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26-1187 CMS Changes to Medicare Advantage Risk Score Calculations
Effective date
Mar 5, 2027
Identified
Oct 14, 2026
Summary
CMS is changing Medicare Advantage risk score calculations to exclude diagnoses from unlinked chart reviews (CRRs not connected to eligible claims or encounters) beginning with the PY 2027 mid-year risk score run. Billing teams must submit claims and encounter data promptly—at least 2–3 weeks before CMS submission deadlines—to ensure diagnoses are linked before the applicable deadline, or they will not be included in risk score calculations.
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What to do
Action · 3 steps
01By Friday, March 5, 2027 (CMS submission deadline for PY 2027 mid-year risk score run): Billing team must submit all claims and encounter data with complete and accurate information to ensure diagnosis linkage before the deadline.
02Target submission between February 12 and February 19, 2027 (2–3 weeks prior) to allow processing and linkage time.
03Providers and billing staff should submit claims and encounter data promptly after each date of service, respond quickly to requests for additional information, and contact Health Net representatives immediately if any issue may delay claim submission or diagnosis linkage.
If missed: Failure to link diagnoses to eligible encounters before the CMS deadline will result in those diagnoses being excluded from MA risk score calculations, reducing risk adjustment revenue.
Original notice
26-1187 CMS Changes to Medicare Advantage Risk Score Calculations
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.