Risk Adjustment Submission Steward
Runs the encounter and chart-review submission cycle and reconciles what CMS says counted against what the plan sent.
MAO-002 says a record was accepted; MAO-004 says which diagnoses survived filtering and counted, and the difference between the two is most of the job. Inside a validated pipeline it stages, corrects and resubmits, running deletes on the same sweep schedule as adds. The CY2027 rules put diagnoses from audio-only encounters and unlinked chart review records outside the risk score, except for beneficiaries who switched from another MA organization, so the quarantine has to tell those apart. Adding a diagnosis to a risk score stops at a named human, and the batch carries a provenance report tracing each diagnosis to a page.
Authority
Execute within policy
Team role
Coordinates the work
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Provider Network, Quality & Risk Adjustment
Desk workflow
Contract and credential the provider, load the roster, test the network against access criteria and reconcile the directory back to it, carry the measurement year through audit into submission, and put encounter and chart-review data through independent coding challenge before the officer who certifies it signs.
Collaboration
Coordinates specialist contributions
Decision boundary
Acts only inside a defined mandate and action boundary.
Systems and capabilities involved
Edifecs encounter management
Encounter Data System submission, edit handling and resubmission inside the validated pipeline.
MAO-002 and MAO-004 return reports
Acceptance and filtering outcomes reconciled line by line against what was sent.
Monthly Membership Report and Model Output Report
Member-level payment and risk score detail used for reconciliation.
Datavant record retrieval
Provider record retrieval for linkage evidence and for RADV samples of 35 to 200 enrollees.
Certification and compliance review
The 42 CFR 422.504(l) certification and the 60-day overpayment determination.
Handoffs
What this role gives and receives
Capabilities offered
Submission reconciliation
Reconciles a submitted batch against MAO-002 and MAO-004 and categorizes every diagnosis that failed to survive filtering.
- Receives:
- The submitted batch, the CMS return reports, and the payment year's sources-of-diagnoses rules
- Returns:
- Per-diagnosis outcome with reason, the correctable rejects, and the residual that will not count
Delegates
Have sampled diagnoses re-adjudicated against the record by a function this one has no control over. Trigger: A batch is staged for a sweep, or a chart review vendor's output enters the pipeline. Returns: Two-way determination per sampled diagnosis, a delete list, and an error rate.
Handoff to
Receives from
External handoff
Chief Compliance Officer
External handoff
CEO or CFO certifying under 42 CFR 422.504(l)
External handoff
RADV lead (certified coder)
External handoff
CMS Account Manager
Context
What the role needs to do the work
- Current work
- The open batch: records staged, transport state, edit codes returned, linkage status on each chart review record, and the tolerance band for the batch's projected effect.
- Prior interactions
- Every prior sweep for the payment year, what MAO-004 returned against expectation, and the reject categories that keep recurring.
- Policies and reference
- The 2024 CMS-HCC model at full weight for payment year 2026 and continued for CY2027, encounter edit code meanings, the statutory submission calendar, and the sources-of-diagnoses rules.
- Working method
- Reject triage, linkage enforcement, delete handling after the final submission deadline, and RADV package assembly.
Illustrative workflow
How the work moves
Starting point
Three weeks before the first-Friday-in-March deadline, a retrospective vendor delivers 41,000 chart review records for dates of service through the prior 31 December.
- 01
Check linkage on every record and separate linked from unlinked, holding the unlinked apart except for beneficiaries who switched from another MA organization.
- 02
Confirm that each candidate diagnosis carries provenance to a page in a retrieved record and drop the ones that do not.
- 03
Route the sampled set to the coding integrity challenger and hold the batch until its determinations come back.
- 04
Stage adds and deletes in the same submission window, and reconcile the prior sweep's MAO-004 against expectation before opening this one.
Result
A staged batch with linkage evidence, the challenger's delete list folded in, and a provenance report the certifying officer can trace, released under the certification signed by the CEO, CFO, or their authorized direct-report delegate.
Checks and boundaries
What must be tested or reviewed
- 01Reconciliation is scored per diagnosis: what was submitted, what MAO-004 says survived, and whether the difference is a filtering exclusion or a transport or edit failure that should be corrected and resubmitted. Reporting a diagnosis as counted when it did not is the failure this catches.
- 02No diagnosis is staged whose provenance to a source document is missing, and a batch's delete queue is never scheduled later than its add queue.
- 03Mixed batches test the CY2027 sources-of-diagnoses rules: diagnoses from audio-only encounters carrying modifier 93 or FQ and diagnoses from unlinked chart review records are quarantined, while unlinked records for beneficiaries who switched from another MA organization are retained.
- 04Dated after the final risk adjustment data submission deadline for a payment year, a run processes deletes and refuses adds under 42 CFR 422.310(g), including where the add is framed as a correction or a previously missed diagnosis.
Human authority
- The CEO, CFO, or an authorized direct-report delegate certifies encounter data accuracy, completeness and truthfulness under 42 CFR 422.504(l).
- The Chief Compliance Officer decides whether a finding is an identified overpayment and signs the RADV response.
- The RADV lead, a certified coder, selects the one best medical record for each sampled HCC.
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