october 9, 2019... hhs risk adjustment data validation (hhs - radv): xml, package 1, 2, & 3...

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HHS Risk Adjustment Data Validation (HHS - RADV): XML, Package 1, 2, & 3 Checks Overview

October 9, 2019

HHS-RADV Webinar Series IV

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regulations that it is based on. We encourage audience members to refer to the applicable r egu lations for complete and current information about the requirements that apply to them.

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Session Agenda

• Session Guidelines • Intended Audience • Purpose • HHS - RADV Timeline and Announcements • Opening of the Audit Tool – Testing & Submission • Issuer Review of Initial Validation Audit (IVA) Findings • Overview of IVA Entity Audit Results Submission XML File Validation

Checks • XML Validation Check Report File Validation Checks • IVA Findings Report Validation Checks • Audit Tool System Generated Passwords for IVA Submission Files • Question & Answer (Q&A) • Resources • Closing Remarks

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Session Guidelines

• This is a 60 - minute webinar session

• For questions regarding HHS - RADV administrative appeals, please email [email protected]

• For questions regarding logistics and registration, please contact the Registrar at: (800) 257-9520

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mailto:[email protected]

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Intended Audience

• Issuers subject to the HHS - RADV Audit requirements under 45 CFR § 153.630

• IVA Entities • Third Party Administrators (TPA) and Support

Vendors

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Session Purpose

• Provide information on validation checks, errors, and warnings produced by the Audit Tool as a result of submitting the IVA Entity Audit Results Submission XML in accordance with the Risk Adjustment Data Validation (RADV) IVA Submission Files Interface Control Document (ICD)

• Provide guidance on Audit Tool System Generated Passwords for IVA Submission Files

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HHS-RADV Timeline

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HHS - RADV Timeline

To access the HHS - RADV Timeline, please log into the Registration for Technical Assistance Portal (REGTAP) and visit the HHS-RADVProgram Area page: www.REGTAP.info/hhsradv.php

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http://www.regtap.info/hhsradv.php

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HHS-RADV Announcements

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IVA Submission ICD – Error Code Update

• The Centers for Medicare & Medicaid Services (CMS) has updated Appendix E, titled Error Codes / Response Messages, of the IVA Submission ICD for XML guidance ‒ Error code 8.5.2 is added for Duplicate Risk Adjustment Medical Claim

Extract (RADVMCE) Report Claim ID and Service Code combinations ‒ The RADVMCE Claim ID and Service Code should be unique when

compared to all other RADVMCE Validation items for a Prescription Drug Category (RXC) in the IVA XML submission

‒ The IVA Entity should correct this error to ensure the submission contains a unique RADVMCE Claim ID and Service Code combination

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IVA Submission ICD – Error Code Update (continued)

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Error Code

Error Message Error Description Description

8.5.2 Duplicate RADVMCE Claim ID/Service Code combination

The RADVMCE Claim ID and Service Code provided is a duplicate and linked to another RXC in the XML Submission

You must make the appropriate corrections to ensure the submission contains a unique RADVMCE Claim ID/Service Code combination

• Example of the updated IVA Submission ICD, which can be found in the Audit Tool

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RXC Validation – Claim Processed Date/Time

• When verifying the RXC Claim Process Date/Time for benefit year 2018, HHS - RADV issuers and their IVA Entity must take the following steps: ‒ Issuers must provide their IVA Entity mapping documentation, workpapers ,

and screen shots to validate the issuer’s source system for this data element to be validated, as noted in the 2018 Benefit Year HHS - RADV Protocols

‒ Refer to sections 9.3.1, 9.3.2, 9.3.3, and Appendices A & B of the 2018 Benefit Year HHS - RADV Protocols, which can be found in the REGTAP Library (at https://www.regtap.info/

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) or in the HHS - RADV Audit Tool library ‒ In the event the IVA Entity does not have this required documentation, it is

the IVA Entities’ responsibility to obtain the documentation from the issuer in order to support the IVA XML and include this information when submitting this information for the Second Validation Audit (SVA)

https://www.regtap.info/

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RXC Validation – Claim Processed Date/Time (continued)

• Regarding External Data Gathering Environment (EDGE) server submission for subsequent year for these data elements, guidance was provided by the EDGE team and the issuer can refer to the below link ‒ https://www.regtap.info/reg_librarye.php?i=3011

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https://www.regtap.info/reg_librarye.php?i=3011

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Opening of Audit Tool for Testing

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Opening of the Audit Tool – Testing

• The IVA Results Submission period opens Monday, November 4, 2019, for testing and/ or submission of IVA findings

• CMS is offering a Test Mode allowing IVA Entities to submit the IVA Entity Audit Results Submission XML to test for any errors

• CMS strongly encourages IVA Entities to submit the IVA Entity Audit Result XML Test Mode for at least one (1) Health Insurance Oversight System (HIOS) ID when the window opens, to ensure that the XML is formatted correctly and accepted by the Audit Tool

• IVA Entities must select ‘test’ to submit the XML file in Test Mode to determine if any warnings/errors exist and to correct as necessary

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Opening of the Audit Tool - Testing (continued)

• The Test Mode only allows submission of the IVA Entity Results Submission XML and only produces the XML Validation Check Report and the IVA Findings Report for Package 1 – The Test Mode is limited to submission of the IVA Entity Audit Results

XML and will not allow for an IVA Entity or issuer to sign off – Package 1 and Package 2 files will not be permitted for submission if

Test Mode is selected – Email notifications to issuers will be disabled for submissions in Test

Mode – The testing window will close November 22, 2019 at 11:59 p.m.

Eastern Time (ET) – After November 22nd all test files will be removed from the Audit Tool

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• The IVA System Generated Password page is currently available to IVA Entities

– IVA Entities can begin encrypting and password protecting their IVA Package 1 and Package 2 files in preparation for upload to the Audit Tool once the IVA Results Submission period opens on November 4, 2019

– All uploaded files must be encrypted and password protected in a Zip file format using the specified Password for the Zip file

• CMS encourages issuers and IVA Entities to ensure that they have access to the Audit Tool by logging in and verifying that their user name and password is working correctly

• If you have a new computer and need to re - establish connectivity to WinAuth for two (2) - factor authentication, please email [email protected] and provide a date/time for the help desk to work with you to resolve issues

Opening of the Audit Tool– Testing (continued)

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Opening of Audit Tool for Submission

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• If the issuer and IVA Entity want to submit the IVA Findings, the XMLs for Package 1 and Package 2 can be submitted as a ‘live submission’ starting November 4, 2019

• Please ensure that you are selecting the correct intended action – Submit

• NOTE: If selecting submit, these submissions will be considered final upon submission and signoff

Opening of the Audit Tool - Submission

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Issuer Review of IVA Findings

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• It is important that issuers review the IVA Findings prior to submission to the Audit Tool

• Issuers and the issuer’s respective IVA Entity should work together to gather the information necessary for a complete RADV audit

• Given the contractual relationship between the issuer and IVA Entity, the findings of the IVA Entity are not disputable through the CMS discrepancy reporting processes set forth in 45 CFR 153.630(d)(2) or appealable under 45 CFR 153.630(d)(3) and 45 CFR 156.1220

– If the SVA Entity finds sufficient pairwise agreement between the SVA and IVA findings, the error rate calculation will be based upon the IVA findings and are not disputable or appealable

Issuer Review of IVA Findings

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Overview of IVA Entity Audit Results Submission XML

File Validation Checks

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Overview of File Validation Checks

• File validation checks are automated checks that the Audit Tool conducts after each IVA Entity upload to the Audit Tool (IVA Entity Audit Results Submission XML, Package 1, Package 2, and Package 3)

• A list of automated validation checks the Audit Tool performs on the submitted IVA documentation can be found in the HHS - RADV IVA Submission Files ICD

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Overview of File Validation Checks (continued)

• The purpose of file validation checks is to: – Facilitate the submission of complete and accurate data, which correctly

reflects IVA Entity audit results

– Confirm that all enrollees selected in the IVA sample are accurately documented within the IVA Entity Audit Results Submission XML

– Enable a consistent comparison between enrollee data from the RADV Sampling Reports and findings documented in the IVA Entity Audit Results Submission XML

– Assist the IVA Entity in remediating significant issues that may impact risk score findings and to provide information on error messages

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Types of Validation Checks

• There are four (4) types of data validation checks that will be performed by the Audit Tool− Required Checks: Verify that the XML element value is present

for required and situational fields as outlined in the ICD − Validity Checks: Verify that the XML element value conforms to

the specified data type and restrictions − Logical Checks: Verify that the XML element value meets the

specified business logic as outlined in the ICD − Referential Validation Checks: Verify that the XML element

value conforms to the data in the RADV Sampling Files

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XML Validation Check Report File Validation Checks

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XML Validation Check Report – File Validation Checks

• The validation checks are executed once the IVA Entity Audit Results Submission XML is submitted to the Audit Tool

• Following the upload of the IVA Entity Audit Results Submission XML to the Audit Tool, IVA Entities receive the XML Validation Check Report─ The XML Validation Check Report contains the results of the following

validations performed by the Audit Tool

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o Required fields in the IVA Entity Audit Results Submission XML are populated

o Fields in the IVA Entity Audit Results Submission XML adhere to the CMS-specified formatting guidance

o Fields in the IVA Entity Audit Results Submission XML adhere to the business rules defined in the ICD

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XML Validation Check Report – File Validation Checks (continued)

• XML Validation Check Report Errors─ If errors result from the validation checks performed, the XML

Validation Check Report will provide an error message

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indicating a ‘Fatal Error’ or a ‘Critical Error’o Fatal Errors: Generated when a file fails to conform to the specified file

layout and data element value restrictions, and as a result, the file is either not machine readable or records are not able to be loaded into the database given the data type restrictions, as indicated on the ICD

o Critical Errors: Generated when the data submitted in a file fails to conform to data element restrictions, fails a business or logical validation, or presents a unique enrollee ID that does not map to RADV Sample Reports data

NOTE: All Fatal and Critical Errors require remediation and resubmission of the IVA Entity Audit Results Submission XML

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• XML Validation Check Report – Outcomes and Required Actions‒ Errors Present:

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If the XML Validation Check Report contains Fatal Errors or Critical Errors, then the IVA Entity Audit Results Submission XML file is rejected and is not processed further. The IVA Entity must correct the XML file and resubmit

‒ No Errors Present: If the XML Validation Check Report does not contain any Fatal Errors or Critical Errors, then the Audit Tool will continue processing the IVA Entity Audit Results Submission XML and will produce the IVA Findings Report

NOTE: The IVA Entity will not be able to move forward with the IVA Submission Process until a valid IVA Entity Audit Results Submission XML is received and processed by the Audit Tool free of Fatal or Critical Errors

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XML Validation Check Report – Potential Error Outcomes

• The XML Validation Check Report will onlyindicate Fatal and Critical Errors, which must be remediated and resubmitted before the IVA Findings Report is available

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Example of a Fatal Error

XML Validation Check Report Fatal Errors – Examples

• In this XML Validation Check Report example, a Fatal Error is indicated in the ‘responseType’ tag

– The tag ‘dataElement’ indicates the data element causing the error in this case, ‘gender’

o The tag ‘responseMessage’ explains the reason for the error in this example, ‘Incorrect field format’

• Resolution à The IVA Entity must correct the enrollee’s gender on the IVA Entity Audit Results Submission XML to adhere to the correct field format and resubmit

– Example: J à M, F, or U

See Appendix E: Error Codes/Response Messages in the ICD for additional information on the ‘responseCode’ tag indicated on the XML Validation Check Report

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Example of Critical Errors

XML Validation Check Report Critical Errors – Examples

• In this XML Validation Check Report example, a Critical Error is indicated in the ‘responseType’ tag

- The tag ‘dataElement’ indicates the data element causing the error in this example, ‘ radvmceLinkedClaimId ’ The tag ‘ responseMessage ’ explains the reason for the error in this case ‘No Claim ID match found.’ when comparing the submitted value against the RADVMCE Report

• Resolution à The IVA Entity must populate the ‘radvmceLinkedClaimId’ tag with an appropriate Claim ID on the RADVMCE Report and resubmit the IVA Entity Audit Results Submission XML

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Example of Critical Errors (continued)

XML Validation Check Report Critical Errors – Examples:

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• In this XML Validation Check Report example, a Critical Error is indicated in the ‘responseType’ tag ─ The tag ‘dataElement’ indicates the data element causing the error, ‘fileName’

o The tag ‘responseMessage’ explains the reason for the error, which in this case, a ‘Duplicate file name.’ exists in the IVA Entity Audit Results Submission XML

• Resolution à The IVA Entity must include a unique file name within the IVA Entity Audit Results Submission XML

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IVA Findings Report File Validation Checks

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IVA Findings Report

• The IVA Findings Report is generated following the successful submission of the IVA Entity Audit Results Submission XML with no Fatal Errors or Critical Errors identified on the XML Validation Check Report

• The IVA Findings Report will include warning messages identified during file processing, enrollee level summary counts, and enrollee risk scores based on IVA findings

NOTE: Package 3 does not

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include an IVA Findings Report

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IVA Findings Report – Warnings

IVA Findings Report Warnings• Provide notification that information provided in the IVA Entity Audit Results

Submission XML may be incorrect or invalid for a given situation, but warnings do not prevent the IVA Entity or issuer from advancing through the IVA Submission Process

- The IVA Findings Report may include warning messages, which indicate variances between IVA findings and RADV sampling reports or other reference documents, and may impact enrollee risk scores

- Warnings do not require remediation and resubmission however, warnings may result in a lower than anticipated risk score for one (1) or more enrollees, therefore, it is recommended that all warnings are reviewed before signing off on the submission

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NOTE: If the IVA Entity chooses to remediate a warning, then the IVA Entity Audit Results Submission XML must be corrected and resubmitted

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IVA Findings Report – Warnings (continued)

NOTE: The IVA Findings Report will only indicate warnings, which do not require remediation and resubmission however, IVA Audit Results Submission XML with warnings may result in a lower than anticipated risk score for one (1) or more enrollees

• The IVA Findings Report will be generated once all Fatal and Critical Errors have been resolved

• IVA Entities must review all warnings to ensure all data was entered as intended

• IVA Entities may remediate warnings and resubmit the IVA Entity Audit Results Submission XML

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IVA Findings Report – Warnings (continued)

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IVA Findings Report Warnings – Examples:

• In the IVA Findings Report example above, a warning is indicated in the ‘responseType’ tag

- The tag ‘dataElement’ indicates the data element causing the warning, ‘diagnosisCode’ o The tag ‘responseMessage’ explains the reason for the warning o In this case, the error is indicating that there is ‘Not a valid ICD-10 code.’

• Resolution à The IVA Entity may, if it choses, enter a valid ICD - 10 - CM code and resubmit the IVA Entity Audit Results Submission XML, although this is not required

REMINDER: IVA Entities are not required to resubmit the IVA Entity Audit Results Submission XML if warnings are identified on the IVA Findings Report

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Audit Tool System Generated Passwords

for IVA Submission Files

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IVA System Generated Passwords Page

• On September 16, 2019 CMS sent IVA Entities an email notifying them that the HHS - RADV Initial Validation Audit System Generated Passwords page is available

• This page includes the list of HIOS IDs associated with your IVA Entity and the randomly assigned encryption password to be used when uploading and downloading Package 1 and Package 2 encrypted files

– The same passwords will be used for Package 3, if it is required ‒ Important to note - All uploaded files must be encrypted and password protected

in a Zip file format using the specified Password for the Zip file • IVA Entities can begin encrypting and password protecting their IVA Package 1

and Package 2 files in preparation for upload to the Audit Tool once the IVA Results Submission period opens on November 4, 2019

• This page also includes the password for the Inter - rater Reliability (IRR) Submission, which is a different password than the password for IVA submission

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Accessing the IVA System Generated Passwords Page

• Log into the Audit Tool • Select the ‘IVA Submission’ tab

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Accessing the IVA System Generated Passwords Page (continued)

• Select the 2018 HHS - RADV Initial Validation Audit System Generated Passwords link

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Reviewing the IVA System Generated Passwords Page

• Hover your mouse over the Password to view the required password for the files

• Follow the instructions in the IVA File Encryption Guide to complete the process for saving and encrypting the file using the assigned password for each HIOS ID

NOTE: The IVA System Generated Password for each HIOS ID must be used when uploading files or the file cannot be processed by the Audit Tool

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Q&A

• Type your question in the text box under the ‘Q&A’ tab located to the left-hand panel of your screen─ To submit your question, click “Submit”

If your question does not receive a response during this webinar session, please submit your question to the HHS - RADV team at [email protected]


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Next Steps

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Next Steps: Training Sessions

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Topic Date

2018 Benefit Year HHS - RADV Inter-rater Reliability (IRR) Process

and ValidationOctober 16, 2019

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Resources

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Locating HHS - RADV Documents in REGTAP

Stakeholders can access additional documents at https://www.REGTAP.info

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in the REGTAP Library.

Under Program Area, select “HHS Risk Adjustment Data Validation (HHS-RADV)”


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Resources: Links

• ICD, XML, and Job Aids ‒ Log in to the Audit Tool

• HHS-RADV Timeline and Protocols‒ HHS - RADV 2018 Benefit Year Timeline

https://www.regtap.info/reg_librarye.php?i=2905‒ HHS - RADV 2018 Benefit Year Protocols


• HHS - RADV Series IV Presentation Slides – 2018 Benefit Year HHS - RADV Introduction

(3/6/19) https://www.regtap.info/reg_librarye.php?i=2457– HHS - RADV Reports Introduction and Updates, IVA Selection, and Conflict of

Interest (3/13/19) https://www.regtap.info/reg_librarye.php?i=2468– Issuer Senior Official Designation

(4/3/19) https://www.regtap.info/reg_librarye.php?i=2819

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• HHS - RADV Series IV Presentation Slides – IVA Entity Designation (4/3/19) https://www.regtap.info/reg_librarye.php?i=2820– Issuer Participation Requirements (4/3/19)

https://www.regtap.info/reg_librarye.php?i=2821– Validating RXC and NDC (5/1/19) https://www.regtap.info/reg_librarye.php?i=2871– 2018 Benefit Year Issuer Exemption & DDVC Web Form (5/8/19)

https://www.regtap.info/reg_librarye.php?i=2885– Sampling Report Distribution & Discrepancy Reporting Process (5/8/19)

https://www.regtap.info/reg_librarye.php?i=2886– Validating RXC and NDC (5/1/19) https://www.regtap.info/reg_librarye.php?i=2871– 2018 Benefit Year Issuer Exemption & DDVC Web Form (5/8/19)

https://www.regtap.info/reg_librarye.php?i=2885– Sampling Report Distribution & Discrepancy Reporting Process (5/8/19)


Resources: Links (continued)

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• HHS - RADV Series IV Presentation Slides – 2017 Benefit Year Error Rate Attestation and Discrepancy Reporting (5/15/19)

https://www.regtap.info/reg_librarye.php?i=2894– 2017 Benefit Year Error Estimation (5/22/19)

https://www.regtap.info/reg_librarye.php?i=2909– 2018 Benefit Year Protocols Updates (5/29/19)

https://www.regtap.info/reg_librarye.php?i=2908– IVA Entity Audit Results Submission ICD, XSD, & XML Guidance (6/26/19)

https://www.regtap.info/reg_librarye.php?i=2934– 2017 Administrative Appeals Process (7/31/19)



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Resource Resource LinkU.S. Department of Health & Human Services (HHS) http://www.hhs.gov/

Centers for Medicare & Medicaid Services (CMS) http://www.cms.gov/

The Center for Consumer Information & Insurance Oversight (CCIIO) web page http://www.cms.gov/cciio

Consumer website on Health Reform http://www.healthcare.gov/

Registration for Technical Assistance Portal (REGTAP) https://www.REGTAP.info

Patient Protection and Affordable Care Act (PPACA)

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html


http://www.hhs.gov/

http://www.cms.gov/

http://www.cms.gov/cciio

http://www.healthcare.gov/


http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html

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Resource Resource LinkHHS Notice of Benefit and Payment Parameters for 2014

http://www.gpo.gov/fdsys/pkg/FR-2013-03-11/pdf/2013-04902.pdf

HHS Notice of Benefit and Payment Parameters for 2015





https://www.gpo.gov/fdsys/pkg/FR-2016-03-08/pdf/2016-04439.pdf









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Resource Resource LinkHHS Notice of Benefit and Payment Parameters for 2019

https://www.govinfo.gov/content/pkg/FR-2018-04-17/pdf/2018-07355.pdf


https://www.federalregister.gov/public-inspection/2019/04/18#special-filing-health-and-human-services-department


https://www.govinfo.gov/content/pkg/FR-2018-04-17/pdf/2018-07355.pdf

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Resource Contact InformationFor RADV policy questions, contact the RADV Team. [email protected]

For EDGE server questions, please contact your Financial Management (FM) Service Representative directly and copy the Centers for Medicare & Medicaid Services (CMS) Help Desk.

[email protected] copy [email protected]

HHS-RADV Audit ToolTo contact us within the HHS - RADV Audit Tool, use the Inquiries tab and select “Submit Inquiry”

Resources: Contact Information




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Closing Remarks