Module 2
Risk Adjustment Operations
Understand how Belong captures, documents, and submits accurate diagnoses to ensure RAF scores reflect true member complexity.
The RAF Lifecycle
- Prospective Identification — Predict members likely to have undocumented conditions
- MER Scheduling — Outreach to get members into an Annual Wellness Visit
- Clinical Documentation — Clinician documents HCC-eligible diagnoses with ICD-10 codes
- Encounter Submission — Claims submitted to CMS within the submission window
- Reconciliation — CMS updates RAF scores; Belong adjusts revenue forecasts
- RADV Readiness — Ensure medical records support every submitted diagnosis
Scenario: Coding Decision
The Underdocumented Diabetic
A member has Type 2 Diabetes with CKD Stage 3 documented in a 2023 chart note. It's now 2025. The MER clinician sees signs consistent with ongoing CKD but the nephrologist hasn't seen the member in 18 months. What should the clinician do?
Knowledge Check
Question 1 of 3
What is a Member Experience Review (MER)?
💡 Reflection: What's the difference between prospective and retrospective risk adjustment? Which is better for Belong and why?