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Risk Adjustment Drives Better Care Outcomes for Members
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 3, 2026
Summary
Horizon Blue is emphasizing that accurate ICD-10-CM diagnosis coding and comprehensive clinical documentation at every visit are critical for Risk Adjustment and HCC reporting. Providers must document all current and coexisting diagnoses to the highest level of specificity and revalidate chronic conditions annually to ensure accurate health status reporting and appropriate care management.
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What to do
immediately · 4 steps
01Providers and billing staff must ensure all clinical documentation includes complete diagnosis coding at every patient encounter.
02Update EMR encounter templates and documentation workflows to prompt providers to document all current and coexisting diagnoses to the highest ICD-10-CM specificity level.
03Implement annual chronic condition revalidation process—flag charts each year for provider review to confirm all relevant conditions are documented and submitted.
04Billing team must verify that all diagnoses documented by providers are coded and submitted on claims.
If missed: Failure to submit complete and specific diagnosis codes will result in inaccurate HCC assignments, lower risk adjustment payments, and missed enrollment in appropriate care management programs.
Original notice
Risk Adjustment Drives Better Care Outcomes for Members
horizonblue.com · Always check the source before changing claims.