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HEDIS/NCQA/Risk Adjustment Updates for Providers

Mar 09, 2020
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The Affordable Care Act’s Commercial Risk Adjustment (“RA”) program equalizes risk for individual and small group plans inside and outside the Marketplace. Health Options complies with this program and its requirement to verify that Members with specific chronic illnesses have an annual provider visit during which their illness is documented. We frequently need to request copies of Members’ medical records for that purpose.     

You can reduce the number of RA-related record requests you receive by including appropriate ICD-10 coding on claims. Additional information about Risk Adjustment, including tips to improve clinical documentation, is available here.  Be aware that this will not affect the quantity of requests for records Health Options needs for HEDIS (Healthcare Effectiveness Data and Information Set), which is a separate program with different information requirements.  

We appreciate your prompt response to our record requests.


The Maine legislature recently passed four bills, effective September 19, 2019, that pertain to health insurance plans and carriers. These regulations do not require any action by providers but may impact Health Options’ processes, payment, and benefits.