Each year, we request your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective), that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC) in order to document and close the coding gaps. 


The CRA Program is specific to our Affordable Care Act (ACA) members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).


With our Retrospective Program, we focus on medical chart collection. We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  This particular effort is part of our compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership. The members’ medical record documentation helps support this data requirement.


Analytics are performed internally on claims that do not have the ICD-10 code for which we suspect a chronic condition. These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.


Anthem network providers - PCPs, specialists, facilities, behavioral health, ancillary, etc. - may receive letters from vendors such as Inovalon, Verscend, Ciox, Sharecare, and Episource requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. 


We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2020). While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.


Electronic options that may make medical chart collection easier for providers:


  • EMR Interoperability
  • Allscripts (Opt in -- signature required to allow for remote review)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • Remote/Direct Anthem access
  • Vendor virtual or onsite visit
  • Secure FTP


The goal of these electronic options is to both improve the medical record data extraction and the experience for Anthem’s network-participating hospitals, clinics and physician offices. If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative, Alicia.Estrada@anthem.com.  


Thank you for your continued efforts with our CRA Program and expediting these medical chart collection requests. 


Featured In:
March 2020 Anthem Maine Provider News