Risk adjustment is a mechanism used in health insurance to account for the overall health and expected medical costs of each individual enrolled in a health plan. For more information view our Risk Adjustment Overview (PDF)
Carolina Complete Health is committed to supporting your efforts to provide the highest quality care to our members. As a result, Carolina Complete Health launched a Continuity of Care (CoC) Risk Adjustment program effective February 2022.
Historical diagnosis is included on the Appointment Agendas when available.
Determine if the Suspected Condition is ‘Active’ or ‘Resolved/Not Present’.
Use the Crosswalk of available ICD10 Codes by clicking on the Suspected Condition or please email your Provider Engagement Coordinator for support.
No, marking ‘Resolved/Not Present’ will not remove a condition from the agenda. We use a 3-year lookback for suspected & documented conditions using data we gather from CMS or the State, along with prescriptions and diagnostics that may have taken place. If a higher/lower acuity level was billed after they indicated ‘Resolved/Not Present’, that new condition category may show up this year.
The facilitator of the program may sign and submit the Appointment Agendas.
Incremental refreshes occur June, August, and October.
Yes, one Appointment Agenda per targeted member (unless they change TIN/Groups). Not all members are in the program, as they may not have any history of Risk Adjusted Disease Conditions.
As members move, the data will update during the various waves if there is still a need to recapture risk conditions that may not have been submitted year to date. Anything written on an Appointment Agenda cannot be used, the Intake Team looks for a name/signature then enters in the Check Boxes only.
Yes, you have the ability to follow the same process as downloading, saving, and printing.
If what they find and document/bill for is within the same family of the Suspected Condition, they would indicate ‘Active Dx/Documented’. In the scenario where the ICD10 Code they are billing is not within the Crosswalk of Codes related to that condition listed, they would indicate ‘Resolved/Not Present’
1st CoC Payment in Quarter 2
2nd CoC Payment in Quarter 3
3rd CoC Payment in Quarter 4
Final CoC Payment in 2023
All providers must have a paid risk adjustable qualifying claim to be eligible for the bonus.
0-49% completed and validated Appointment Agenda Tier 1
50-79% completed and validated Appointment Agenda Tier 2
80-100% completed and validated Appointment Agenda Tier 3
Spreadsheets are acceptable. You must follow strict requirements, one spreadsheet per TIN number. Provider can send in as many spreadsheets as they want (1 TIN # per spreadsheet), however they MUST NOT include previously submitted Members, Only submit newly completed Appointment Agendas/members on each spreadsheet.
Audio & Video required, billing according to CMS & State guidelines. The provider must document that the Telehealth visit was conducted via audio and video communication.