Autonomous, Agentic AI Solutions for the Entire Risk-Adjustment Lifecycle

Intelligent agents now collaborate across member targeting, chart retrieval, coding, submissions, and audits — closing gaps, ensuring compliance, and protecting revenue in real time.

PREDICTIVE RISK ADJUSTMENT ENGINE

CLOSE PREDICTED GAPS AT POINT OF CARE THROUGH EHR-INTEGRATED PHYSICIAN WORKFLOW

3-Pillar Value Proposition

1. Chart AI Copilot 

Delivering real-time clinical intelligence at the chart level

Leverages proprietary NLP and LLMs to scan structured & unstructured data for HCCs and missed coding opportunities. 

• Assists coders and QA teams with compliant code suggestions, source-linked references, and confidence scoring. 

• Supports prospective, retrospective, and concurrent chart reviews. 

• Tracks every action for audit-readiness and traceability (full audit trail). 

• Seamlessly integrates with your existing EHR or coding platform. 

2. CMS Submission Compliance

Automated validation and reconciliation across your entire submission pipeline

Ingests and analyses X12 837 I/P/D encounter files. 

• Monitors TA1, 999, 277CA, MAO-002, MAO-004, MMR, and MOR files for errors and rejection trends. 

• Real-time dashboards flag rejected or dropped encounters. 

• Built-in reconciliation tools link rejected claims to charts, ensuring no revenue is lost. 

• Keeps your plan audit-ready and aligned with CMS requirements. 

3. RAF Optimization

Drive more accurate risk scoring and maximize revenue without over-coding

Identifies undocumented HCCs across clinical records using AI. 

• Prioritizes high-impact, high-chronic patients to close the right gaps first. 

• Supports prospective programs that improve performance before the look-back ends. 

• Reduces risk of over- or under-coding by flagging anomalies with contextual evidence. 

• Generates predictive RAF impact and submission completeness metrics.

Powered by Agentic AI & Fine-Tuned LLMs
Every Health Data Max solution leverage Agentic AI—a multi-agent intelligence architecture designed to continuously review CMS files, member charts, and claims data. Each product, from chart review to RADV defense, benefits from these agents’ ability to reason, validate, and adapt to changing CMS models.
This ensures unmatched accuracy, auditability, and compliance across your risk adjustment lifecycle.

Learn About latest CMS Medicare Advantage Rules

Exploring CMS’s 2026 Advance Notice: Key Updates for Medicare Advantage and Part D Programs

Summary

Medicare Advantage & Part D Updates

The 2026 Advance Notice outlines major shifts for Medicare Advantage and Part D:

• Medicare Advantage: A 5.93% effective growth rate in capitation rates — the largest in nine years. CMS will also fully implement the 2024 CMS-HCC risk adjustment model and finalize phase-in adjustments for indirect medical education costs.

• Part D: A new $2,100 annual out-of-pocket cap on prescription drug costs, with expanded manufacturer discounts in both the initial and catastrophic phases of coverage. Risk adjustment is being updated to align with the redesigned benefit design and cost-sharing structure.

• Star Ratings: Introduction of a Kidney Health Evaluation measure for patients with diabetes, plus increased weighting for measures tied to maintaining or improving physical and mental health.

Broader Program & System Changes

Beyond payments and benefits, CMS is moving forward with systemic improvements:

• PACE Program: Gradual transition to the updated CMS-HCC model, starting with a 10% blend in 2026 and reaching full adoption by 2029.

• MARx System: Migration to a cloud-based infrastructure for improved scalability and security.

• Normalization Factors: Updated to reflect trends from both pre- and post-COVID-19 periods.

These updates are designed to strengthen payment accuracy, audit readiness, and beneficiary protections, while driving higher-quality outcomes across Medicare Advantage, Part D, and PACE programs.

FAQs

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