3 Colo. Code Regs. § 702-4-2-96-6

Current through Register Vol. 47, No. 24, December 25, 2024

Section 3 CCR 702-4-2-96-6 - Risk Adjustment

A. Carriers must provide a detailed description of the risk adjustment methodology(ies) utilized in an APM for primary care services to all providers participating in the APM. This description must include, at a minimum:

1. Definitions of key terms used to describe the methodology, including "concurrent" and "prospective";

2. A description of the data that is used in the methodology, including but not limited to:

a. The general morbidity assumptions associated with the population used to calibrate the model; and

b. The services included in the calculation of risk scores, based on the payment arrangement used in the APM in which the provider is participating; and

3. A description of adjustments made to the data in risk adjustment calculations, including:

a. Historical adjustments;

b. Trends or future adjustments; and

c. Patient mix adjustments (across providers).

B. Carriers must also provide a description of how the risk adjustment methodology interacts with provider payments, including but not limited to:

1. A clear explanation of any retrospective uses of provider data; and

2. For risk adjustment methodologies that are applied at the end of a contract period, a clear explanation of any reconciliation processes and how and when they are applied.

3 CCR 702-4-2-96-6

46 CR 24, December 25, 2023, effective 1/30/2024