Risk Adjustment Platform

Reimagining Risk Adjustment for Medicare Advantage

Medicare Advantage plans face growing regulatory scrutiny, shifting CMS guidelines, and constant pressure to optimize coding accuracy. Legacy tools only tackle fragments of the workflow—leaving gaps, errors, and lost revenue. 

Health Data Max changes that. 

Our AI-powered, cloud-based Risk Adjustment Platform delivers end-to-end capabilities across prospective, concurrent, and retrospective workflows. From predicting undocumented HCCs to validating submissions and reconciling CMS responses, we ensure your organization stays compliant, accurate, and profitable. 

Built for Accuracy. Designed for Action. 

At the heart of our platform is proprietary Natural Language Processing (NLP) and custom-trained Large Language Models (LLMs) that: 

  • Extract diagnoses and clinical evidence from structured and unstructured data 

  • Detect coding inconsistencies and unsubstantiated conditions 

  • Surface missed opportunities to close care gaps and improve RAF scoring 

Whether it’s claims data, chart notes, or discharge summaries—our engine delivers clinical intelligence that drives real results. 

What Sets HDM Apart? 

🔍 Prospective HCC Identification 
AI algorithms highlight members with likely undocumented chronic conditions based on history, utilization, and clinical similarity. 

📋 Retrospective Chart Review & Validation 
Easily link/delink diagnoses for CMS audit readiness, ensuring compliant documentation. 

📑 Intelligent Chart Prioritization 
Queue high-value charts with the greatest compliance or revenue impact. 

🛡️ Audit & Compliance Preparedness 
Monitor insufficient documentation, corrective actions, and maintain a defensible audit trail for RADV or external audits. 

⚡ Real-time Coding Support 
In-workflow AI suggestions validate codes before submissions, reducing downstream errors. 

All-in-One. No Gaps Left Behind. 

Our web-based platform is designed for coders, clinical reviewers, and audit teams with: 

  • Role-based access for secure, tailored workflows 

  • Configurable dashboards for full submission visibility 

  • Seamless integrations with payer/provider systems 

Whether your goal is to: 
✔ Defend against RADV audits 
✔ Improve RAF score accuracy 
✔ Close care gaps on high-risk patients 
✔ Eliminate data leakage and errors 

…Health Data Max gives you the visibility and automation to act decisively. 

Key Features 

📊 Data Consolidation & Management 

  • Extract, transform, and consolidate encounter data for CMS submission 

  • Operational reporting for complete transparency 

🧾 Claims Transactions 

  • Generate and submit clean claims (X12 5010 837 I, P, DME) 

  • Support for standard, capitated, void, adjusted, chart-linked/unlinked, and atypical encounters 

🔄 CMS Response Handling 

  • Load and process all CMS responses (TA1, 999, 277CA, MAO-002, MAO-004, MORs, MMRs, and more) 

  • Full audit trail of every transaction 

⚠️ Error Management 

  • Configurable error queues with automated detection, correction, and reconciliation 

🤖 Advanced HCC Analytics 

  • Clinical AI-based HCC rules engine 

  • Predictive models to optimize prospective and concurrent risk adjustment 

The HDM Advantage 

  • End-to-end workflow automation 

  • AI-driven accuracy and compliance 

  • Seamless CMS integration 

  • Defensible audit trails 

✨ With HDM, risk adjustment is no longer a burden—it’s a strategic advantage. 

📩 [Request a Demo] to see the platform in action. 

Features:

Data_funnel.png

DATA CONSOLIDATION

ROBUST DATA MANAGEMENT

Extract, transform, and consolidate encounter data for submission to CMS, paired with operational reporting

CLAIMS TRANSACTIONS

STREAMLINED CLAIM TRANSACTIONS

Generate and submit clean claims transactions required for all encounter types (X12 5010 837 I, P, and DME)

Document.png
Response.png

CMS RESPONSES

DETAILED AND ACTIONABLE

Load and process CMS responses to claims transactions (TA1, 999, 277CA, MA-002, MA-004, MORs and others)

ERROR MANAGEMENT

RESOLUTION & CORRECTION

Get access to highly configurable and robust error queue management

Error.png
Financial.png

ADVANCED HCC ANALYTICS

MACHINE LEARNING DRIVEN ANALYTICS

Clinical AI-based HCC rules engine to give more predictability into your HCC recapture and provides robust leverage to your prospective and concurrent Risk adjustment processes

ENCOUNTER SUPPORT

FULL-RANGE OF SUPPORT TOOLS

Support all variations of encounters including: standard, capitated, void and adjusted, chart linked and unlinked, and deleted, as well as encounters from atypical providers

Tools.png