CMS Risk Score Policy Change

Effective for Dates of Service in 2026, Payment Year 2027

Beginning with the mid-year risk score run in PY2027, CMS will exclude DOS 2026 diagnosis submissions on unlinked Chart Review Records (CRRs) from Medicare Advantage risk score calculations. Diagnoses not linked to an eligible encounter may no longer be reflected in member risk scores.

Wellcare’s Operational Approach

In response, Wellcare will hold all unlinked ASM/Active DX and retrospective chart review submissions until they can be linked to an eligible encounter. To ensure accurate risk score captures, timely claim submission is now essential so diagnoses can be appropriately linked before submission to CMS.

What we need from you

The following immediate actions are needed to help ensure 2026 chart review diagnoses can be linked before CMS deadlines:

• Submit claims and encounter data promptly after each 2026 date of service. Delays in submission directly risk excluding diagnoses from risk score calculations.
• Ensure claims are complete and accurate to avoid processing delays that could prevent timely linkage.
• Respond immediately to any requests for additional information needed to resolve claim or encounter issues.
• Contact your Wellcare representative without delay if there are any issues that could affect claim submission or diagnosis linkage.

Important: CMS Implementation Timeline

Per CMS guidance issued on May 7, 2026, CMS will exclude all remaining unlinked diagnoses and reissue applicable MAO-004 reports accordingly, beginning with the mid-year risk score run.

To avoid exclusion, submit claims and encounter data at least 2 to 3 weeks before each CMS deadline. Data received after that window may not be processed in time.

Example: The CMS deadline for the PY2027 mid-year risk score run is March 5, 2027. To allow time for processing and linkage, target submitting claims by February 12 – 19, 2027.

If you have questions or need assistance, please contact your Wellcare representative immediately.

References

• Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2026, 2027, and 2028 (PDF)
• Risk Adjustment Policy and Operations User Group: 2027 Rate Announcement (PDF)
• Advance Notice of Methodological Changes for Calendar Year (CY) 2027 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (PDF)