Prospective Risk Adjustment Programs

• These programs utilize tools such as In Home Assessments and In Office Assessments to proactively capture diagnostic information.
• The In Office Assessment Program is a pre-visit and point-of-care program that helps improve patient outcomes by supporting early detection and ongoing annual assessment of chronic conditions for members. Fidelis Care partners with Optum on the In Office Assessment Program.
• Fidelis Care has partnered with Inovalon, a healthcare technology company, to offer a In Home Assessment/Personal Health Visit at no additional cost to qualifying Fidelis Care Qualified Health Plan (QHP) members and Wellcare By Fidelis Care members. The Personal Health Visit gives members the opportunity to meet with a health care professional who can help them stay healthy. The results of any In Home Assessments completed by our members will be shared with their regular doctor. The visit is not meant to take the place of any of existing doctor appointment(s) and does not replace the care they receive through their regular doctor(s).

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Retrospective Risk Adjustment Programs

• These programs utilize chart review to look back in time for missing data.
• This allows Fidelis Care to meet the New York State Department of Health requirement that health plans submit complete diagnostic information regarding their members.
• To meet this requirement, we will requesting your cooperation to facilitate standard and routine chart review for your patients enrolled in Fidelis Care throughout the year for various products (Medicaid, Medicare and Marketplace).
• The goal of the Chart Review program is to close risk and care gaps not reported or coded correctly and to ensure that members are coded to the highest specify.
• The programs are administered by vendors on behalf of Fidelis Care and Centene Corporation. Vendors retrieve targeted charts from providers. You will receive an outreach letter from our vendor with a list of the charts we are looking for you to submit. There are various ways you can submit the charts, which are outlined in the letter.
• Charts are targeted based on suspected unreported conditions for a member.
• Coders then review medical charts to identify and report diagnosis codes that were not submitted on the claim.
• We appreciate your cooperation with any chart review efforts.

If you have been outreached by us to participate in a chart review initiative or prospective risk adjustment service, such as Continuity of Care (CoC) or an In Office Assessment, we encourage your participation in these programs to support the goals outlined above. If you have questions about any of our risk adjustment activities, please e-mail NYRiskAdjustment@fideliscare.org.