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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

November 2015

Affordable Care Act and Risk Adjustment

In line with the risk adjustment program implemented as a result of the Affordable Care Act (ACA) reforms that took effect January 1, 2014, Harvard Pilgrim would like to remind providers of the importance of seeing your chronic patients illnesses annually — and reporting diagnosis codes completely and accurately. 

The ACA’s risk adjustment program measures and compares the relative health status among health plans’ membership by calculating average risk scores. Since the accuracy of these risk scores is dependent on complete and accurate reporting of diagnoses by physicians, risk adjustment creates an opportunity for health plans and providers to review coding practices and identify and correct common coding gaps.

Harvard Pilgrim encourages providers to keep the following tips in mind when reporting diagnosis codes:

  • All relevant, confirmed diagnosis codes should be reported via claims submission at least once per year for each patient (preferably every 6 months).
  • Be aware of how many diagnosis codes per claim are allowed in your system. Harvard Pilgrim’s systems are capable of accepting more than 20 diagnosis codes in a single claim.
  • Confirm that the provider billing office submits all relevant diagnoses from that encounter with the claim regardless of its impact to claims payment. If you use a clearinghouse, confirm that they are not dropping diagnosis codes.

For more detailed information and helpful coding tips, please refer to this article from the January 2015 issue of Network Matters. If you have any questions, contact Harvard Pilgrim’s ACA risk adjustment program at 617-509-2199.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator