Government Financial Solutions

Medicare Advantage health plans are required to submit qualified member diagnostic data to CMS on a quarterly basis for the purpose of assessing the member’s health risk status and in order to pay the Plan a risk adjusted premium to provide care and drug coverage to the member.

Currently CMS requires this data to be submitted using a minimum data set called the RAPS format. Plans must be able to determine what RAPS transactions have been submitted and stored or rejected by CMS. The rejects must be corrected and resubmitted to CMS.

The Voyager Risk Adjustment Suite comprises four software modules. Each module solves a portion of the overall challenge a Plan has to ensure correct and timely payment from CMS.

1) The Voyager RAPS Management Module allows a Plan to import all of their claim/encounter data and correctly filter and submit a CMS RAPS file. The system will also import the reply file and determine what transactions were stored or rejected by CMS.

2) The Voyager EDPS Module allows a Plan to import all of their claim/encounter data and correctly filter and submit a 837 v5010 file with all Plan adjudicated claims and encounters on a monthly basis.

The system will also import the reply file and determine what transactions were stored or rejected by CMS.

3) The HCC Analytics Module is responsible for identifying missing and miscoded HCC transactions that can be reported at the member or the provider levels. In addition, the module will use the stored data in the RAPS Management Module to calculate a forecasted Risk Adjustment Factor for each member.

4) The Charts and Projects Module is responsible for creating, managing and tracking the results of a Plan’s retrospective and prospective intervention programs.