Commercial Risk Adjustment

  • The provider's role in commercial risk adjustment

    Commercial risk adjustment is part of the Affordable Care Act. Its goal is to stabilize risk for individual and small group plans inside and outside of the Exchange marketplace. It helps health plans like Premera continue to offer much-needed coverage for a diverse population.

    Providers play a huge part in the overall success of commercial risk adjustment. From specifically coding patient visits to submitting claims and assisting with audits, risk adjustment involves all levels of staff in a provider's office.

    Here you can learn more about how we're partnering with providers in commercial risk adjustment efforts through medical records requests, and provider education.

    Medical records requests

    Medical records requests are a key part of risk adjustment activities and are necessary to help us manage risk and make sure our members have access to quality, affordable healthcare.

    Each fall, in compliance with requirements of the Affordable Care Act, Premera requests medical records from providers in order to validate that claims information match documentation. You may receive a letter from Altegra Health requesting copies of some of your patients' records.

    You may also receive a letter from Cognisight to participate in the annual Risk Adjustment Data Validation (RADV) Audit mandated by CMS every summer. For RADV, a letter will come from Cognisight requesting copies of some of your patients' records.

    Coding and documentation best practices

    With the Affordable Care Act's risk adjustment mandate and the recent transition to ICD-10, there is increased focus on documentation and coding standards.

    The following resources can help you improve documentation and coding:

    Resources for coders and billing staff

    For more information

    If you have questions, please call Physician and Provider Relations at 877-342-5258, option 4, or email ProviderEngagementTeam@premera.com.