Following liveRDR. Delgado · care management leadSKS. Kaur, PharmD · clinical
Live transcriptMember statements highlighted
This call◆ Live coach
Before you dial3 things
Newly enrolled 7/28. No HRA on file, no prior contact — this is the first conversation.
Six active medications from three prescribers. Pharmacy has flagged the fill pattern.
Caregiver element is blank. A daughter is listed and has never been contacted.
You rate the assistant
Nothing marked on this call yet.
Marks go to the weekly prompt review. In August this team retired 3 prompts and rewrote 1 — none of it was a vendor decision.
Draft HRA documentationNothing is written to the record until Joanne confirms it
Functional and cognitive status
Stopped driving six months ago after getting lost on a familiar route. Lives alone, second floor, no elevator. Cognitive screen triggered from this call.
◆ AI drafted
Transportation barrier
Two appointments missed this spring, both for lack of a ride. Daughter is 40 minutes away and works full time. NEMT benefit never used.
◆ AI drafted
Medication review — incomplete by design
Member could name four of six. Not asked to guess; reconciliation to be completed from 90-day pharmacy claims. Duplicate-class question routed to S. Kaur, PharmD.
Needs pharmacy
Mood and behavioral health — offer declined
Reports low mood since his wife died fourteen months ago. Behavioral health referral offered and declined; reason documented in his words. Will re-offer at next contact.
◆ AI drafted
Caregiver element
Daughter Ellen named, calls Sundays. Permission to contact obtained on this call — clears the blank caregiver field flagged at stage 1.
◆ AI drafted
↔The coach suggests and the care manager decides — and she rates every suggestion, which is the only scoring in the product. What she confirms here becomes the assessment the care model is built from.
Care management · Stage 3 of 5
Individualized care plan
344 plans active · every completed HRA must have one
HRA73%
412 / 564 complete
→
Care model84%
29 unassigned
→
ICP61%
38 unmatched
→
ICT81%
280 with a team
→
Transitions67%
12 open
38No care plan
29Drafts ready
44No member involvement
18Goals not measurable
Needs actionOldest first
WhenMemberAction neededWhy
160 daysD. Okafor, 68Draft ICPHRA completed 3/12 · draft generated from the assessment
Member is an 80-year-old male, newly enrolled, living alone on a second floor with no elevator. Stopped driving six months ago after getting lost on a familiar route. Daughter lives forty minutes away, works full time, visits most weekends.
Could not name two of his six medications during the call and said he forgets doses "some days". Checks glucose when he remembers. Missed two appointments this spring, both for transportation.
Describes low mood since his wife died fourteen months ago. Declined a behavioral health referral, said he would "rather not make it a thing."
◆
Try:
Proposed care model◆ Confirm or change
Risk tierMedium / rising
RAF 1.42 · 4 HCCs · no admissions
Vulnerable◆ Designated
Cognitive screen positive · lives alone
ModelsDementiaDiabetes
HRA cognitive items · dx 6/30 encounter
State◆ CICM dementia
Dementia + lives alone + limited caregiver
Care plan · 3 problems
Cognitive decline
Goal: maintain independent medication use · review in 90 days
◆ Dementia
Diabetes management
Goal: A1c below 8.0% · quarterly monitoring
◆ Diabetes
Caregiver engagement
Goal: daughter named and participating by next review
◆ Vulnerable
Care team · 4 members
Care manager
Joanne Pak · lead
◆ All models
PCP
Dr. R. Feld
◆ Standard
Dementia care specialist
Trained per state criteria · 2 available on staff
◆ CICM required
Pharmacy
Polypharmacy, 6 active medications
◆ Diabetes
CadenceTier sets the floor
Care manager contact
Medium / rising tier floor is 60 days
◆ Risk tier
ICT review
Escalates automatically if the tier rises
◆ Risk tier
Engagement mode
CICM dementia population · telephonic not permitted
◆ CICM required
Reassessment
HRA repeats annually at minimum
◆ Standard
↔The care manager confirms four things. The care plan and the care team are built from them.
6/30PCP office visit · cognitive screenDr. R. Feld
5/12Endocrinology follow-upSierra Diabetes Care
3/04PCP office visitDr. R. Feld
11/18Optometry, annualValley Eye Associates
—No inpatient or ED utilization in 12 months
Labs & vitalsMost recent
HbA1c7.9%5/12
eGFR725/12
LDL965/12
MoCA21 / 306/30
BP148/866/30
Medications6 activeAug
ConditionsFrom claims and encounters
6/30Mild cognitive impairmentMoCA 21 · new this year
2019Type 2 diabetesOral agents, no insulin
2016HypertensionTwo agents
2021Osteoarthritis, kneesStairs noted as a barrier
Coverage & contacts
Medicare + Medi-CalAligned, full dual
PCPDr. R. Feld
CaregiverDaughter, 40 min away
TransportationNo longer drives
LTSSNone in place
Care modelAwaiting assignment
↔Nothing here was entered by hand. Every line arrived from claims, encounters, or the assessment.
Care management · Enrollment
Redetermination watch
Medi-Cal renewals ahead · plan deeming period is 180 days, set by the state contract
⚠Most duals who lose Medicaid lose it for administrative reasons, not because their circumstances changed. A missed envelope costs the plan the member, the capitation, and a CTM complaint.
47Renewals in 90 days
3● Deeming expiring
12▲ In deeming now
8Unreachable
Needs actionSorted by days until coverage ends
WhenMemberAction neededWhy
9 daysE. Duran, 74EscalateDeeming day 171 of 180 · 4 outreach attempts · disenrollment notice queued
22 daysH. Kowalski, 81Assist renewalDeeming day 158 · packet returned incomplete, income verification missing
26 daysB. Ferreira, 66Assist renewalDeeming day 154 · no response · county has an old mailing address on file
12 daysN. Achebe, 69Assist renewalRenewal letter mailed 7/26 · packet not returned · lives alone
19 daysG. Silva, 67Assist renewalRenewal due 9/07 · two missed appointments, may not be opening mail
31 daysA. Bello, 72Confirm addressRenewal due 9/19 · address on file differs from the one given at the HRA
44 daysM. Torres, 71Assist renewalRenewal due 10/02 · packet sent, member confirmed receipt
—+40 moreAssist renewal
↔During deeming the plan covers Medicare benefits but not Medicaid ones, so the member can be billed cost-sharing they have never paid before. That call usually lands on care management, not enrollment.
Plan · Setup
Data sources
DualWorks reads from the systems you already run · nothing is replaced
6Connected
2▲ Partial
1● Not connected
4.2MRecords nightly
Connected systemsRead-only · no writes back to source
State eligibility fileMedi-Cal statusDual status, redetermination dates, deeming clockWeeklyLive
MSSP / IHSS / waiverState program dataLTSS utilization · required for risk stratificationManual · 30d lagPartial
Summit IPADelegate extractDelegated care management records19 days stalePartial
County behavioral healthSpecialty MH and SUDNot connected · CICM populations under-identified—Off
Add a data sourceMost connect in under a week
◆Connecting county behavioral health would identify an estimated 38 additional members in the CICM serious mental health needs population, currently invisible to plan claims alone. Specialty mental health and substance use data may be exchanged for care coordination under HIPAA health care operations.
↔DualWorks does not replace the care management platform or the core system. It reads from both and returns the member-level view neither one can assemble alone.
Care management · Stage 3
ICT session
Thursday 2:00pm · R. Nguyen, 74 · member 2 of 4
Recording00:07:12
Following liveRDR. Delgado · care management leadSKS. Kaur, PharmD · in the roomNotes below are private to Joanne — they are not part of the ICT record.
A1c up from 7.8% in February. eGFR declining. Neither has been discussed at an ICT.
What this team needs to decide◆ AI surfaced
◆
3 behavioral health visits, none in the care plan
The ICP still lists BH as a pending referral. Surfaced from claims — not on anyone's prep list.
◆
ED visit 7/02, cardiology follow-up never scheduled
Surfaced from the ADT feed. Open transitions item.
◆
A1c 9.2%, up from 7.8% — statin PDC at 61%
Refill gaps line up with the BH visit dates. Pharmacy is on this team.
◆
Caregiver question still unanswered
State-required. Member lives alone; daughter listed, never engaged.
Care team3 of 5
JPJoanne PakCare managerPresent
MADr. M. AlvarezPCPPresent
SKS. KaurPharmacyPresent
DRDr. D. ReyesBehavioral health · requiredNo reply
Two invitations logged. A third is required before sign-off.
◉ Live scribeTranscribing · ask it anything
Dr. Alvarez: I wasn't aware of the behavioral health visits. That changes how I read the ED visit.
J. Pak: Then let's move BH into the active plan, and I'll reach the daughter first.
◆
Try:
In the momentPrivate to Joanne · 2 notes
SKS. Kaur, PharmDprivate to you · 07:04
Before you move BH into the plan — the statin PDC and the refill gaps line up with the weeks he was in BH treatment, not with the A1c. I can say that here if you want it on the record, or I can take it offline with Dr. Alvarez. Your call.
RDR. Delgado · care management leadprivate to you · 07:26
Good — you got Dr. Alvarez to say out loud that the BH visits changed how he reads the ED visit. Get that into the decision field in his words, not a summary. And before you close: nobody has named who is contacting the daughter, which is the element that failed audit last quarter.
Follow-up actions
Update ICP: behavioral health as active problem
J. Pak · due 8/22 · clears the stale-plan flag on stage 2
◆ AI drafted
Contact daughter, complete the caregiver element
J. Pak · due 8/26 · clears the HRA gap on stage 1
◆ AI drafted
Third invitation to Dr. Reyes
Auto-send · attempt 3 of 3 · required for sign-off
Required
↔Who attended, what was decided, and what changed in the care plan — captured in the structure CMS asks about. The universe row writes itself.
Model of care progress · Stage 4 of 4
Transitions of care
36 transitions this month · 24 coordinated inside the required window · 12 open
HRA73%
412 / 564 complete
→
ICP61%
38 HRAs unmatched
→
ICT81%
280 / 344 with ICP
→
Transitions67%
12 discharge gaps
SourcesEssette · care managementQNXT · enrollment, claims, encountersADT feed · regional HIESummit IPA · delegate extract, 19d stale
⚠12 discharges this month have no coordination note. Transitions are the stage most often missed because the clock starts on an event the plan does not control — and the ADT feed is the only warning.
36Transitions this month
12No coordination noteMOC 2 findings
4.1hMedian ADT to first contactWas 31h before alerting
19No follow-up visit scheduledReadmission driver
Open transitions — clock running
C. Batista, 73 — discharged 6/14, BH inpatient
ADT received 6/14 · no member contact, no medication reconciliation, no follow-up appointment · 66 days open · ICT was complete, the handoff was not
Overdue
SNF pathway — MCCP4011 not documented
7 SNF discharges routed through a pathway with no written procedure · the P&P referenced in the MOC does not exist in the policy library
4 discharges inside the window, contact not yet made
Assigned and alerting · no finding yet if closed on time
Coordination elements — completeness on closed transitionsContact alone does not close the loop
Member or caregiver contacted
24 of 24 closed transitions
100%
Medication reconciliation documented
17 of 24 · the most frequently skipped element on an otherwise closed transition
71%
Follow-up visit scheduled
14 of 24 · tracked because it moves readmissions, not because it is scored
58%
Care plan updated to reflect the event
16 of 24 · an ICP that does not reflect a hospitalization is stale at the next reassessment
67%
↔Chain closed: a transition that updates the care plan feeds the next reassessment cycle, and the member re-enters at the ICP stage rather than starting over. Members whose full chain is intact are marked audit-ready on the compliance view.
Quality & compliance
Today
Wednesday, August 19 · RADV PY2021 notice window open · MOC renewal in 62 days
⚠CMS is now auditing all eligible MA contracts annually rather than roughly 60 per year. Sample sizes run 35–200 enrollees by contract size, with a five-month record submission window. Assume your contract is sampled every year and staff to it.
38 members have a completed HRA with no ICP · the single most common program audit finding · all 38 are assigned and moving
At risk
MOC 2 — Transitions of care
12 discharges this month with no coordination note inside the required window · SNF pathway MCCP4011 not documented
At risk
MOC 2 — ICT composition
81% of members with an ICP have a documented ICT · BH and LTSS participation is the gap, not attendance volume
Below target
MOC 4 — Prior-period QI goals
NCQA scores whether you met the goals you set last cycle · HRA target partially met · draft narrative ready for review
Partial
MOC 3 — Network
Adequacy filings current · LTSS referral network documented · no open findings
Compliant
◆Two regulators, one operation. This contract answers to CMS through the NCQA-reviewed MOC and to DHCS through the State Medicaid Agency Contract and the CY2027 policy guide. The state elements are scored on a separate California-specific matrix that goes only to DHCS, not to CMS. No Medicare-oriented vendor tracks them.
California-specific MOC matrix CalAIMState elements mapped to the MOC narrative · reviewed separately by DHCS
Element 1B — CICM population criteria and identification
MOC must list all eight CICM populations with the state's criteria and describe how plan-led care management identifies them · current narrative names six and describes identification generically
Insufficient
Element 2A — dementia care specialist training program
Required description of the training program for ICT dementia specialists · no program documented and no training records exist to evidence it
Missing
Element 2E — CBO participation in the ICT
Where the plan contracts with community-based organizations for CICM populations, the MOC must explain how their participation in a member's ICT is facilitated · narrative asserts participation without describing the mechanism
Thin
Element 2F — care transition protocols across settings
Must cover community, institutional, and hospital settings, care coordinator roles, Medi-Cal HCBS provision, and how SMAC information-sharing requirements are incorporated · settings covered, information-sharing language not incorporated
Partial
Element 1B — palliative care referral criteria
Plan adopts the state minimum eligibility criteria rather than submitting broader criteria for approval
Addressed
State deliverables calendar CalAIMSubmitted to DHCS separately from anything filed with CMS
MOC and California-specific matrix
On-cycle submission annually · off-cycle revisions due to DHCS within five business days of submission to CMS · the five-day clock is the one plans miss
Next cycle
HRA tool
Resubmission required only when the Caregiver question changes · last submitted and confirmed
Current
Integrated member materials
ANOC, Summary of Benefits, ID card, Member Handbook, formulary, provider and pharmacy directory · filed to DHCS and DMHC on a staggered summer schedule
On track
↔Where these actually get fixed: every finding above is already a task on a named care manager's queue. This page is oversight, not a second workflow — you are watching the chain close, not chasing it by email.
Quality & compliance · Delegation
Delegation oversight
Care management delegated to Summit IPA effective Jan 2027 · administered by their MSO · plan retains full accountability
⚠Delegating the function does not delegate the audit. When CMS samples a member, it samples the plan's contract. Work performed by the delegate is evidence the plan must produce, in the plan's format, on the plan's timeline.
◆State approval may be required before this delegation can proceed. CalAIM Under the CY2027 policy guide, exclusively aligned enrollment D-SNPs must be directly responsible for care coordination and related member functions unless the plan has advance approval from DHCS. The state's stated position is that having a standalone entity provide care coordination separate from other key plan functions is not aligned with an integrated plan approach for dual members. No approval request is on file for this arrangement.
19dDelegate extract stalenessContract says weekly
62%Delegate records audit-parseableFree text, not structured
4Pre-delegation gaps unresolvedGo-live in 4 months
431Members transferring
Pre-delegation readinessAssessed against the MOC the plan is accountable for
ICT documentation standard not demonstrated
Delegate documents care conferences as narrative notes · no participant roster, no invitation attempts, no decision capture · would not produce a defensible universe today
Blocking
No agreed universe layout
Delegate has not confirmed it can produce member-level extracts in CMS table format · discovered in an audit, this becomes the plan's finding
Blocking
No DHCS advance-approval request filed
Care coordination delegation for an EAE contract requires advance state approval · go-live is scheduled in 4 months and nothing has been submitted
Blocking
HRA instrument mismatch
Delegate uses its own assessment across its other Medicare Advantage clients · does not include the Caregiver question or the Tier 1 and Tier 2 LTSS questions this contract requires, and is not an integrated Medicare and Medi-Cal instrument
Open
No dementia care specialist capability
Delegate has no trained dementia specialists and no training program · 19 members requiring one transfer under this arrangement
Open
Transition alerting not connected
Delegate is not on the regional ADT feed · the 72-hour clock would start when someone notices, not when the member is discharged
Open
Ongoing oversight evidence
Q2 oversight report — 19 days late
Contractual cadence is quarterly within 15 days of close · second consecutive late submission · corrective action language available in the contract
Annual delegate audit — scheduled Oct
DualWorks pre-populates the sample from delegate extract data so the audit tests real records rather than the ones the delegate selects
On schedule
↔Why this lives with compliance, not contracting: contracting owns the terms and the renewal. Compliance owns whether the delegate's work would survive a member-level audit — which is a different question, asked continuously rather than annually.
Risk adjustment
Today
Wednesday, August 19 · CY2027 encounter-linkage rule in effect · PY2026 final run closes January
⚠CY2027 rule change. CMS finalized the exclusion of diagnoses from unlinked chart review records, with a narrow exception for members switching between MA organizations. Codes must trace to a real clinical encounter with MEAT-level documentation. Every item below shows its encounter link — items that cannot be linked are not submittable.
89Encounter-linked, pending reviewSubmittable
31Unlinked — not submittableRoute to prospective
14Deletes recommendedPrior-year, unsupported
$412KDefensible RAF gapLinked items only
Deletes recommended — unsupported codes currently on fileReviewed first, before any additions
14 prior-year diagnoses with no supporting documentation
A 2026 False Claims Act settlement turned on a chart review program that added codes but failed to delete unsupported ones the same review identified. DualWorks surfaces both directions and logs the decision either way.
31 suspects with no qualifying encounter
Documentation supports the condition but no linkable face-to-face encounter exists · not submittable under CY2027 · routed to the prospective list for the member's next visit
89 encounter-linked items ready for coder review
Each shows the encounter date, rendering provider, and the MEAT evidence in the note · reviewed one at a time, no bulk approval
↔Why this sits next to compliance: the same member-level evidence trail that defends a RADV sample is what proves the MOC chain. One record, two audiences. Undercoding is a general provider behavior, worst where capitation makes the diagnosis irrelevant to payment — not an FQHC-specific problem.
Network management
Today
Wednesday, August 19 · 5 arrangements off track · 14 credentialing expirables inside 60 days
5VBC arrangements off trackQuality gates missed
14Credentialing expirablesInside 60 days
3Specialties at minimumNo attrition margin
2Delegated entitiesOversight reports due
⚠Contracting, credentialing, and adequacy are the same providers viewed three ways. A lapsed credential removes a provider from the adequacy count and can invalidate claims paid under the contract — these are one workflow, not three.
Needs attention across the network
North Valley FQHC — VBC arrangement, renewal 11/1
Diagnosis capture 34% below panel average · quality withhold at risk · the contract's coding support clause has never been exercised
Off track
Endocrinology — single provider meeting time and distance
One county · this provider's recredentialing is also due in 5 weeks · losing them puts the county out of compliance the same day
Single point
Summit IPA — delegated care management and credentialing
Q2 oversight report 19 days late · delegated credentialing file audit not yet scheduled for the annual cycle
Oversight gap
Behavioral health — 11% directory variance
Meets adequacy on paper · last validation sweep found listed providers unreachable or not accepting new D-SNP members
Directory risk
↔Inbound from care management: 22 members have a PCP who has never responded to an ICT invitation. Documented attempts protect the plan on audit, but a provider who never participates is a contracting problem, not a documentation one.
Network management
VBC operations
9 value-based arrangements · 3 at risk of no settlement · midyear gate performance
ℹAttribution, quality gates, and settlement modeling are tracked continuously rather than reconciled at year end, so an arrangement that is drifting can still be corrected inside the measurement year.
9Active arrangements
3Projecting no settlementAt current run rate
1,412Attributed members48% of D-SNP panel
2Arrangements with unexercised clausesCoding support
Arrangement performance — midyear
North Valley FQHC — quality withhold
312 attributed members · 2 of 6 gates met · diagnosis capture is the binding constraint and the contract already contains a coding support provision the plan has not invoked
No payout projected
Coastal Community Health — shared savings
287 attributed members · 2 of 5 gates met · total cost of care tracking above benchmark, driven by avoidable ED utilization in a population overlapping the CICM at-risk group
No payout projected
Summit IPA — capitated, care management delegated
431 members transferring January · capitation rate set on submitted diagnosis codes, and the delegate has not demonstrated it can document to the plan's standard
Watch
6 additional arrangements on track
Gates met or ahead of pace · settlement modeling refreshed monthly
On track
Attribution integrityMembers counted in more than one arrangement, or in none
37 members attributed to two arrangements
Overlapping panel assignment between an IPA and a directly contracted FQHC · both would claim credit at settlement
193 members unattributed
No VBC arrangement covers these members · no provider carries accountability for their outcomes or their coding
↔Shared with risk adjustment: capitation and settlement both depend on submitted diagnosis codes. Where a provider is capitated, accurate coding determines the plan's rate — which is exactly why the coding support clause exists and why leaving it unused is expensive.
Network management
Credentialing
1,847 practitioners · 14 expirables inside 60 days · delegated credentialing file audit due October
⚠A lapsed credential is not only a credentialing problem. The practitioner drops out of the adequacy count, claims paid during the lapse may be recoverable, and the directory continues to list them.
14Expirables inside 60 days4 inside 14 days
31Recredentialing due this cycleThree-year cadence
612Delegated to Summit IPAFile audit not scheduled
Expiring credentials
4 practitioners — expiring inside 14 days
Includes the sole endocrinologist meeting time and distance in one county · no renewal documentation received after two requests
Adequacy impact
10 practitioners — expiring in 15 to 60 days
Automated requests sent · 3 have no response on file and move to outreach escalation this week
31 recredentialing files due
Primary source verification in progress · files must reach committee before the current cycle closes
Delegated credentialing oversight612 practitioners credentialed by the delegate, accountable to the plan
Annual file audit not yet scheduled
Sample must be drawn by the plan rather than supplied by the delegate · DualWorks pre-selects from the delegate roster so the audit tests real files
Roster reconciliation — 41 discrepancies
Practitioners on the delegate roster who do not appear in the plan directory, and the reverse · each discrepancy is a directory accuracy exposure and an adequacy counting error
↔Feeds adequacy directly: the credentialed roster is the denominator for every time and distance calculation. Adequacy filed against an unreconciled roster is filed against numbers the plan cannot support.
Operating model
Where the money goes
A D-SNP loses margin twice on the same operation — once on the burden of proving the work happened, once on the care that did not happen well enough
Cost of proving
$[X] PMPM
Admin spend proving the work: CM documentation, ICT prep and write-up, compliance evidence assembly, analyst hours behind every report
Cost of missing
47
Members meeting the state's avoidable-utilization criteria · 9 were never identified for care management at all
Cost of finding out late
4wk
Typical lag between a member falling out of the care model and anyone with authority to act seeing it in a report
How it runs today
Report-driven
1
Care management works
Calls, assessments, care conferences · documented in free text in whatever system the team was given
2
Compliance requests an extract
Monthly or ahead of an audit · a ticket to the data team, not a query anyone can run
3
Data team assembles it
Joins care management records to enrollment and claims · reconciles what the source systems disagree on
4
Report identifies what went wrong
Gaps, misses, members who fell out of the model · four weeks after the fact
5
Population health is told what to fix
A remediation list arrives from outside the team · the window to have prevented any of it has closed
The data arrives after the work, so it can only grade it. Documentation gets rebuilt by hand at audit time because it was never captured in the shape the regulator asks for.
How it runs here
Work-driven
1
Data arrives in front of the work
Enrollment, claims, ADT, pharmacy, state program data · resolved to the member overnight
2
It sets the care manager's day
A queue ordered by who is falling out of the care model and what clock is running · not by enrollment date or alphabet
3
The work is recorded as it happens
Participation, decisions, care plan changes captured live and structured · nothing written up afterward from memory
4
Gaps surface the same day
A member falling out of the model is a task this morning rather than a finding next quarter
5
Evidence is already assembled
Universes, oversight packets, and state deliverables export from the same records the work created
The data leads the work instead of grading it. Compliance stops being a project and becomes a byproduct of doing the work well.
What changes for each team
Care management
Stops reconstructing. The queue is prioritized by risk and clock, and documentation is a side effect of the encounter rather than an evening task.
Compliance
Stops requesting. Sees the same member records continuously and can run an audit simulation on demand instead of commissioning an extract.
Risk adjustment
Stops sweeping retrospectively. Suspects route to the member's next real encounter, which is the only path that survives the CY2027 linkage requirement.
Network management
Stops discovering at renewal. A provider who never participates in a care team shows up as a contracting signal while there is still time to act on it.
↔The claim, stated plainly: nobody buys a better report. The wager is that the same member-level data a compliance report gets assembled from is more valuable pointed forward — telling a care manager who to call this morning — than pointed backward at what should have happened four weeks ago.
Plan leadership
Today
Wednesday, August 19 · plan-wide view across all teams
3Open MOC findingsAll assigned
$412KDefensible RAF gap
62dTo MOC renewal
7.4hWeekly documentation hours savedPer care manager
ℹEach team sees only its own work. This view is the only place the whole chain is visible at once — which is also the only place you can see where work stops moving between teams.
Where work is stalling between teams
Care management → compliance
38 ICP gaps assigned 11 days ago · 9 closed · at current rate the MOC renewal date arrives with findings still open
Behind pace
Contracting → risk adjustment
Coding support clause exists in the North Valley contract and has never been exercised · 34% capture gap persists
Unused lever
Delegate → plan
Summit IPA oversight report 19 days late · plan carries the audit exposure regardless of who does the work
Oversight gap
DualWorks Intelligence
Recommendations
Ranked by impact · synthesized across MOC, RAF, Stars, eligibility, and contracts · updated this morning
This week
This month
Plan learning
✦DualWorks analyzes activity across all modules daily and surfaces the highest-impact actions in priority order. Recommendations are ranked by a combination of financial impact, compliance risk, and deadline proximity. Dismiss or act — the system learns from both.
Priority 1 · Compliance riskMOC audit finding
C. Batista discharged 16 days ago — no transition coordination note logged
CMS auditors sample discharge events and trace the 48-hour contact requirement. This is an open MOC 2 finding today. The longer it stays open, the more exposure you carry into the NCQA renewal. A care manager needs to log the note — this takes 5 minutes.
Source: MOC compliance · Transitions of care· Deadline: immediate
Priority 2 · Revenue · $47,200/yrSep 4 deadline
89 linked chart reviews are approved and ready — submit to CMS before September 4
If submitted before the PY2027 initial deadline (Sep 4, 8pm ET), these codes raise member RAF scores and increase CMS premium payments starting January 2027. If missed, codes roll to the mid-year window and payments are delayed 6 months. Top items: C. Batista +$2,470/yr (CHF, HCC 85), F. Okonkwo +$2,470/yr (CHF, HCC 85), R. Nguyen +$1,570/yr (MDD, HCC 59).
A. Reyes has not returned her Medicaid renewal packet — deadline July 15
If Medicaid lapses, she loses dual eligible status and must be disenrolled from the D-SNP. She also has an open Stars gap (A1c overdue, W3 measure) and a BH referral pending. A single phone call today can prevent the cascade. Call script: verify she received the renewal packet, offer to conference in the state Medicaid office if needed.
38 members have completed HRAs with no ICP — the most common NCQA audit finding
NCQA auditors trace the HRA → ICP link at the member level. 38 broken chains is significant exposure heading into the October renewal. Recommend assigning a care manager to work through 5–8 per day over the next two weeks. DualWorks has the list sorted by enrollment date — oldest gaps first.
Source: MOC compliance · HRA → ICP linkage· Deadline: Oct 2026 NCQA renewal
Priority 5 · Stars · $1.2M QBP gapW3 measures
Two members this week can move triple-weighted Stars measures — outreach is due now
R. Nguyen (A1c overdue, 47 days no response) and C. Batista (BP uncontrolled, last voicemail 22 days ago) both have PCP visits scheduled in the next 2 weeks — coordinate the clinical orders before those visits. These are W3 measures where each additional compliant member moves the contract rating. SVHP needs 27 more members controlled on blood sugar and 93 on blood pressure to reach 4.5 stars.
Source: Stars tracker · Blood Sugar Controlled · Controlling BP· Acts on measurement year 2026
Priority 6 · Contract performance$1.64M overrun
North Coast Medical Group and Sierra Cardiology are both over budget and below quality — claw-back review triggered
North Coast is +$900 PMPM over contract with quality at 64% vs 72% target. Sierra Cardiology is +$1,490 PMPM with quality at 58% vs 70% target. Both meet the dual-threshold claw-back trigger in their contracts. Recommend scheduling a performance review meeting with each before the semi-annual review date. DualWorks can generate the performance report for the meeting.
Source: Provider contracts · VBC performance· Semi-annual review due
Priority 7 · 2027 preparationBuild now
Mental health and physical health improvement measures move to W3 in 2027 — start building now
Both measures are currently W1 but jump to triple-weight in 2027. SVHP is at 59% on mental health (target 72%) and 68% on physical health (target 75%). These are patient-reported HOS survey measures — the work to improve them takes 12–18 months. A. Reyes has a low HOS mental health score with no BH referral on file. Starting BH referral workflows now puts the plan on track for the 2027 measurement year.
Source: Stars tracker · Mental Health · Physical Health measures· Measurement year 2027
Priority 8 · New enrollmentAction within 90 days
3 new members enrolled today — HRA clock started, and G. Williams has a prior RAF score worth acting on
G. Williams (74, CHF + DM2) transferred from another MA plan with a prior RAF score of 1.12 on file. Completing her HRA quickly and submitting encounter data will capture her diagnoses for PY2027 RAF before the September deadline. B. Santos still needs Medicaid alignment verified — if alignment fails, she cannot remain enrolled after 2027.
Source: Eligibility & alignment · New member queue· HRA due Sep 28, 2026
✦Longer-horizon recommendations — strategic actions for the next 30–60 days that don't require immediate action but have high impact if started now.
MOC renewal preparation — Oct 2026 deadline97 days out
✕
Create ICT assembly P&P
No policy exists for ICT assembly — NCQA will flag this. Draft and link before submission.
✕
Add SNF pathway to MCCP4011
Current policy covers hospital discharge only. SNF and ED transitions are not defined.
–
Close 38 HRA → ICP gaps
At 5/day, closure in 8 weeks. Start now to be clean at renewal.
✓
MOC population narrative — approved
No changes needed for renewal.
North Coast & Sierra Cardiology performance reviewsSchedule within 30 days
Both providers meet the dual-threshold claw-back trigger (over budget + below quality target). A performance review meeting should be scheduled within 30 days of the trigger. DualWorks can generate the performance report — PMPM variance, quality measure breakdowns, member-level attribution list — formatted for a provider conversation.
56 unaligned members — start outreach before Q42030 mandate
The 2030 alignment mandate requires all enrolled members to be in the affiliated Medicaid MCO. 38 are with a different MCO (outreach to switch), 11 are on FFS Medicaid (state enrollment process needed), and 7 have data discrepancies that need resolution first. Starting outreach now spreads the workload over 3.5 years instead of compressing it into the final year.
✦DualWorks learns from patterns across your plan — what's working, what's not, and how your performance compares to what the model predicts. These are observations, not alerts.
What's working
M. Torres — your best-managed member
Full chain complete: HRA → ICP → ICT → transition documented. Post-discharge follow-up happened within 24h. Spending $340 below RAF prediction. This is the care model working as designed.
Model case
Shasta Community Health — highest-performing VBC provider
Under contracted PMPM by $360 · quality at 82% vs 78% target · coding compliance 89%. Shared savings eligible at semi-annual review. The combination of VBC incentive and strong coding compliance is the relationship to replicate.
Replicate this
Breast cancer screening at 83% — one of your strongest Stars measures
Above the 4.5-star threshold already. Whatever outreach workflow is driving this should be documented and applied to colorectal screening (64%) and flu vaccine measures.
Apply elsewhere
Patterns DualWorks has detected
FQHC coding gap is concentrated at North Valley and Coastal
34% and 29% coding compliance respectively — both BH-primary. The pattern suggests behavioral health visits at FQHCs are systematically undercoded. This is a provider engagement issue, not a chart review issue. Consider a dedicated coding education session with both FQHCs.
Provider engagement
HRA gaps are clustering in members enrolled Jan–Mar 2026
The enrollment cohort from Q1 2026 has a disproportionate share of overdue HRAs. This suggests a care manager capacity issue in that period, not a systemic process failure. The fix is targeted catch-up, not a process redesign.
Cohort pattern
Blood pressure control is your biggest Stars gap — and it's correlated with FQHC attribution
61% of members with uncontrolled BP are attributed to FQHC providers. FQHCs have less ability to coordinate medication management than integrated PCP practices. Targeted care management outreach to this sub-population may move the measure faster than broad outreach.
Target sub-population
What to watch
Part D specialty drug exposure is growing
IRA changes mean SVHP now absorbs up to 60% of catastrophic coverage costs. With a small plan population, a single member on a cell/gene therapy could materially affect MLR. DualWorks does not currently track Part D risk — this is a gap worth monitoring.
Watch
Medicaid redetermination churn may accelerate in Q3
Four members are currently at redetermination risk. State redetermination cycles tend to cluster — if the state processes a batch renewal in July, the number of at-risk members could spike. Early outreach on all four now prevents a Q3 disenrollment wave.
Watch
G. Williams (new transfer) has the highest RAF potential of today's enrollments
Prior RAF score 1.12, CHF + DM2 history. If HRA is completed quickly and encounter data submitted before Sep 4, her diagnoses capture for PY2027. This is $8,000+ in annual premium if the RAF score holds — worth prioritizing in the new member queue.
Opportunity
Sierra Valley Health Plan · H9999-001
My D-SNP
DualAccess Complete · CY2026 · 2,940 members · updated this morning
$24.2MEst. annual CMS revenue2,940 members · avg $8,230 PMPM
$20.9MEst. annual medical costs86.2% MLR · target ≤85%
$3.3MEst. gross margin13.8% · before admin costs
$627KRAF revenue gapUncaptured · 412 members
$1.2MQBP uplift availableAt 4.5 stars vs current 4.0
Plan performance over time
Avg RAF score
Stars rating
MOC completion %
Jan – Jun 2026
Metric
Jan
Feb
Mar
Apr
May
Jun
Trend
Avg RAF score
0.94
0.98
1.01
1.03
1.05
1.06
↑ +0.12
Stars rating
3.6
3.7
3.8
3.9
4.0
4.0
→ Flat
MOC completion
54%
58%
61%
64%
68%
73%
↑ +19pp
Revenue driversWhat moves the premium
Base capitation (current RAF)$23.5M/yr
Avg RAF 1.06 · 2,940 members
Quality bonus payment (4.0 ★)+$680K/yr
At 4.5 ★ this becomes +$1.9M · gap = $1.2M
RAF gap — uncaptured revenue−$627K/yr
412 members undercoded · 89 items ready for UM approval
Revenue if RAF gap closed + 4.5 ★+$1.83M/yr
$627K RAF + $1.2M QBP · both achievable this plan year
Compliance healthWhat CMS audits
MOC audit readiness
HRA 73% · ICP 61% · Transitions 67%
71%
3 gaps
Stars rating
6 measures below target · W3 measures lagging
4.0 ★
At threshold
RAF coding compliance
412 members undercoded · FQHCs at 29–34%
$627K
Gap
Policy library
2 stale · 3 MOC conflicts · ICT P&P missing
14
3 conflicts
Medicaid alignment
56 unaligned · 4 redetermination alerts · 2027 rule met
98%
2027 compliant
Upcoming deadlines
Medicaid renewal — A. Reyes
Lapse = D-SNP disenrollment
Jul 15
15 days
RAF initial EDS submission — PY2027
89 codes · $47K revenue · 8pm ET hard stop
Sep 4
66 days
HRA deadline — 3 new members
Enrolled today · 90-day clock started
Sep 28
90 days
NCQA MOC renewal
2 P&P gaps must be resolved first
Oct 2026
~97 days
AEP · Stars ratings published
2027 QBP tier set based on current trajectory
Oct–Nov
~120 days
Member snapshot2,940 enrolled
Medicaid aligned
2,884
HRA completed
2,146
ICP active
1,793
ICT assembled
1,452
RAF coding gaps flagged
412
Enrolled today
+3
Redetermination at risk
4
DualWorks
D-SNP at a glance
From launch to daily operations — click any phase to open the workstation
Phase 1 · Pre-launch
Build the MOC
Define your SNP population, care coordination model, provider network, and QI goals. Submit to NCQA for approval before go-live.
↳ Launch new MOC↳ Policy library
Phase 2 · Enrollment
Enroll members
Receive 834 transactions from CMS and state Medicaid. Verify dual eligibility and alignment. Start 90-day HRA clock for every new member.
↳ Eligibility & alignment
Phase 3 · Network
Contract providers
Contract PCPs, BH providers, FQHCs, and LTSS partners. Set VBC or FFS terms. Activate coding compliance monitoring for FQHCs from day one.
↳ Add new provider↳ Provider contracts
Phase 4 · Operations
Run the plan daily
Complete HRAs, build ICPs, assemble ICTs, document transitions. DualWorks tracks model of care progress end to end and delivers a daily action digest to the care team.
↳ Member queue↳ Daily digest
Ongoing — the three revenue & compliance enginesRun continuously once the plan is live
📋
MOC compliance
CMS audits the HRA → ICP → ICT → transition chain for every member. DualWorks tracks every link and flags gaps before an auditor does.
→ HRA within 90 days of enrollment→ ICP must follow every HRA→ ICT assembled for every active ICP→ Transition note within 48h of discharge→ 100% on all four — or it's an audit finding
3 gaps openOpen MOC →
💰
Risk adjustment
CMS pays based on RAF scores. If a provider documents a diagnosis but doesn't code it, the plan is underpaid. DualWorks detects the gap via linked chart review and routes it to UM for approval.
→ DualWorks reads provider chart narrative→ Flags diagnoses documented but not coded→ UM team reviews and approves→ Submitted to CMS via EDS by Sep 4 deadline→ Higher RAF score = higher CMS premium Jan 2027
89 pending · $627K gapOpen RAF →
★
Stars
CMS pays quality bonus payments (QBP) based on Star ratings. SVHP is at 4.0 — on the bonus threshold but $1.2M below the 4.5-star tier. Six measures need to move.
→ Triple-weighted measures drive the most movement→ DualWorks surfaces member-level actions daily→ SNP Care Management measure tied to MOC directly→ Physical & mental health move to W3 in 2027→ 4.5 stars = +$412/member/year in QBP
4.0 ★ · 6 below targetOpen Stars →
CMS annual calendar — key deadlines
JanCMS begins paying updated premiums based on prior year RAF scores · Stars QBP payments beginRevenue
Jan–MarNCQA MOC renewal window · submit updated MOC and evidence package · auditors sample member recordsMOC renewal
Mar (1st Fri)RAF mid-year EDS submission deadline · last chance to add codes from prior calendar year before final reconciliationRAF mid-year
AprCMS Rate Announcement published · next year capitation rates and risk adjustment methodology finalizedRate notice
JunPlan bids due to CMS · benefit design, premiums, and cost-sharing for the following yearBids due
Sep 4, 2026RAF initial EDS submission deadline for PY2027 · codes submitted by 8pm ET are included in January payment run · 89 items pending in DualWorksRAF deadline
OctSVHP NCQA MOC renewal deadline · DualWorks audit simulation and evidence export availableMOC deadline
Oct–NovAnnual enrollment period (AEP) · members can switch plans · Stars ratings for next year published · QBP tiers setAEP · Stars
Feb (next yr)RAF final reconciliation deadline · after this date no new diagnoses accepted for this payment year · only deletes permitted per 42 CFR § 422.310(g)RAF hard stop
Overview
Dashboard
CY2026 · 2,940 members · H9999-001 · updated this morning
4.0 ★Contract Stars ratingAt QBP threshold, not above
73%HRA completionCMS target: 100%
$627KEst. RAF revenue gap412 members undercoded
3MOC audit gapsHRA→ICP, TOC, ICT incomplete
$1.2MQBP uplift at 4.5 ★6 measures need to move
Priority member actions today18 critical of 312
C. Batista, 73
Discharged 6/14 · no transition coord. note logged · MOC 2 finding
TOC gap
D. Okafor, 68
HRA done · no ICP · 47 days unresolved · audit exposure
ICP missing
R. Nguyen, 74
MDD documented at FQHC · not coded · RAF gap $1,570/yr
RAF gap
C. Batista, 73
BP uncontrolled · no outreach in 22 days · W3 Stars measure
Stars gap
F. Okonkwo, 71
HRA not started · enrolled 6 months · COPD + CHF undercoded
HRA overdue
MOC audit readiness3 gaps
✓
NCQA-approved MOC
v2.1 approved · renewal Oct 2026
–
HRA completion ≥80%
73% · 38 HRAs with no ICP follow-up
✕
ICPs for all enrolled members
61% complete · most common audit finding
✕
TOC within 48h of discharge
12 discharges uncoordinated this month
✓
Provider network adequacy
47 FQHCs contracted · CMS standards met
–
QI goals from prior MOC period
Partially met · NCQA will evaluate at renewal
Operations
Member risk queue
312 members · sorted by urgency · updated this morning
18Critical — action today
94High — action this week
200Moderate — monitor
12TOC in 48h window
All members
C. Batista, 73 · H9999-000891
Discharge 6/14 · BH inpatient · no TOC contact logged · MOC 2 finding open
TOC needed
D. Okafor, 68 · H9999-001203
HRA complete 3/12 · no ICP · 47 days · CMS expects immediate follow-up · audit exposure
ICP missing
F. Okonkwo, 71 · H9999-001887
Enrolled 6 months · HRA not started · COPD + CHF · RAF gap and MOC gap compounding
HRA not started
R. Nguyen, 74 · H9999-002341
3 BH visits at FQHC · MDD documented, not coded · RAF gap $1,570/yr · 47 days since last outreach
RAF gap
A. Reyes, 66 · H9999-001654
A1c overdue · BP uncontrolled · colorectal screening needed · 3 Stars measures at risk
Stars gap
M. Torres, 71 · H9999-001847
Post-discharge · ICP active · care manager assigned · TOC documented · on track
Managed
306 more members · Load more
Compliance
Model of care
v2.1 · NCQA approved · renewal Oct 2026 · 3 audit gaps open
Progress by member
MOC standards
Audit simulation
⚠CMS auditors trace every member: HRA → ICP → ICT → care coordination at transition. 38 members have completed HRAs with no ICP — the most common audit finding. 12 members were discharged this month with no coordination note. Both are direct MOC 2 failures.
73%HRA completionCMS target: 100%
61%ICP completion38 HRAs unmatched
81%ICT assembledWhere ICP exists
67%Transitions coordinated12 discharge gaps
MOC 1 · PopulationApprovedNCQA renewal Oct 2026
MOC 2 · HRA73%412 / 564 complete
MOC 2 · ICP61%38 HRAs unmatched
MOC 2 · ICT81%280 / 344 with ICP
MOC 2 · Transitions67%12 discharges uncoord.
Members not progressing
D. Okafor, 68
HRA completed 3/12 · no ICP · no ICT · CHF · North Valley FQHC primary
ICP missing
R. Nguyen, 74
HRA done 2/28 · ICP draft only · ICT missing · 3 BH visits uncoded at FQHC
ICP incomplete · no ICT
C. Batista, 73
HRA 1/15 · ICP active · ICT assembled · discharged 6/14 · no transition note logged
Transition gap
F. Okonkwo, 71
Enrolled 6 months · HRA not started · all downstream steps blocked · COPD + CHF
HRA not started
L. Patel, 77
HRA done 4/3 · ICP active · ICT partial — BH provider not included · DM2 + CKD
ICT missing BH
M. Torres, 71
Full chain complete · HRA → ICP → ICT → TOC documented at 5/30 discharge · audit-ready
Audit-ready
MOC standard statusNCQA renewal Oct 2026
MOC 1 — Population description
NCQA-approved narrative · meaningful differentiation from general MA population documented
Approved
MOC 2 — HRA completion
73% complete · CMS target 100% · 38 HRAs completed with no ICP follow-up
Below target
MOC 2 — HRA → ICP linkage
61% ICP completion · most common NCQA audit finding · ICP must follow every HRA
At risk
MOC 2 — ICT assembly
81% of members with ICP have ICT · must include BH and LTSS providers for D-SNP population
Below target
MOC 2 — Transitions of care
67% of discharges have documented coordination · 12 gaps this month · MCCP4011 SNF pathway missing
NCQA evaluates whether plan fulfilled goals set in prior MOC · partial fulfillment on HRA targets
Partial
ℹThe audit simulation pulls your live MOC, linked P&Ps, and member-level chain data and runs through the same member-sampling logic CMS uses. It surfaces findings before an auditor does.
Run audit simulation
Simulates a CMS member-level audit against your current MOC and chain data. Surfaces findings before go-live.
Export evidence package
Export MOC, linked P&Ps, audit trail, and member chain documentation formatted for CMS submission.
Compliance · Model of care
Launch new MOC
4 steps · DualWorks guides each section and checks it against NCQA standards before submission
Step 1
SNP population
Step 2
Care coordination
Step 3
Provider network
Step 4
QI goals
ℹMOC 1 — SNP population description. NCQA requires your population narrative to show meaningful differentiation from a general MA population. DualWorks checks your submission against CMS member data and flags if the description is too generic.
SNP type & contract
Population descriptionNCQA checks for meaningful differentiation from general MA
✓ DualWorks check: population narrative shows meaningful differentiation from general MA — NCQA standard met
ℹMOC 2 — Care coordination. This is the most operationally intensive standard and where most plans get dinged. CMS will sample member records and trace HRA → ICP → ICT → transitions. Every element below must be defined and achievable — NCQA does not accept targets below 100%.
Health risk assessment (HRA)Must be 100% goal
Linked P&P
MCQP1021Initial health appointment1 gap — IHA/HRA alignment undefined
Individualized care plan (ICP)Must follow every HRA
Measurable outcomesSelf-management goalsHealthcare preferencesTailored servicesGoals met / not met tracking
Linked P&P
MCCP2019SPD identification & care coordinationIn sync
Interdisciplinary care team (ICT)
Linked P&P
—No P&P linked for ICT assemblyMissing — required for MOC 2
Transitions of care
Linked P&P
MCCP4011Hospital discharge & transition planningGap — SNF pathway not defined
ℹMOC 3 — Provider network. NCQA requires documentation of network adequacy specific to your D-SNP population — not just general MA standards. BH, LTSS, and FQHC relationships must be explicitly addressed.
Network adequacy documentation
Clinical practice guideline oversightNCQA requirement · CY2027+
ℹMOC 4 — Quality measurement and performance improvement. NCQA evaluates whether you fulfilled the goals you set in the prior MOC period. All goals for HRA, ICP, and ICT completion must be set at 100%. DualWorks tracks these in real time and surfaces gaps before renewal.
QI goals for CY2027All must be set at 100% per CMS guidance
HRA completion rate
Goal: 100% of enrolled members within 90 days · current: 73%
ICP completion rate
Goal: 100% of members with completed HRA · current: 61%
ICT assembly rate
Goal: 100% of members with active ICP · current: 81%
Transition of care contact within 48h
Goal: 100% of discharges · current: 67%
RAF coding gap closure rate
DualWorks-tracked · not a CMS MOC requirement but linked to QI program
Prior MOC period fulfillmentNCQA will review at renewal — DualWorks tracks this continuously
HRA completion — CY2026 goal was 100%
Current: 73% · gap will be flagged at NCQA renewal · DualWorks alert active
Current month: 67% · plan-wide average 84% · improving
Partial
P&P resolution — required before submission2 unresolved
✕ MOC cannot be submitted to NCQA until all linked P&P gaps are resolved. Two items need action.
ICT assembly — no P&P linked
MOC 2 requires a policy defining how ICTs are assembled, who is required, and what happens if a provider declines to participate. No policy currently exists.
New P&P required
MCCP4011 — SNF transition pathway missing
Current policy covers hospital discharge only. SNF and ED transitions are not defined. NCQA will flag this at audit — the addendum must be added before submission.
Edit existing P&P
MCQP1021 — IHA/HRA alignment gap
Policy references IHA but plan uses SVHP HRA v3.2. Minor terminology update needed — does not block submission but should be corrected before NCQA review.
Recommended update
MCCP2019 — SPD identification & care coordination
In sync with MOC 2 care coordination requirements. No changes needed.
Resolved
MCRA0003 — Linked chart review & RAF coding
Current · FQHC-specific workflow recommended addition but does not block MOC submission.
ℹThree triple-weighted (W3) clinical outcome measures — blood sugar control, blood pressure, readmissions — and medication adherence are where a fraction of a star translates directly to QBP dollars. Two measures move to W3 in 2027. Build for those now.
Part C measure performance2026 measurement year · 33 measures
Member-level Stars action queueActions that move the rating this week
R. Nguyen, 74 — Blood Sugar Controlled (W3)
A1c overdue · 47 days no response · PCP visit scheduled 7/8 → coordinate A1c order before that visit
High · W3
C. Batista, 73 — Controlling Blood Pressure (W3)
BP uncontrolled at last visit · 22 days since voicemail → mail BP log + coordinate med review with PCP
High · W3
F. Okonkwo, 71 — Colorectal Screening (W1)
First outreach · send FIT kit → no provider visit needed
Medium
A. Reyes, 66 — Mental Health (W1 → W3 in 2027)
HOS score low · no BH referral on file → BH referral + social worker follow-up
Build for 2027
Compliance
Risk adjustment
412 coding gaps · $627K est. uncaptured revenue · 89 items pending UM review
412Members with coding gaps
$627KEst. annual RAF gapIf not closed
89Codes pending UM reviewReady for approval today
34%FQHC coding complianceLowest provider segment
⚠DualWorks detects diagnoses documented in provider chart narratives that were not submitted on encounters — linked chart review, CMS-permitted. Approving a code raises the member's RAF score, which raises the CMS premium the plan receives the following plan year. Your team reviews and approves before any code is submitted.
Linked chart review queue — pending UM approval
89 items · updated this morning
R. Nguyen, 74North Valley FQHC · 6/18/2026HCC 59
Major depressive disorder, recurrent severe (F33.2)
RAF: 0.82 → 1.03PMPM: $6,140 → $7,710+$1,570/yr
C. Batista, 73Coastal Community Health · 6/14/2026HCC 85
Congestive heart failure, unspecified (I50.9)
RAF: 0.91 → 1.24PMPM: $6,810 → $9,280+$2,470/yr
F. Okonkwo, 71Lakeview Medical · 6/10/2026HCC 85
CHF noted in assessment — COPD submitted, CHF not coded
RAF: 0.88 → 1.21PMPM: $6,590 → $9,060+$2,470/yr
D. Okafor, 68North Valley FQHC · 6/5/2026HCC 136
DM2 with diabetic nephropathy (E11.65) in provider notes
RAF: 0.74 → 0.93PMPM: $5,550 → $6,970+$1,420/yr
L. Patel, 77Shasta Community Health · 6/20/2026HCC 137
UM team reviews linked chart review queue and approves each diagnosis. DualWorks validates the HCC code against the clinical documentation before flagging for submission. No code goes to CMS without sign-off.
Submit via EDS to CMSSubmit before Sep 4, 2026
Approved codes are packaged as ANSI 837 v5010 encounter records and submitted to CMS through the Encounter Data System (EDS) — the system CMS fully transitioned to in 2024, replacing RAPS. DualWorks generates the submission file; your EDI team sends it. Deadline: September 4, 2026 by 8:00 PM ET to be included in the PY2027 initial run.
CMS calculates updated risk scoresJan 2027
CMS runs the initial PY2027 risk score calculation using submitted encounter data. Member RAF scores are updated to reflect approved diagnoses. For R. Nguyen: RAF 0.82 → 1.03. For C. Batista: RAF 0.91 → 1.24. Higher RAF scores = higher monthly capitation payment to SVHP.
Higher capitation payments beginJan–Jun 2027
CMS pays the updated premium prospectively each month. For the 89 items currently in queue, this is an estimated +$47,200/year in additional revenue — paid monthly starting January 2027.
Mid-year submission windowMar 2027
If codes are approved after the September deadline, they can still be submitted in the mid-year window (first Friday of March 2027). Mid-year submissions are included in the mid-year risk score recalculation. Payments adjust retroactively for January–June 2027.
Final reconciliation — hard stop~Feb 2028
After the final deadline, CMS will not accept any new diagnoses for PY2027. Only deletions can be processed. Per 42 CFR § 422.310(g), diagnoses submitted after the final deadline are excluded from all payment calculations for that year — no exceptions.
⚡ 89 codes approved today = filed before Sep 4, 2026 initial deadline = PY2027 payments begin January 2027
What CMS accepts vs. rejectsLinked chart review rules — as of CY2026
✓ Accepted — linked chart review (CMS-permitted)
Diagnosis documented in provider's clinical narrative and linked to a face-to-face encounter. DualWorks only surfaces these. ACAP fought to protect this mechanism — it's the primary tool community plans use to close RAF gaps at FQHCs.
Allowed
✕ Rejected — unlinked chart review (banned since 2023)
Adding diagnoses that are not linked to a documented face-to-face encounter. CMS banned unlinked chart reviews for risk score calculation. DualWorks does not generate these — every item in the queue is linked to a specific provider visit date.
Not allowed
✕ Rejected — post-final-deadline submissions
Any new diagnosis submitted after the final reconciliation deadline (~Feb 2028 for PY2027) will not be included in any payment calculation. Only deletes are processed after that point per 42 CFR § 422.310(g).
Hard cutoff
Compliance
Policy library
14 policies linked to MOC · 3 conflicts · 2 stale
14Policies linked to MOC
3MOC conflicts
2Stale — APL not applied
11Triggers active
All policies
MCQP1021
Initial health appointment
HRA protocol · v3.2 · Updated Jan 2026
1 gapTrigger active
MCCP2019
SPD identification & care coordination
HRA protocol · v2.8 · Current
In syncTrigger active
MCAP7002
CalAIM enhanced care management
Care management · v2.1 · APL 26-004 not applied
Stale1 gap
MCCP4011
Hospital discharge & transition planning
Transitions of care · SNF pathway missing
Current1 gap
MCRA0003
Linked chart review & RAF coding
Risk adjustment · Current · FQHC workflow not defined
Sent to care team every morning at 7 AM · no login required
✓This is the email DualWorks sends your care coordination and UM teams every morning. All three compliance engines — MOC, risk adjustment, and Stars — surface in one prioritized list. The team works it top to bottom. No dashboard, no training, no login.
These members have stalled somewhere in the model of care. CMS traces HRA → ICP → ICT → transitions at the member level, so every stall is both a member not being served and a potential finding.
D. Okafor, 68 — HRA completed 3/12. No ICP on file. Assign to care manager to complete ICP this week. CHF · North Valley FQHC primary
ICP missing
C. Batista, 73 — Discharged inpatient 6/14. No transition coordination note logged. Log note in DualWorks today to close this finding. CHF + DM2 · full ICP active
Transition gap
F. Okonkwo, 71 — Enrolled 6 months. HRA not started. Schedule HRA outreach this week. COPD · Lakeview Medical
HRA not started
💰 Risk adjustment — 89 codes pending UM review
Diagnoses documented in provider chart narratives, not submitted on encounters. Linked chart review — CMS permitted. Approve before submission. Est. total if approved: +$47,200/year.
R. Nguyen, 74 — Major depressive disorder (F33.2) documented at North Valley FQHC 6/18. Not submitted. HCC 59 · +0.21 RAF.
+$1,570/yr
C. Batista, 73 — CHF (I50.9) in discharge summary from Coastal Community 6/14. Not submitted. HCC 85 · +0.33 RAF.
+$2,470/yr
F. Okonkwo, 71 — CHF noted in assessment section at Lakeview 6/10. COPD submitted, CHF not added. HCC 85 · +0.33 RAF.
412 members spending above RAF prediction · avg gap $340 PMPM · MLR 86.2%
$8,240Avg projected PMPM↑ $340 vs. RAF prediction
$7,900Avg RAF-predicted PMPM
$627KEst. annual RAF revenue gap412 members undercoded
86.2%Projected MLRTarget ≤85%
⚠412 members are spending more than their RAF score predicts. The $340 PMPM average gap is driven by undercoded behavioral health diagnoses at FQHCs — conditions being treated but not submitted to the plan. Closing these codes increases RAF revenue and brings projected spend in line with reimbursement.
Member spend vs. RAF prediction
Member
RAF score
Predicted PMPM
Actual PMPM
Gap
Status
R. Nguyen, 743 BH visits at FQHC · diagnoses undocumented
0.82
$6,140
$9,870
+$3,730
RAF gap
C. Batista, 73CHF + DM2 · BH admission undercoded
0.91
$6,810
$10,240
+$3,430
RAF gap
D. Okafor, 68HRA not complete · risk score provisional
0.74
$5,550
$7,210
+$1,660
HRA pending
M. Torres, 71Post-discharge · ICP active · care managed
1.24
$9,280
$8,940
−$340
On track
J. Washington, 79LTSS active · complex but well-managed
1.41
$10,560
$10,120
−$440
On track
Plan
Provider network
47 contracted providers · 12 FQHCs · CMS network adequacy met · 67 FQHC coding gaps this quarter
47Total contracted providers
12FQHCs contracted
67FQHC coding gaps this quarterPPS model removes incentive to code
$214KEst. RAF revenue at risk
⚠FQHCs are paid on a PPS rate per visit — no financial incentive to submit diagnosis codes to the plan. Their cost performance looks fine, but they are the primary source of RAF undercoding. "Coding compliance" tracks how often visits result in submitted diagnoses matching what DualWorks detects via linked chart review.
FQHC provider coding compliance12 FQHCs · this quarter
$318KShared savings earned3 VBC providers under budget
Value-based contracts
FFS & FQHC
ℹVBC providers are measured against contracted PMPM budget and quality targets set at signing. Cost variance is actual PMPM vs. contracted PMPM across attributed D-SNP members. Providers below threshold on both cost and quality trigger a shared savings claw-back review.
VBC provider performance
14 providers · Jan–Jun 2026
Provider
Members
Contract PMPM
Actual PMPM
Cost variance
Quality target
Quality actual
Status
Shasta Community HealthPrimary care · VBC yr 3
312
$7,200
$6,840
−$360
78%
82%
Shared savings
Redwood Community ClinicPrimary + BH · VBC yr 2
187
$8,100
$7,950
−$150
75%
77%
On track
Humboldt IPAPrimary care · VBC yr 1
156
$7,800
$7,650
−$150
76%
79%
On track
Valley Medical AssociatesPrimary care · VBC yr 2
241
$7,600
$8,340
+$740
75%
71%
Off target
North Coast Medical GroupSpecialist-heavy · VBC yr 1
98
$9,200
$10,100
+$900
72%
64%
Review needed
Sierra Cardiology PartnersCardiology · VBC yr 1
74
$11,400
$12,890
+$1,490
70%
58%
Review needed
Under contracted PMPM + above quality target
Over budget or below quality
Over budget and below quality — claw-back review
⚠FQHCs are paid on a PPS rate per visit — their cost performance always looks compliant because the rate is fixed. The real risk is coding compliance: how often their visit documentation matches what DualWorks detects via linked chart review. Low coding compliance = RAF revenue left on the table.
ℹDualWorks checks the provider NPI against CMS enrollment records, flags any active sanctions or exclusions, and confirms the provider type before you set contract terms.
Provider identification
CMS enrollment & exclusion checkRuns on NPI verify
PECOS enrollment status
Verify NPI to check active Medicare enrollment
Pending NPI
OIG exclusion list
Checks OIG LEIE for active exclusions
Pending NPI
SAM.gov debarment
Federal debarment and suspension check
Pending NPI
State Medicaid sanctions
NY eMedNY provider exclusion file
Pending NPI
ℹChoose the contract model first — this determines which rate fields apply. VBC contracts set a PMPM budget with shared savings/risk terms. FFS contracts set fee schedule terms. FQHC contracts are always PPS-rate and DualWorks automatically flags the coding compliance gap this creates.
⚠FQHC coding compliance alert. FQHCs are paid on a PPS rate regardless of diagnosis codes submitted. This removes their financial incentive to code for the plan. DualWorks will automatically run linked chart reviews against all FQHC visits and surface RAF gaps to your UM team daily.
FQHC PPS rate terms
$/ visit
ℹ DualWorks will activate daily linked chart review monitoring for this FQHC on contract effective date. RAF gaps will surface in the risk adjustment queue automatically.
ℹQuality targets are agreed at contract signing and tracked by DualWorks throughout the contract year. For VBC providers, missing both cost and quality targets triggers a shared savings claw-back review. For FFS/FQHC providers, quality targets are advisory but feed into Stars measure tracking.
Stars-aligned quality targetsSet the contracted threshold for each measure
Diabetes care — blood sugar controlled
HbA1c <9% · W3 Stars measure · SVHP current: 71%
Below plan avg
Controlling blood pressure
<140/90 · W3 Stars measure · SVHP current: 61%
Below plan avg
Medication adherence — statins
PDC ≥80% · W3 Stars measure
Above plan avg
Breast cancer screening
Mammography · W1 · SVHP current: 83%
On track
Colorectal cancer screening
W1 · SVHP current: 64%
Below plan avg
DualWorks tracks each target monthly and alerts the contract team when a provider falls more than 5 points below threshold.
Overall quality composite threshold
across all contracted measures
✓Review the contract summary below. Once activated, DualWorks begins tracking cost and quality performance against these terms from the contract effective date. The provider will appear in the Provider contracts dashboard with live variance data.
Contract summaryReview before activating
Provider
Tri-County Medical Group · NPI 1234567890 · Primary care
4Medicaid redetermination alertsAt risk of losing dual status
Today's changes
New member queue
Alignment status
Medicaid redetermination
ℹDualWorks receives 834 eligibility transactions from CMS and state Medicaid files daily. Each change is classified by type, cascaded to affected workflows (HRA queue, MOC chain, open RAF reviews), and surfaced here with the required action and deadline.
Eligibility change feed — Monday, June 30, 2026
New enrollments — 3 members
T. Okonkwo, 71 · H9999-002941 · Enrolled today
New D-SNP enrollment · aligned to affiliated Medicaid MCO · Albany County · attributed to North Valley FQHC
New enrollmentHRA due Sep 28, 2026
B. Santos, 67 · H9999-002942 · Enrolled today
New D-SNP enrollment · Medicaid alignment pending verification · Rensselaer County · no PCP attributed yet
Alignment unverifiedHRA due Sep 28, 2026
G. Williams, 74 · H9999-002943 · Enrolled today
Transfer from another MA plan · prior RAF score 1.12 on file · CHF + DM2 · Schenectady County
RAF history availableHRA due Sep 28, 2026
Terminations — 2 members
P. Morales, 69 · H9999-001654 · Moved out of service area
Address change to Cedar County — outside H9999 footprint · disenrollment effective Jul 1 · ICP active · 2 open RAF codes in queue
K. Adeyemi, 82 · H9999-000734 · Deceased — CMS notification received
Death reported via CMS MMR · effective Jun 28 · ICP active · 1 open RAF code · disenrollment processed
DeceasedClose ICP · cancel RAF item
Medicaid status changes — 2 members
A. Reyes, 66 · H9999-001654 · Medicaid redetermination — eligibility at risk
State Medicaid redetermination period open · renewal packet not returned · if Medicaid lapses, member loses dual status and must be disenrolled from D-SNP · deadline Jul 15
Redetermination riskAction by Jul 15
S. Park, 73 · H9999-001102 · Medicaid reinstated
Medicaid eligibility reinstated after 47-day gap · dual eligible status restored · D-SNP enrollment reinstated effective Jul 1 · HRA needed within 90 days
ReinstatedHRA due Sep 28, 2026
⚠Every new enrollment triggers a 90-day HRA clock (MOC 2 requirement). Missing this window is the most common audit finding. DualWorks tracks every new member's HRA deadline from day of enrollment and escalates at 60 days if not completed.
New enrollments — HRA clock runningAll members enrolled in last 90 days without completed HRA
ℹAs of 2027, D-SNPs can only enroll new members who are already in the affiliated Medicaid MCO. By 2030, all enrolled members must be aligned. 56 currently enrolled members are not in the affiliated Medicaid plan — they must be outreached and either aligned or disenrolled before the mandate.
2,884Aligned members2027 new-enrollment rule met
56Unaligned — must resolve by 2030No outreach started
3.5 yrsUntil 2030 mandateAction plan needed now
Unaligned members — 2030 resolution required
Group 1 — Medicaid with different MCO (38 members)
Members enrolled in Medicaid managed care but with a different MCO than the affiliated plan. Outreach goal: encourage voluntary switch to affiliated Medicaid MCO. If they switch, alignment is achieved without disenrollment from D-SNP.
Outreach first
Group 2 — Fee-for-service Medicaid (11 members)
Members receiving Medicaid through traditional FFS, not managed care. Cannot be aligned unless they enroll in the affiliated MCO. Higher complexity — state enrollment process required.
Complex — state process
Group 3 — Medicaid status unclear (7 members)
CMS file and state Medicaid file don't match for these members. DualWorks flagged the discrepancy — manual verification needed before any outreach.
Data discrepancy
⚠If a member's Medicaid eligibility lapses — even briefly — they lose dual eligible status and must be disenrolled from the D-SNP. DualWorks monitors state redetermination files and alerts the team when a member's renewal is at risk, before the lapse occurs.
Redetermination risk — active alerts4 members · renewal packets not returned
A. Reyes, 66 · H9999-001654
Medicaid renewal packet mailed May 15 · not returned · deadline Jul 15 · if lapsed: disenrollment from D-SNP required · open ICP and 1 RAF code in queue
15 days to lapse
C. Batista, 73 · H9999-000891
Renewal packet mailed Jun 1 · not returned · deadline Jul 31 · member has active ICP and open transition gap
31 days to lapse
L. Patel, 77 · H9999-002109
Renewal packet mailed Jun 10 · not returned · deadline Aug 10
41 days to lapse
R. Nguyen, 74 · H9999-002341
Renewal submitted but processing delayed at state · status unconfirmed · open RAF codes worth $1,570/yr could be lost if disenrolled
Processing delay
What happens if Medicaid lapses
✕
Member loses dual eligible status
D-SNP enrollment requires active Medicaid — lapse triggers mandatory disenrollment
✕
Open RAF codes are cancelled
Any in-flight chart review items for this member are voided — revenue lost
✕
Active ICP must be closed
Care coordination documentation must be closed and transition of care note filed
✓
Reinstatement is possible
If Medicaid is reinstated within the same plan year, member can re-enroll in D-SNP — DualWorks flags reinstatements in the daily feed (e.g. S. Park today)