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Risk Adjustment Programs


Risk Adjustment Processing Systems (RAPS) is a Medicare program whereby program payments are adjusted based on a higher assignment of members with chronic conditions.

Because this is a government-administered plan, collection of accurate and complete diagnoses from providers each year is critical to the continuity of the plan. (Government systems do not carry diagnosis information over from the prior year).

To facilitate this documentation, Wellcare engages providers in various methods to validate member diagnoses. These methods include:

  • Giving specific diagnosis history to providers to assist in updating current year documentation
  • Utilizing in-home assessments for members who have difficulty in accessing care or are homebound or for other factors limiting the plan’s ability to update diagnosis history
  • Retrieving medical records from providers to ensure diagnoses were completely and accurately submitted on the claims
  • Partnering with providers through incentive programs to ensure Quality and Health History goals (See below for details on current programs)

Continuity of Care (CoC) Program

Wellcare cares about the quality of health care delivered to our members. Our CoC Program recognizes providers like you who collaborate to deliver and appropriately document quality care to our members. Our CoC Program incorporates HEDIS®, Continuity of Care, and Pharmacy measures into a singular, comprehensive program.

You can earn bonuses by submitting documentation of current health status (ICD10 codes) and STAR HEDIS/ Medication Adherence Measures (CPT, ICD 10, and NDC codes).

The program leverages your existing workflow:

  • Schedule and conduct patient exams.
  • Use the Appointment Agenda, HEDIS reports and RxEffect® as guides to close care gaps and update diagnoses.
  • Sign, date, and fax the completed Appointment Agenda and/or Comprehensive Exam Medical Record to
    1-813-464-8879 or submit electronically via RxEffect (if applicable).
  • Provide appropriate medications to your members and encourage them to fill their prescriptions; consider 90-day supplies for members stable on therapy.
  • Submit all appropriate diagnostic and procedure codes on your claim and document in the Patient’s medical record.

If you have questions about our CoC Program, please contact your Provider Relations Representative, Quality Practice Advisor, or call Provider Services at 1-855-538-0454 (TTY 711). You can reach us Monday–Friday from 8 a.m. to 6:30 p.m.

You can find more information in the Other Resources box after logging on to provider.wellcare.com.

Thank you for working with us to deliver quality health care to our members.

 

 

 

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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최근 업데이트 날짜: 12/3/2020