Improve risk adjustment submission rates


The facts

Submitting timely and accurate risk adjustment data to the Centers for Medicare & Medicaid Services (CMS) for Medicare and commercial risk adjustment can be complicated and difficult. Payers have navigated numerous challenges and setbacks in the ongoing transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data Processing System (EDPS). And setting up and running the dedicated EDGE server required for commercial risk adjustment requires expensive and difficult-to-maintain IT resources. Health plans must grapple with all these tasks while maintaining compliance in the evolving risk adjustment regulatory landscape.

Cotiviti’s Submissions solution alleviates these burdens, combining technology with subject-matter expertise to reduce the time and cost involved in the submission of risk adjustment data while optimizing revenue opportunities for health plans.


Achieve proven match rates of hierarchical condition category (HCC) edits properly submitted to CMS

Consolidate activities with a single data storage solution accessible by Medicare and commercial risk adjustment systems

Gain transparency and visibility into risk adjustment programs at all stages with simplified reconciliations

Validate the ROI associated with Cotiviti solutions and improve revenue forecasts

Fine-tune ongoing suspect analytics with encounter data

Increase the accuracy and efficiency of RAPS and EDPS submissions

Cotiviti combines our technology with deep subject-matter expertise to reduce the time and cost involved with RAPS and EDPS management. Our experts continuously evaluate our proprietary claims-filtering algorithms for RAPS submission, based upon the latest CMS guidance. We are the primary submitter of RAPS data for our clients, taking on the burden of maintaining CMS connections.

Using our proprietary workflow tool, Cotiviti experts also pre-edit your organization’s encounter data, format it, and submit properly formatted 837 claims to CMS on your behalf. You can log into our systems and use our front-end user interface to correct errors in your encounter data and queue the corrected encounter data for submission to CMS. Our solution also offers single data stream processing for EDPS and RAPS customers, enabling a single file extract to Cotiviti that supports both RAPS and EDPS submissions for claims, membership, and provider data.

Our RAPS and EDPS reporting suite includes a variety of detailed and summary reports that help you plan and prioritize reconciliation and submission work, project risk scores and financial impact based on return data, and provide historical views for trending purposes.


Reduce the cost and technical complexity of EDGE server hosting and data submission

Cotiviti provides dedicated, secure EDGE servers that are configured and maintained based on CMS guidelines. Clients submit their data directly to Cotiviti, and we scrub the data for extraction and submit it to CMS in a compliant format. CMS then processes enrollment, medical, provider, and pharmacy data for the purposes of risk adjustment and reinsurance calculations.

Our user-friendly platform allows you to access submission results and analytic and operational reports, as well as perform error reconciliation. Encounter data submissions stored on our platform feed into and fine-tune our Suspect Analytics for increased sensitivity to the highest-potential members the following year.

Feel confident with proven results

With more than 20 years of experience providing risk adjustment solutions to meet the evolving requirements of health plans, Cotiviti is a partner you can trust.


Results that speak for themselves

Clients have averaged 99 percent acceptance for Medicare risk adjustment submissions for the past three years.

Clients have averaged 98 percent acceptance for commercial risk adjustment submissions since inception of our program in 2014.

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