CMS Pub. 100-16, ch. 7, § 120.2.5

As part of the requirement that plans submit accurate risk adjustment data, CMS requires

that plans work to minimize the submission of duplicate diagnosis clusters. CMS

considers a plan submission that contains 5% or greater duplicate diagnosis clusters to be

a high level of duplicate submissions and to be in violation of the requirement to submit

accurate data.

Failure to submit accurate and timely risk adjustment production files may result in: 1)

incorrect payments to your MA organization; 2) loss of monthly prospective revenue

relating to beneficiary-health status; 3) payment recovery through a lump-sum recovery;

4) cessation of monthly payments throughout the remainder of a coverage year; and/or 5)

adjusting payments in a subsequent year. Non-compliance with these requirements may

result in CMS restricting future risk adjustment submissions by your MA organization.

Table 23, below, provides tips to assist plan sponsors in tracking diagnosis clusters so

that they can be compliant with the guidance on the 5 percent benchmark for duplicate

diagnosis cluster errors. CMS communicates to submitters a 502-error code for each

diagnosis cluster that shares the same attributes as one previously submitted and stored in

the RAPS database. CMS reviews files weekly and identifies diagnosis clusters; each

502-error code counts toward the 5 percent benchmark. If the submitter is a third party

and the file contains records for multiple plans, the review will occur at the plan level

within the file.

Table 23. Tips for Ensuring Compliance with the 5 Percent Benchmark

for Duplicate Diagnosis Cluster Error Guidance

Tips Description

Identify a

Duplicate

Diagnosis Cluster

CMS defines a Duplicate Diagnosis Cluster as one that shares all of

the same attributes (HIC Number, Provider Type, From and Through

Dates and Diagnosis) as one previously submitted and stored in the

RAPS database.

Review Reports

Review current and previous RAPS Return Files to determine which

clusters RAPS stored. If RAPS stored the cluster, MA organizations

should not resubmit.

Understand Error

Resolution

300-Level Errors

Resubmit all clusters associated with the record, this would not

create a duplicate diagnosis because none of the records were

previously stored.

400-Level Errors

Only resubmit the specific cluster that resulted in the 400-level error

message. Do not resubmit all clusters within the record, only the

clusters that contain errors.

Understanding

Modifying Data

MA organizations should only resubmit the diagnosis clusters that

require a modification.

For example, an MA organization submits eight clusters, and the

following week the organization notices the date of service submitted

was incorrect in one of the clusters, the organization must submit that

specific cluster with a “D” in the delete indicator field, and submit a

new cluster with the correct date.

Resubmitting all of the remaining seven clusters would create seven

duplicates.

120.2.6 - Health Insurance Portability and Accountability Act (HIPAA)

(Rev. 118; Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012 (for ASC X12 5010); Implementation: ICD-10: Upon Implementation of ICD-10,

ASC X12: January 1, 2012 (for ASC X12 5010))

Effective October 16, 2003, when HIPAA transaction standards became mandatory, all

electronic claims/encounters sent from providers/physicians to MA organizations (health

plans) constitute a HIPAA covered transaction. Any MA organization that receives an

electronic claim/encounter from a provider/physician must use the current applicable

ASC X12 837 format.

MA organizations cannot request that a physician resubmit data previously submitted

(same patient, same diagnosis) using a different format (e.g., HCFA 1500) if the

physician initially submits data in ASC X12 professional format for purposes of risk

adjustment data collection.

In accordance with Final Rule 45 CFR Part 152, effective March 17, 2009, CMS adopted

X12 Version 5010 for HIPAA transactions. The final rule mandates covered entities MA

organizations (health plans) comply no later than January 1, 2012.