Leading EDGE®

Lines and dots illustration. Tools to Help ACA Marketplace Vendors Maximize Risk Adjustment Returns.
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Maximize your risk adjustment transfer by prioritizing the claims that will have the most impact.

This tool allows you to triage denied, pending, orphaned, or rejected claims to maximize your risk score return. With only 4 months provided for runout in the ACA, your resources can be limited as the deadline for submission draws near. This tool identifies which claims will increase your risk score if accepted to the EDGE server.

Lines and dots illustration. Tools to Help Risk Adjustment in the ACA Markets.

Pricing and Information

Data Requirements and Sample Output

Provide us with your enrollment, medical, pharmacy, and supplemental (if available) claims data based on the data format provided in our data dictionary. This should include any denied claims or claims pending final adjudication, and data should come from as close to your source system as possible (i.e. avoid extraction processes that may filter out any claims based on enrollment spans, reference tables, etc.).

Additionally, send us the latest RACSD, RARSD, and RATEE files from your EDGE server. If you have submitted claims since the latest CMS-deployed command execution, run a local execution first and send us the local output. Finally, send us a crosswalk from your EDGE identifiers to the identifiers supplied in the extracts above.

A sample report from the Leading EDGE® analysis is provided here.

Self-Service Model

We provide you with the SQL code, you execute it. This model leverages the data structure from our open source DIY HHS-HCC model, so if you’re using that model, this self-service tool will fit right into your work flow.

Pricing

  • $25,000 per year, for 1 HIOS

  • $15,000 per year for each additional HIOS

  • Up to 250,000 members ($0.02 PMPY for additional members)

  • 4 hours implementation and consulting time provided

Full-Service Model

Provide us with your data files and your latest EDGE server files and we’ll provide you with a list of claims to prioritize. Sample contract for this model is available here.

Pricing

  • $15,000 per HIOS ID for one run.

  • $50,000 for bundle of 5 runs within same HIOS ID

  • Up to 250,000 members ($0.01 per additional member above 250,000)

  • 1 hour of consultation per run provided.

  • 24 hour turnaround time guaranteed if clean file provided

  • Fee fully refundable if it doesn’t yield any actionable results