By the time a risk adjustment issue shows up in a report, it may have been sitting in the data for months. Rejected claims, missing member months or unresolved diagnosis issues can affect risk scores and transfers. The sooner a health plan catches those issues, the more room it has to fix them before the April 30 final risk adjustment data submission deadline. 

The plans that handle this well use the months beforehand as working time, with four recurring priorities that keep the process moving and make final submission far more manageable. 

1. Monitor EDGE Data Throughout the Risk Adjustment Cycle 

Risk adjustment starts with the data feeding the HHS EDGE environment, including enrollment, medical and pharmacy claims, encounters and diagnosis information. 

Issuers submit and update risk adjustment data throughout the year, while CMS evaluates EDGE data at interim points to assess whether enrollment and claims data are accumulating as expected. CMS doesn’t require one universal monthly or quarterly submission schedule, but April 30 is the final cutoff for benefit-year data. 

Health plans need visibility into both what they submit and what EDGE actually accepts. 

Plans should regularly compare EDGE activity against internal expectations, including: 

• Member months versus internal enrollment 

• Medical and pharmacy claims volume 

• Accepted versus rejected records 

• Recurring error types 

• Unexpected gaps or changes between processing runs 

2. Use Interim Data to Catch Risk Adjustment Problems Early 

EDGE and CMS reports provide health plans with recurring opportunities to compare what was processed with what they expected to see. 

Unexpected shifts in member months, claims volume or interim risk scores can point to missing data, claims runout, rejected records or another discrepancy that needs investigation. Tracing those differences back to the source gives teams time to determine whether a correction is necessary. 

Before April 30, issuers can correct rejected records, submit missing data, and make updates. That flexibility narrows sharply once the deadline passes. CMS will still process deletions of previously submitted data, but it generally won’t accept new additions that would increase the amounts used in final transfer calculations. Data sufficiency also carries financial consequences. If an issuer fails to provide sufficient data for HHS to apply the risk adjustment methodology, federal rules allow HHS to assess a default risk adjustment charge. 

The goal should be to enter the final submission period resolving known issues, not discovering them for the first time. 

3. Review Final Transfers and Escalate Discrepancies 

The final data deadline closes one phase of risk adjustment, but the cycle continues. HHS calculates final risk adjustment transfers after the submission window and notifies issuers of final payments or charges by June 30. 

Health plans then need to compare those results with the data and expectations developed during the year. That review should include confirming that the diagnosis codes reflected in the final calculation align with the applicable CMS risk adjustment model and current code mappings. CMS updates the diagnosis-code crosswalks and related model instructions during the benefit year, so those changes can create discrepancies that need to be understood and reconciled. 

Federal rules provide a process for issuers to confirm final information or report discrepancies, with reconsideration available for qualifying issues. Before April 30, teams are focused on correcting the data that feed the calculation. After final results are issued, the focus shifts to determining whether HHS’s results accurately reflect the submitted data and whether any issue requires a formal discrepancy or reconsideration process. 

4. Maintain Clear Ownership and an Audit-Ready Record 

Risk adjustment touches enrollment, claims, pharmacy, IT, actuarial, finance, compliance and regulatory teams, often with vendors supporting parts of the process. 

CMS doesn’t prescribe which internal team owns each activity, but health plans still need clear responsibility for monitoring data, investigating discrepancies, making corrections and confirming that issues are resolved. 

That ownership also needs to extend to documentation. Federal rules require issuers to retain records sufficient to evaluate risk adjustment compliance for at least 10 years. Those records may include source data, EDGE submissions and outputs, reconciliation materials, attestations, correspondence and supporting documentation. 

They can also become important later during HHS Risk Adjustment Data Validation, or HHS-RADV. RADV is a separate formal validation process from routine EDGE data review, but it relies on the underlying records supporting what the issuer submitted. 

Build Clear Ownership Across the Risk Adjustment Process 

The real advantage of a year-round risk adjustment process is creating more opportunities to catch problems early, while there’s still time to act on them. 

The faster teams can move from new data to review, reconciliation and correction, the less likely an issue is to carry forward into interim results, final transfers or later validation. By April 30, the goal should be to close out a well-managed process rather than uncover problems that have been building throughout the year. 

ClearFile helps health plans bring more structure, visibility and accountability to year-round risk adjustment workflows. See how our regulatory experts and technology can support stronger risk adjustment accuracy.