Risk Scores
HCC risk coding, RAF scores, and recapture opportunity management · Plan Year 2025
Avg HCC Score
2.47
▲ 0.12 vs. prior year
Avg RAF Score
1.83
▲ 0.08 vs. prior year
High-Risk Members
312
▲ 18 from last quarter
Recapture Opportunities
$2.1M
147 members with gaps
Recapture Opportunity Alerts
89 members have suspected HCC conditions not yet coded in 2025
Estimated revenue impact: $847,000. Schedule AWV appointments to capture diagnoses before sweep date.
CMS RAF final submission sweep: 58 days remaining
Current capture rate: 71.3%. Target: 85%+ for full reimbursement. 147 chase letters queued for provider outreach.
RAF Score Trend — 12 Months
Avg RAF
Target
Apr '24JunAugOctDecFeb '25Mar '25
Risk Tier Distribution1,847 total members
1,847
Members
Critical (RAF≥3.0) — 314
High (2.0–2.99) — 517
Medium (1.0–1.99) — 572
Low (<1.0) — 444
RAF Score Breakdown by Condition Category
Patient Risk Score Table
1,847 members
| Patient | HCC Score | RAF Score | Risk Tier | Suspected Conditions | Last Calculated | Actions |
|---|---|---|---|---|---|---|
Eleanor Mitchell DOB: 03/12/1938 · ID: M-00142 |
8.2 | 3.41 | Critical | CHFCKD+2 gaps | Today | |
Robert Johnson DOB: 07/28/1935 · ID: M-00089 |
7.8 | 3.18 | Critical | COPDT2DM+4 gaps | 5 days ago | |
Maria Gonzalez DOB: 11/05/1940 · ID: M-00217 |
5.4 | 2.67 | High | HTNDiabetes | Yesterday | |
William Chen DOB: 05/19/1933 · ID: M-00334 |
4.9 | 2.41 | High | CHF+1 gap | 2 days ago | |
Dorothy Patterson DOB: 02/14/1937 · ID: M-00451 |
3.2 | 1.88 | Medium | Depression | 1 week ago | |
Harold Lewis DOB: 09/30/1942 · ID: M-00512 |
2.8 | 1.62 | Medium | ArthritisAsthma | 3 days ago | |
Beatrice Thompson DOB: 06/08/1936 · ID: M-00673 |
1.4 | 0.94 | Low | Hypertension | Today | |
James Morrison DOB: 12/22/1939 · ID: M-00789 |
4.1 | 2.29 | High | CKD+3 gaps | 18 days ago |
Showing 8 of 1,847 members