DualWorks Intelligence
Recommendations
Ranked by impact · synthesized across MOC, RAF, Stars, eligibility, and contracts · updated this morning
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.
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.
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. MVP needs 27 more members controlled on blood sugar and 93 on blood pressure to reach 4.5 stars.
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.
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. MVP 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Part D specialty drug exposure is growing
IRA changes mean MVP 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.
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.
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.
MVP Health Care · H3305-034
My D-SNP
DualAccess Complete · CY2026 · 2,940 members · updated this morning
| 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 |
DualWorks
D-SNP at a glance
From launch to daily operations — click any phase to open the workstation
Overview
Dashboard
CY2026 · 2,940 members · H3305-034 · updated this morning
Operations
Member risk queue
312 members · sorted by urgency · updated this morning
Compliance
Model of care
v2.1 · NCQA approved · renewal Oct 2026 · 3 audit gaps open
D. Okafor, 68
HRA completed 3/12 · no ICP · no ICT · CHF · North Valley FQHC primary
R. Nguyen, 74
HRA done 2/28 · ICP draft only · ICT missing · 3 BH visits uncoded at FQHC
C. Batista, 73
HRA 1/15 · ICP active · ICT assembled · discharged 6/14 · no transition note logged
F. Okonkwo, 71
Enrolled 6 months · HRA not started · all downstream steps blocked · COPD + CHF
L. Patel, 77
HRA done 4/3 · ICP active · ICT partial — BH provider not included · DM2 + CKD
M. Torres, 71
Full chain complete · HRA → ICP → ICT → TOC documented at 5/30 discharge · audit-ready
MOC 1 — Population description
NCQA-approved narrative · meaningful differentiation from general MA population documented
MOC 2 — HRA completion
73% complete · CMS target 100% · 38 HRAs completed with no ICP follow-up
MOC 2 — HRA → ICP linkage
61% ICP completion · most common NCQA audit finding · ICP must follow every HRA
MOC 2 — ICT assembly
81% of members with ICP have ICT · must include BH and LTSS providers for D-SNP population
MOC 2 — Transitions of care
67% of discharges have documented coordination · 12 gaps this month · MCCP4011 SNF pathway missing
MOC 3 — Provider network
47 FQHCs contracted · BH coverage meets DMHC standards · LTSS referral network documented
MOC 4 — QI goals from prior period
NCQA evaluates whether plan fulfilled goals set in prior MOC · partial fulfillment on HRA targets
Simulates a CMS member-level audit against your current MOC and chain data. Surfaces findings before go-live.
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
Compliance
Stars tracker
4.0 overall · 6 measures below target · $1.2M QBP uplift at 4.5
R. Nguyen, 74 — Blood Sugar Controlled (W3)
A1c overdue · 47 days no response · PCP visit scheduled 7/8 → coordinate A1c order before that visit
C. Batista, 73 — Controlling Blood Pressure (W3)
BP uncontrolled at last visit · 22 days since voicemail → mail BP log + coordinate med review with PCP
F. Okonkwo, 71 — Colorectal Screening (W1)
First outreach · send FIT kit → no provider visit needed
A. Reyes, 66 — Mental Health (W1 → W3 in 2027)
HOS score low · no BH referral on file → BH referral + social worker follow-up
Compliance
Risk adjustment
412 coding gaps · $627K est. uncaptured revenue · 89 items pending UM review
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.
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 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 MVP.
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.
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.
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.
✓ 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.
✕ 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.
✕ 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).
Compliance
Policy library
14 policies linked to MOC · 3 conflicts · 2 stale
Operations
Daily digest
Sent to care team every morning at 7 AM · no login required
⚠ MOC compliance — 3 items need action today
These members have broken audit chains. CMS traces HRA → ICP → ICT → transitions at the member level. Each gap is a potential finding.
💰 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.
+ 86 more items in review queue → Open full queue in DualWorks
★ Stars — 4 member actions due this week
MVP is at 4.0 stars — $1.2M below the 4.5-star QBP bonus. These members move the rating if reached this week.
DualWorks Operations Engine · MVP Health Care H3305-034 · Open full dashboard → · Manage digest settings
Plan
Member spend
412 members spending above RAF prediction · avg gap $340 PMPM · MLR 86.2%
| 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
North Valley FQHC
47 D-SNP visits this quarter · rate compliance 100% · coding compliance 34%
Coastal Community Health
31 D-SNP visits · BH primary · rate compliance 100% · coding compliance 29%
Lakeview Medical Clinic
22 D-SNP visits · mixed primary · rate compliance 100% · coding compliance 61%
Shasta Community Health
312 attributed members · primary care · coding compliance 89%
Plan
Provider contracts
47 providers · 14 VBC · 33 FFS/FQHC · 5 off target · 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 |
| Provider | Type | D-SNP visits | Contract rate | Billed rate | Rate compliance | Coding compliance | RAF impact |
|---|---|---|---|---|---|---|---|
| North Valley FQHC47 D-SNP visits this quarter | FQHC · PPS | 47 | $287/visit | $287/visit | 100% | 34% | High RAF risk |
| Coastal Community HealthBH primary · 31 visits | FQHC · PPS | 31 | $301/visit | $301/visit | 100% | 29% | High RAF risk |
| Lakeview Medical ClinicMixed primary · 22 visits | FQHC · PPS | 22 | $274/visit | $274/visit | 100% | 61% | Moderate RAF risk |
| Sierra Specialty GroupCardiology · 18 visits | FFS | 18 | Fee schedule | Fee schedule | 98% | 89% | Low risk |
| Redding Behavioral HealthBH specialist · 41 visits | FFS | 41 | Fee schedule | Fee schedule | 96% | 84% | Low risk |
| Mt. Shasta Primary CareRural primary · 29 visits | FFS | 29 | Fee schedule | +4% over | 81% | 88% | Rate review |
Plan · Provider contracts
Add new provider
4 steps · provider details → contract type & rates → quality targets → review & activate
PECOS enrollment status
Verify NPI to check active Medicare enrollment
OIG exclusion list
Checks OIG LEIE for active exclusions
SAM.gov debarment
Federal debarment and suspension check
State Medicaid sanctions
NY eMedNY provider exclusion file
Plan
Eligibility & alignment
2,940 enrolled · 7 changes today · 56 unaligned · 2030 alignment mandate
T. Okonkwo, 71 · H3305-002941 · Enrolled today
New D-SNP enrollment · aligned to affiliated Medicaid MCO · Albany County · attributed to North Valley FQHC
B. Santos, 67 · H3305-002942 · Enrolled today
New D-SNP enrollment · Medicaid alignment pending verification · Rensselaer County · no PCP attributed yet
G. Williams, 74 · H3305-002943 · Enrolled today
Transfer from another MA plan · prior RAF score 1.12 on file · CHF + DM2 · Schenectady County
P. Morales, 69 · H3305-001654 · Moved out of service area
Address change to Saratoga County — outside H3305 footprint · disenrollment effective Jul 1 · ICP active · 2 open RAF codes in queue
K. Adeyemi, 82 · H3305-000734 · Deceased — CMS notification received
Death reported via CMS MMR · effective Jun 28 · ICP active · 1 open RAF code · disenrollment processed
A. Reyes, 66 · H3305-001654 · 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
S. Park, 73 · H3305-001102 · 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
| Member | Enrolled | HRA deadline | Days remaining | Alignment | Action |
|---|---|---|---|---|---|
| F. Okonkwo, 71COPD + CHF · Lakeview Medical | Jan 3, 2026 | Apr 3, 2026 | 88 days overdue | Aligned | |
| D. Okafor, 68CHF · North Valley FQHC | Mar 12, 2026 | Jun 10, 2026 | 20 days overdue | Aligned | |
| B. Santos, 67New today · no PCP yet | Jun 30, 2026 | Sep 28, 2026 | 90 days | Unverified | |
| T. Okonkwo, 71New today · North Valley FQHC | Jun 30, 2026 | Sep 28, 2026 | 90 days | Aligned | |
| G. Williams, 74Transfer · prior RAF 1.12 · CHF + DM2 | Jun 30, 2026 | Sep 28, 2026 | 90 days | Aligned |
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.
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.
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.
A. Reyes, 66 · H3305-001654
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
C. Batista, 73 · H3305-000891
Renewal packet mailed Jun 1 · not returned · deadline Jul 31 · member has active ICP and open transition gap
L. Patel, 77 · H3305-002109
Renewal packet mailed Jun 10 · not returned · deadline Aug 10
R. Nguyen, 74 · H3305-002341
Renewal submitted but processing delayed at state · status unconfirmed · open RAF codes worth $1,570/yr could be lost if disenrolled