10/13/2026
Unlinked diagnoses may not be included in Medicare Advantage risk scores
The Centers for Medicare & Medicaid Services (CMS) is changing how diagnoses from unlinked chart reviews are used in Medicare Advantage (MA) risk score calculations beginning with the Payment Year (PY) 2027 mid-year risk score run.
What is changing?
A chart review record (CRR) is a diagnosis identified during a medical record review. An unlinked CRR cannot be connected to an eligible claim or encounter.
- Beginning with the PY 2027 mid-year risk score run, CMS may exclude diagnoses identified through unlinked CRRs from MA risk score calculations. If a diagnosis identified through a chart review is not linked to an eligible encounter before applicable CMS submission deadlines, it may not be included in risk score calculations.
What you need to do
To support diagnosis linkage:
- Submit claims and encounter data promptly after each date of service.
- Submit complete and accurate claims to help avoid processing delays.
- Respond quickly to requests for additional information needed to resolve claim or encounter issues.
- Contact your Wellcare representative promptly if an issue may delay claim submission or diagnosis linkage.
CMS risk adjustment submission schedule
Note: The schedule below is organized by CMS submission deadline.
| Risk score run | Dates of service | CMS submission deadline | Anticipated payment month1 |
|---|---|---|---|
| 2027 Initial | July 1, 2025 through June 30, 2026 | Friday, September 4, 2026 | January 2027 |
| 2026 Final run | January 1, 2025 through December 31, 2025 | Monday, February 1, 2027 | Monitor MARx monthly payment letters in HPMS |
| 2027 Mid-year | January 1, 2026 through December 31, 2026 | Friday, March 5, 2027 | Monitor MARx monthly payment letters in HPMS |
| 2028 Initial | July 1, 2026 through June 30, 2027 | Friday, September 3, 2027 | January 2028 |
| 2027 Final run | January 1, 2026 through December 31, 2026 | Monday, January 31, 2028 | Monitor MARx monthly payment letters in HPMS |
MARx – Medicare Advantage/Prescription Drug System
HPMS – Health Plan Management System
Submit claims early
Submit claims and encounter data at least 2 to 3 weeks before each CMS submission deadline to allow time for processing and diagnosis linkage.
Example: The CMS deadline for the PY 2027 mid-year risk score run is March 5, 2027. To allow time for processing and diagnosis linkage, target claim submission between February 12 and February 19, 2027.
References
- Deadline for submitting risk adjustment data for use in risk score calculation runs for payment years 2026, 2027 and 2028: https://go.cms.gov/4rfeAoq
- Risk adjustment policy and operations user group: 2027 Rate Announcement: bit.ly/CMS-RiskAdjustmentPolicy_2027-Rate
- Advance Notice of Methodological Changes for Calendar Year (CY) 2027 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies: www.cms.gov/files/document/2027-advance-notice.pdf
Need help? Contact us
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at www.wellcare.com/California/Providers/Medicare.
If you have questions regarding the information contained in this update, contact 866-999-3945.
This information applies to Physicians and Practitioners, Independent Practice Associations (IPAs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
