In Medicare Advantage, risk adjustment isn’t just a compliance checkbox — it’s the core of your financial health and audit security. But between disjointed claims data, rigid CMS submission rules, shifting HCC models, and RADV audits waiting in the wings, the process is often fragmented and risky.
Health Data Max (HDM) is built to change that. Our comprehensive risk adjustment and compliance platform supports your entire workflow — from the first claim to the final audit defense.
Step 1: Clean Claims — The Start of Risk Accuracy
Everything begins with claims data. Our platform ingests Part C and Part D provider claims and refines them into structured, ready-to-use information that forms each member’s risk and clinical profile.
What we deliver:
Early risk profiles for every member
Provider quality trends and insights
Detection of documentation gaps before they become CMS issues
Think of it as creating a solid foundation — because clean inputs set the stage for clean outcomes.
Step 2: EDI 837 Encounter Submissions — Streamlined and Automated
After adjudication, we transform your claims into CMS-ready EDI 837 encounters. With our Encounter Submission Engine, your data is prepared for seamless submission.
We help you:
Format encounters to CMS standards — no rejections for structure
Automate Part C and D submissions
Monitor and trace responses to know exactly what CMS accepted or flagged
Your data isn’t just submitted — it’s delivered polished and ready for audit scrutiny.
Step 3: Decoding CMS Responses — From EDI Confusion to Clarity
Once your data is with CMS, responses start rolling in — and we’re ready. Our platform translates every feedback file into actionable insights:
TA1: File received?
999: Syntax approved?
277: Claim-level status updates
MAO-002: Final CMS verdict — accepted, rejected, or retry
We provide:
Real-time error alerts
Clear resolution pathways
Visual dashboards that simplify EDI feedback
No need to interpret complex codes — we do the heavy lifting.
Step 4: Owning the Monthly CMS Files — MAO-004, MMR, MOR & More
Many solutions focus solely on submissions. We go deeper, helping you unlock the insights from monthly CMS files:
MAO-004: Did your diagnoses pass the CMS filter?
MMR: What payments did CMS send, and how were they calculated?
MOR: Which HCCs counted toward your risk score?
With HDM, you stay in control of payments, documentation gaps, and audit preparedness — without surprises.
Step 5: Smarter Medical Chart Coding — Driven by AI/NLP
Compliance starts with accurate documentation. HDM’s AI/NLP-driven chart review module sharpens your coding process:
Validate each diagnosis against the clinical record
Detect undercoding or missing HCCs
Identify mismatches between what providers submit and what CMS records
Plus, we’ve made chart reviews faster and smarter:
Smart Summary: AI-generated snapshots of the entire chart
Chart Copilot: Chat directly with chart content to clarify codes or spot inconsistencies
In a RADV audit, “almost accurate” isn’t enough — we help you get it right.
Step 6: Beyond Compliance — Managing Population Risk Proactively
Risk adjustment is about more than meeting CMS standards — it’s a strategic lever for population health and financial forecasting.
With HDM, you can:
Monitor real-time risk shifts across populations
Pinpoint high-risk members needing intervention
Predict revenue based on coding trends and gaps
Prepare for RADV with confidence, not scramble
We help you move from reactive to proactive — managing both risk and opportunity.
Why Choose Health Data Max
End-to-end workflow support: From claims to CMS to audits
Built-in compliance checks: Reduce rejections, mitigate audit risks
Financial transparency: Know where every CMS dollar comes from
AI-driven intelligence: For faster, smarter coding reviews
When CMS regulations evolve and audit scrutiny intensifies, Health Data Max ensures your risk adjustment stays compliant, optimized, and profitable.
Ready to Transform Your Risk Adjustment Strategy? Schedule a demo today at sales@healthdatamax.com