Your definitive resource for MOR analysis, validation, and optimization

Quick Start: What You Need to Know

The MOR is CMS's only official feedback on your risk scores. Master it, and you master Medicare Advantage payments.

The Big Picture

What it is: CMS's report showing which diagnoses became paying HCCs
Why it matters: Direct impact on your revenue and compliance
When you get it: Monthly (Jan-June) + Final reconciliation
Who gets what: MA plans get Part C, PDP gets Part D, MA-PD gets both

The MOR Transformation Story

Before MOR Analysis: The Audit Nightmare

100s of hours spent on manual chart reviews
Low compliance with CMS requirements
Low STAR ratings due to missed opportunities
Revenue leakage from unidentified coding gaps

After MOR Mastery: The Success Story

Saves 100s of hours with automated insights
High accuracy in risk score validation
Achieves ⭐⭐⭐⭐⭐ ratings through precision
Drives measurable revenue impact

What Is the MOR? (The 60-Second Explanation)

Think of the MOR as CMS's receipt for your risk adjustment submissions.

Your Submission: "Member John has diabetes (E11.9)"
     ↓
CMS Processing: Filters, validates, applies hierarchy
     ↓
MOR Result: "HCC 19 - Diabetes triggered for John"

Bottom Line: The MOR shows which of your submitted diagnoses actually became paying HCCs.

Two File Types: Pick Your Weapon

For Human Review: MOR Report (HCCMODR)

Perfect for:

Small to medium plans
Manual validation
Spot-checking specific members

What you see:

Member names and demographics
Plain English HCC descriptions
Easy-to-read format

For Automation: MOR Data File (HCCMODD)

Perfect for:

Large plans with tech resources
Automated processing
System integration

What you get:

Binary flags (1 = HCC triggered, 0 = not triggered)
Fixed-width format for databases
200-byte records (Part C), 168-180 bytes (Part D)

MOR Timeline: When and What You Get

The CMS Risk Model Schedule

Initial Model Run:

Timing: Occurs early in the year
Purpose: Forms the basis for January through June payments
MOR Impact: Creates the monthly MORs you receive from January to June

Mid-Year Model Run:

Timing: Happens mid-cycle during the year
Purpose: Updates risk scores and drives July through December payments
MOR Impact: Generates the monthly MORs you receive from July to December

Final Model Run:

Timing: Takes place at year-end
Purpose: Produces definitive scores used for final reconciliation process
MOR Impact: Creates the Final MOR, which serves as the definitive source for all appeals and final validation

Monthly vs. Final MOR

Monthly MORs (Jan-June):

Real-time feedback on current payments
Use for ongoing validation
Course-correct during the year

Final MOR:

The definitive truth for appeals
Use for final reconciliation
Your audit defense document

Plan-Specific Distribution

MA Plans (Medicare Advantage Only):

Receive: Part C MOR only
Focus: Medical HCCs and risk adjustment for medical services
Why it matters: Allows concentration on medical condition coding and documentation without prescription drug complexity

PDP Plans (Prescription Drug Plans Only):

Receive: Part D MOR only
Focus: Prescription drug models and medication-related risk factors
Why it matters: Enables targeted analysis of drug utilization patterns and pharmacy-based risk adjustment

MA-PD Plans (Medicare Advantage with Prescription Drug Coverage):

Receive: Both Part C and Part D MORs
Focus: Complete risk picture covering both medical and prescription drug components
Why it matters: Provides comprehensive view of member risk across all covered services, essential for integrated care management and complete revenue optimization

From Diagnosis to Payment: The HCC Journey

The 5-Step Process

1. SUBMIT → You send diagnosis E11.9 (Type 2 diabetes)
2. MAP → CMS maps E11.9 to Condition Category 19
3. GROUP → CC 19 becomes HCC 19 (Diabetes)  
4. FILTER → CMS applies hierarchy rules
5. PAY → HCC 19 appears on MOR = Payment triggered

Why Diagnoses Get Excluded from MOR

Common Reasons Your Diagnosis Didn't Make It:

No Payment HCC Issue:

Problem: Your diagnosis uses non-specific codes that don't map to paying HCCs
Example: Using broad, unspecified diagnostic codes instead of detailed ones
Solution: Use more specific ICD-10 codes that map to actual payment categories

Hierarchy Override Problem:

Problem: A mild condition gets excluded when a more severe condition exists in the same hierarchy
Example: Documenting mild diabetes complications when severe complications are also present
Solution: Always document and submit the most severe condition in each hierarchy to maximize payment

Timing Issues:

Problem: Diagnoses submitted outside the acceptable service date windows
Example: Late submissions that miss CMS processing deadlines
Solution: Ensure all encounters are submitted within the required service date windows

Data Quality Problems:

Problem: Encounter data contains formatting errors or incorrect structure
Example: Improper file formatting, missing required fields, or invalid code formats
Solution: Implement robust validation processes for encounter data before submission to ensure proper formatting and completeness

Accessing Your MOR Files

Download Options

MARx UI: Web-based, user-friendly
EFT Mailbox: Automated delivery (Gentran, TIBCO, Connect:Direct)
CMS Enterprise Portal: For historical files

File Naming Convention

P.R[CONTRACT].HCCMODR.D[YYMM]01.T[TIMESTAMP]

Example: P.RH1234.HCCMODR.D2501.T143022

H1234 = Your contract
25 = Year 2025
01 = January

Strategic Applications: Make Your MOR Work

Revenue Optimization

Coding Gap Analysis

MOR Shows: Member has HCC 18 (Diabetes) 
Your Records: Also shows diabetic complications
Opportunity: Submit complication codes for higher HCC

Provider Feedback Loop

Show providers their HCC capture rates
Demonstrate documentation impact on payments
Target training based on MOR results

Compliance & Audit Defense

Validation Checklist

Internal risk scores match MOR results
All expected HCCs appear on MOR
No unexpected exclusions
Proper hierarchy application

Audit Preparation

MOR = Your official CMS documentation
Links diagnoses to payments
Supports appeals and corrections

Operational Excellence

For Small Plans

Manual MOR review process
Focus on high-value members
Target obvious gaps first

For Large Plans

Automated MOR processing
Dashboard development
Advanced analytics and trending

Full Risk (FR) Concept Simplified

Member Categories

Continuing Enrollees:

Definition: Members who have maintained 12 or more months of continuous Medicare Part A and Part B coverage
Risk Scoring: Receive full HCC hierarchy application with complete risk adjustment calculations
Impact: CMS has sufficient historical data to apply comprehensive risk scoring methodology

New Enrollees:

Definition: Members with less than 12 months of continuous Medicare Part A and Part B coverage
Risk Scoring: Receive modified scoring approach with limited historical data integration
Impact: CMS applies adjusted risk calculation methods due to insufficient claims history for full risk assessment

Strategic Tip: Plans get separate scores for each group and can choose which to use for payment strategies.

MOR vs. MAO-004: Know the Difference

Quick Comparison

MAO-004 File:

Purpose: Comprehensive record of all accepted diagnoses
Content: Everything CMS received and accepted from your submissions, regardless of payment impact
Scope: Includes all diagnoses that passed CMS validation, even those that don't generate revenue

MOR File:

Purpose: Payment-focused report showing only revenue-generating conditions
Content: Only diagnoses that became paying HCCs after hierarchy application and filtering
Scope: Filtered subset of MAO-004 that directly impacts your risk adjustment payments

Key Point: A diagnosis can be in MAO-004 but missing from MOR due to hierarchy rules or non-payment status.

Advanced Use Cases

Trending and Analytics

Track HCC capture rates over time
Identify seasonal patterns
Monitor provider performance

Targeted Interventions

Focus on members with gap opportunities
Prioritize high-RAF potential diagnoses
Optimize coding resources

Financial Planning

Project revenue based on MOR patterns
Budget for risk adjustment operations
Forecast payment reconciliations

Your MOR Action Plan

Month 1: Foundation

Set up MOR file access
Choose report vs. data file format
Create basic validation process

Month 2: Analysis

Compare MOR to internal projections
Identify top 10 coding gaps
Build provider feedback reports

Month 3: Optimization

Implement systematic gap analysis
Create MOR dashboard
Train providers on documentation impact

The Bottom Line

The MOR is your direct line to CMS's risk adjustment brain.

Every successful Medicare Advantage plan uses their MOR to:

Validate payments before surprises
Find revenue hiding in plain sight
Build bulletproof audit defenses
Optimize their entire risk adjustment machine

Ready to transform your MOR analysis? The data is waiting in your next monthly file.

At HealthDataMax, we help MAOs automate, decode, and act on MOR data—turning compliance requirements into revenue opportunities. Ready to see it live? Book a demo today.

Quick Reference

Key File Types: Report (human-readable) vs. Data (automated) Access Methods: MARx UI, EFT Mailbox, CMS Portal
Timing: Monthly (real-time) vs. Final (definitive) Applications: Validation, optimization, audit defense