction isn’t used for RADV calculations, and prescription data by itself isn’t what RADV validates to support diagnoses.

Claims-based data are the diagnoses and procedures that appear on the claims submitted by providers to payers, and these codes determine a patient’s risk score in the risk-adjustment model. In RADV, auditors verify that those claimed diagnoses are actually supported by the patient’s medical records, ensuring the risk scores—and the resulting payments—are accurate. The other ideas miss the point: admissions dates alone don’t capture the full set of diagnoses/procedures on claims, patient satisfaction isn’t used for RADV calculations, and prescription data by itself isn’t what RADV validates to support diagnoses.