AAPC-CRC Certified Risk Adjustment Coder - Set 5 - Part 3

Correct Answer: The State, or HHS on its behalf, by June 30 of the following year

Under 45 CFR 153.310(e), a State, or HHS on behalf of the State, must notify issuers of risk adjustment payments due or charges owed annually by June 30 of the year following the benefit year. Option b is incorrect because issuers are the recipients of the notice about payments due or charges owed, not the party that sends it. Option c is incorrect because the regulation sets an annual date of June 30 of the year following the benefit year, not the close of the benefit year. Option d is incorrect because the rule gives the duty to the State, or HHS acting on the State's behalf, and sets the deadline in the year after the benefit year.

Correct Answer: Conduct oversight and monitoring

Under 45 CFR 153.310(c)(3), a State operating a risk adjustment program must conduct oversight and monitoring of that program. This duty is separate from administering the Federally certified methodology through a qualified entity. Option a is incorrect because deferral to HHS happens when a State forgoes implementation, for example by not electing to operate risk adjustment; an operating State keeps its functions. Option b is incorrect because the regulation directs a State operating risk adjustment to collect risk adjustment data, although it may vary the amount and type collected. Option c is incorrect because the State must require issuers offering risk adjustment covered plans to comply with the data privacy and security standards in the data collection approach.

Correct Answer: Accounting of all receipts and expenditures

Under the general oversight requirements for State-operated programs, a State running risk adjustment must keep an accounting of all receipts and expenditures for payments, charges and administrative functions and activities for each benefit year. Option a is incorrect because validating such a sample is a data validation duty of the State or HHS on its behalf, not the benefit-year record the State keeps. Option b is incorrect because the regulation requires an administrative process to appeal findings on software implementation or data validation, not a per-year log as the oversight record. Option d is incorrect because enrollees are assigned to the applicable risk pool of the State where the employer's policy was filed, which is a placement rule rather than a record-keeping duty.

Correct Answer: Pay the net charges to the State, or HHS on behalf of the State

An issuer with a net balance of risk adjustment charges payable is notified by the State, or HHS on behalf of the State, and must remit those charges to the State or to HHS, as applicable. Option b is incorrect because the notification flows the other way: the State, or HHS on behalf of the State, informs the issuer of its net charges payable. Option c is incorrect because this is a user fee duty that applies where HHS operates risk adjustment for a State, and it does not answer a charge notice. Option d is incorrect because contract penalties are only an option the issuer may use to secure complete, timely, accurate data from contractors, and they do not settle a charge.

Correct Answer: At least 30 calendar days

Under the audits and compliance reviews provision, HHS will provide at least 30 calendar days advance notice of its intent to conduct an audit of an issuer of a risk adjustment covered plan. Option a is incorrect because 10 is the number of years an issuer must maintain documents and records for each benefit year, not the audit notice period. Option c is incorrect because the audit provision sets a shorter minimum notice period of 30 calendar days, so a 60-day figure overstates what HHS must provide. Option d is incorrect because the notice period is counted in calendar days, not business days, so this changes the unit the audit provision actually uses.

Correct Answer: Internal Revenue Service

The records maintenance requirement directs issuers to make documents and records available to HHS, the OIG, the Comptroller General, or their designees, or to the State where it operates risk adjustment. The Internal Revenue Service is not listed. Option a is incorrect because the regulation lists the OIG among the entities entitled to request an issuer's risk adjustment documents and records, so it belongs to the set the stem describes. Option b is incorrect because the Comptroller General appears by name in the records availability provision, alongside HHS and the OIG, so it is a proper recipient of such requests. Option d is incorrect because HHS is named in the records maintenance requirement as an entity that may request the documents and records for verification, investigation, audit or other review.

Correct Answer: Initial validation audit and second validation audit

Under 45 CFR 153.630(a), an issuer of a risk adjustment covered plan in a State where HHS operates risk adjustment must have an initial and second validation audit performed on its risk adjustment data. Option a is incorrect because recoupment is an HHS action taken after an issuer fails to comply with audit activities, and the independent auditor performs the initial audit rather than a separate review. Option c is incorrect because the regulation names a second validation audit as the follow-on step; a written corrective action plan is a response to final audit report findings, not a separate audit. Option d is incorrect because high-cost risk pool payments appear only as payments HHS may recoup when audit activities fail; the regulation does not describe a pool audit as a required validation step.

Correct Answer: reviewers

The regulation requires the initial validation auditor to measure and report inter-rater reliability rates among its reviewers, and to achieve a consistency measure of at least 95 percent, reporting to the issuer and HHS. Option a is incorrect because issuers are the entities whose risk adjustment data are being validated, and they receive the report; they are not the group whose consistency is measured. Option b is incorrect because permitted providers generate the medical record documentation under review; they do not take part in the auditor's review work or consistency measure. Option c is incorrect because enrollees are the individuals whose risk scores are validated through the sample, so they are subjects of the audit and not raters.

Correct Answer: File a discrepancy report

Under 45 CFR 153.630(d), an issuer must either confirm the initial validation audit sample determined by HHS or file a discrepancy report to dispute it, in the manner set forth by HHS. Option b is incorrect because the appeal process applies to findings of a second validation audit or a risk score error rate calculation, not to the initial sample. Option c is incorrect because the initial validation audit sample is determined by HHS, so the issuer has no authority to substitute its own selection. Option d is incorrect because HHS, not the issuer, selects the subsample for a second validation audit, and that audit does not serve as a sample dispute.

Correct Answer: Ensure the initial validation auditor cooperates with HHS

Under 45 CFR 153.630(c), the issuer must comply with HHS standards for the second validation audit and must ensure the initial validation auditor cooperates with HHS and the second validation auditor. Option a is incorrect because a default data validation charge is imposed when an issuer fails to engage an initial validation auditor or to submit initial audit results, not as a duty tied to the second audit. Option b is incorrect because the 30-day period applies to confirming or disputing the risk score error rate calculation, while second audit findings carry a 15-day period. Option c is incorrect because the regulation assigns selection of the subsample to HHS, not to the issuer, so the issuer has no role in choosing which data are reviewed.