Risk Adjustment / HCC
Hierarchical Condition Categories — RAF Score Management & Opportunity Identification
Average RAF Score
1.847
↑ 0.12 YoY
Risk Adjustment Factor
Potential RAF
2.214
+0.367 opportunity
Revenue Opportunity
$4.2M
↑ Recapture potential
Across 1,284 members
HCC Recapture Rate
73.4%
↑ 5.2% YoY
Prior year to current
Active HCC Conditions
| HCC Code | Condition | Members | RAF Weight | Revenue Impact | Recapture Status | Last Encounter |
|---|---|---|---|---|---|---|
| HCC 19 | Diabetes without Complication | 1,247 | 0.105 | $892K | Captured | Jan 2026 |
| HCC 18 | Diabetes with Chronic Complication | 489 | 0.302 | $1.1M | In Progress | Nov 2025 |
| HCC 108 | Vascular Disease with Complication | 312 | 0.461 | $780K | Captured | Dec 2025 |
| HCC 85 | Congestive Heart Failure | 287 | 0.323 | $673K | In Progress | Oct 2025 |
| HCC 111 | Chronic Obstructive Pulmonary Disease | 341 | 0.335 | $644K | Not Recaptured | Sep 2025 |
| HCC 22 | Morbid Obesity | 543 | 0.273 | $605K | Captured | Jan 2026 |
| HCC 40 | Rheumatoid Arthritis | 198 | 0.421 | $456K | In Progress | Nov 2025 |
| HCC 96 | Specified Heart Arrhythmias | 267 | 0.299 | $387K | Captured | Dec 2025 |
Suspected Conditions (Unconfirmed)
AI-identified conditions needing clinical confirmation
Chronic Kidney Disease Stage 3
HCC 138 — 187 members suspected
$428K
opportunity
Major Depressive Disorder
HCC 59 — 143 members suspected
$312K
opportunity
Peripheral Arterial Disease
HCC 108 — 98 members suspected
$218K
opportunity
Atrial Fibrillation
HCC 96 — 76 members suspected
$176K
opportunity
Submission Calendar
CMS Risk Adjustment Data Submission (RADS) deadlines
Jan 14, 2026
Initial Submission — Q4 2025
Submitted
Mar 31, 2026 — 87 days
Mid-Year Sweep Submission
Upcoming
Jul 31, 2026
Final Data Submission — CY 2025
Planned
Sep 30, 2026
Reconciliation / Correction Window
Future