Which data source and model does Medicaid risk adjustment rely on to calculate risk scores?

Which data source and model does Medicaid risk adjustment rely on to calculate risk scores?

• A. CDPS to calculate risk scores based on demographics and diagnoses
• B. CMS-HCC crosswalk to calculate annual risk scores
• C. RAPS and EDS to calculate risk scores
• D. IPERA data review to calculate risk scores

Answer: (B)

Medicaid risk adjustment uses the CMS-HCC risk adjustment framework. Diagnoses from encounter or claim data are first mapped into Hierarchical Condition Categories (HCCs) using the CMS-HCC crosswalk. Those HCCs are then input into the CMS-HCC model to calculate annual risk scores. The crosswalk is the essential link that converts ICD diagnoses into the HCC inputs the model needs. This is why this option is the best fit: it pairs the diagnostic data mapping step (the crosswalk) with the CMS-HCC model that produces the risk scores. The other choices either refer to a different risk-adjustment model (CDPS), describe data sources rather than the model itself (RAPS/EDS), or relate to a completely different activity (IPERA data review).

Medicaid risk adjustment uses the CMS-HCC risk adjustment framework. Diagnoses from encounter or claim data are first mapped into Hierarchical Condition Categories (HCCs) using the CMS-HCC crosswalk. Those HCCs are then input into the CMS-HCC model to calculate annual risk scores. The crosswalk is the essential link that converts ICD diagnoses into the HCC inputs the model needs. This is why this option is the best fit: it pairs the diagnostic data mapping step (the crosswalk) with the CMS-HCC model that produces the risk scores. The other choices either refer to a different risk-adjustment model (CDPS), describe data sources rather than the model itself (RAPS/EDS), or relate to a completely different activity (IPERA data review).