CMS Risk Adjustment Data Validation (RADV) Practice Exam

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• What does the ESRD risk adjustment model add to CMS-HCC?
• What is a Medicare Advantage Organization (MAO)?
• What is meant by an error rate in RADV?
• CRCs are tasked with which outcome?
• How many members are typically targeted and utilized?
• What is used in the Medicare risk adjustment model to calculate annual risk scores for MAO members?
• Which scenario best supports a diagnosis as active for RAF?
• What is an acceptable diagnostic reason for a diagnosed condition?
• Which entity conducts Medicare RADV audits?
• What is a risk score or RAF?
• In the Medicaid RADV process, who conducts the audits and who shares the results with states?
• What is the primary purpose of risk adjustment in Medicare Advantage?
• What is the purpose of the Contract-Level RADV audit?
• What is the commercial risk adjustment payment model, and who does it serve?
• How does hierarchy elimination work in the CMS-HCC model?
• How can incomplete documentation lead to RADV findings?
• How do up-to-date coding guidelines impact RADV?
• Which is NOT a component of the CMS RADV six-step process?
• What is the purpose of HCC crosswalks?
• What is a risk-adjusted payment in MA plans?
• What is the CMS-HCC model and what is its role in risk adjustment?
• What happens if payments based on diagnoses are not supported in a RADV audit?
• What is the role of sampling/validation methodologies in RADV practice?
• Which statement best describes the goal of the commercial risk adjustment payment model?
• What does RAF stand for in the RADV context?
• How does CMS define a valid evidence trail for a diagnosis?
• How can training impact RADV outcomes?
• What is the purpose of a quality assurance (QA) step in RADV?
• What is the purpose of evidence requests in RADV?
• The HHS-RADV audit is required by which statute?
• What does the HCC model aim to do in terms of patient health and costs?
• When ED data conflicts with chart documentation, which source is typically treated as authoritative?
• How does the CDPS model handle hierarchical conditions?
• What are the two major RADV audits conducted by CMS for Medicare?
• Which statement best describes the difference between RAPS and EDS?
• How do RADV results influence a plan’s data governance?
• What is the relationship between RAPS data and RADV?
• What is the primary objective of a RADV audit?
• Which statement about risk adjustment and care is true?
• Accurate risk scores support which goals?
• What are the two main sources of diagnosis data used to calculate risk scores?
• What are Hierarchical Condition Categories (HCCs)?
• What evidence links a diagnosis to a patient's care for RAF validation?
• How might CMS handle discrepancies between ED data and chart documentation?
• CDPS is the Medicaid Chronic Illness and Disability Payment System. What is it in risk adjustment terms?
• Why are HCCs called hierarchical?
• What does the 21st Century Cures Act address in the context of risk adjustment?
• How can health plans use RADV findings to improve their practices?
• What is the End-Stage Renal Disease (ESRD) risk adjustment model?
• Under what condition is the Part D crosswalk used in risk scoring?
• What is “claims-based data” and how does RADV relate to it?
• Which of the following illustrates a timing issue in RADV findings?
• What is the purpose of the RADV audit checklist created by CMS?
• What is risk adjustment?
• How can the results benefit health plans?
• Risk adjustment discrepancies are identified when what occurs?
• What is the purpose of the Encounter Data System (EDS)?
• In Dual Eligible Special Needs Plans (D-SNPs), how are risk scores calculated?
• Which option is NOT typically acceptable evidence to validate a diagnosis?
• Which model is used to calculate risk scores in Medicare Advantage (MA)?
• What is the purpose of the National sample RADV audit?
• What is the role of CMS in RADV audits?
• Why is risk adjustment critical for health insurance plans?
• What is the typical timeline window for providing the selected sample enrollees?
• What is the difference between a diagnosis code and a condition in RADV contexts?
• Encounter Data System (EDS) replaces which prior system?
• What is the role of a medical coder in RADV?
• What best describes a condition in the RADV context?
• What types of organizations perform RADV audits?
• EDS data sources rely on which data input?
• Which of the following is NOT a demographic factor listed for risk score calculation?
• What are rule-out diagnoses, and how should they be treated in RADV?
• How is the RAF recalculated if a diagnosis is added or removed during RADV?
• Which of the following is an example of an upcoding risk in RADV findings?
• What steps should a plan take if a chart is unavailable?
• What is a corrective action plan (CAP) in RADV?
• Which statement about HCC updates is accurate?
• How does CMS define a supported diagnosis for an HCC?
• What is the impact of documentation quality on RADV outcomes?
• In the commercial model, which statement best describes the distribution of risk adjustment funds?
• What does RAF stand for, and how is it used in CMS risk adjustment?
• Which description correctly defines a Medicare plan that contracts with CMS to offer Medicare benefits including prescription components?
• Why is the distinction between current and historical diagnoses important in RADV?
• Which condition types are used to determine annual risk scores under the Medicare risk adjustment model?
• What are common CMS updates that could impact RADV practice?
• What is the goal of the RADV process?
• Which statement best describes a component used to determine an enrollee\'s RAF?
• What is the purpose of chart retrieval in a RADV audit?
• Which of the following describes the demographic factors considered in risk score calculation?
• What is the role of providers in RADV?
• What is the purpose of capturing diagnoses in an HCC model?
• What is required for a diagnosis to count toward RAF in the measurement year?
• What is the primary purpose of the RADV program?
• Which statement best describes the role of documentation, results, and plans in validating diagnoses for RADV?
• What defines a risk adjustment discrepancy?
• In the CMS-HCC framework, how are conditions from different families treated for risk scoring?
• How are conditions organized in the HCC coding model?
• What is the primary data source for risk adjustment validation in RADV?
• How often are HCCs updated?
• In commercial RADV audits, how is the sampling design described?
• In commercial RADV audits, how is the sampled data typically stratified?
• What is the impact of partial record retrieval on RADV results?
• What does the National sample RADV audit focus on?
• Which act introduced variables counting conditions in the HCC adjustment model and paved the way for using EDS for risk score calculations?
• The RADV process goal is to eliminate premium differences among health plans based on what?
• What is the concept of upcoding in RADV?
• What is the Medicaid Integrity Program (MIP)?
• What is the CMS-HCC crosswalk used for?
• What type of documentation is typically requested as evidence in RADV?
• What is the RADV program's primary purpose within CMS?
• What is the difference between a full chart review and a focused chart review?
• What does the acronym RADV stand for?
• What is the Children's Health Insurance Program (CHIP)?
• In RADV, diagnoses must be active in the measurement year to be included in RAF. True or False?
• What is the ultimate use of final RADV results?
• What are some typical categories of RADV findings?
• What is the purpose of stratification in the RADV sampling?
• How does CMS use RADV results to adjust payments?
• What is the approach used for RADV audits in Medicare?
• Which statement about RAPS is true?
• What types of evidence are typically acceptable to validate a diagnosis?
• RADV audit process is associated with which domain?
• In risk adjustment, how do HCCs relate to disease diagnoses?
• Which statement best captures CRCs' impact on patient care and reimbursement?
• How are the weights in CMS-HCC model used in RAF calculation?
• What causes a risk score to increase or decrease?
• What is the difference between encounter data and chart documentation in RADV?
• Why is coding accuracy important in the RADV audit process?
• What is the significance of the 21st Century Cures Act for risk adjustment?
• How does the CMS-HCC model handle multiple diagnoses mapping to a single HCC?
• What are the three major risk adjustment payment models?
• How are enrollees classified in the commercial risk adjustment model?
• What are Hierarchical Condition Categories (HCCs)?
• What is the difference between ICD-10-CM coding and CPT coding in RADV?
• What is the appeals process in RADV?
• Which practice best supports accurate RAF during RADV?
• How does risk adjustment differ from the fee-for-service (FFS) payment methodology?
• Which option correctly contrasts RAPS and EDS data sources?
• Why is coding specificity important in RADV?
• What is the role of prepayment versus postpayment RADV?
• What is the RADV audit?
• How is the measurement year defined in RADV?
• What happens if documentation cannot be located?
• What is the role of the Certified Risk Adjustment Coder (CRC)?
• RADV findings help health plans in which way?
• Which of the following is a common challenge plan sponsors face in RADV?
• What are the primary data sources CMS uses for RADV?
• What do providers submit on claims that insurers use to identify needed programs and services for enrollees?
• What is a prospective payment model in risk adjustment?
• What is the main objective of postpayment RADV?
• When do RADV audits occur?
• Which statement about QA in RADV is correct?
• What is the RxHCC crosswalk used for?
• Which statement best explains why CRCs matter in risk adjustment workflows?
• What is the purpose of RAF in CMS payments?
• What is the role of the National Provider Identifier (NPI) in risk adjustment?
• What is chart abstraction in RADV?
• What is the External Data Gathering Environment (EDGE) used for in risk adjustment?
• Which statement best describes the purpose of risk adjustment scoring?
• How do RADV audits operate for commercial risk adjustment?
• Which practice helps improve RADV accuracy?
• Who created the RADV audit checklist used in risk adjustment audits?
• Which of the following best describes the relationship between chart documentation and the diagnoses used for RAF calculations?
• What is the Programs of All-inclusive Care for the Elderly (PACE)?
• How are enrollees selected for a RADV sample?
• Which statement best describes the role of CRCs in risk adjustment?
• What is meant by a sampling process in RADV?
• Which role is most closely associated with risk scores in payer reimbursement?
• Why is stratification used in RADV sampling?
• What are Dual Eligible Special Needs Plans (D-SNPs)?
• Which factor most directly affects the calculation of an enrollee's RAF in a RADV context?
• What is the HHS-RADV audit?
• RAPS data sources are primarily from what?
• What is the role of the second validation auditor?
• Which CMS processing system is used in RADV to handle risk adjustment data?