Skip to contentBuilt for CMS Rules
RAF/HCC, Star Ratings, and MARx reconciliation are handled as native workflows, not a report bolted on after the fact.
Medicare & Government Program OperationsHealthOS Plan: Risk Adjustment and Star Ratings,
HealthOS Plan: Risk Adjustment and Star Ratings,
Without the Quarterly Guesswork
Manage enrollment, prior authorization, risk adjustment, and contract performance for Medicare Advantage, Medicaid MCOs, and government programs, with AI PASS surfacing HCC gaps and Star Ratings risk while there's still time to act on them.
HITRUSTSOC 2 Type IICMSHL7 FHIR
Risk AdjustmentStar RatingsEnrollmentContracts
HCC Capture87.3%
Clean Claims94.2%
Open Gaps1,204
Member #55214Diabetes HCC suspected, unconfirmed
ReviewMeasure: Colorectal ScreeningCare gap closure in progress
OpenMARx Batch 0619Reconciled, no discrepancies
CompleteAIAI PASS flagged 42 likely HCC gaps this week and projected two Star measures trending below threshold.
Workspace Overview
What Is HealthOS Plan?
HealthOS Plan is the workspace for running Medicare Advantage, Medicaid MCO, and other government program operations: risk adjustment, Star Ratings and HEDIS, enrollment reconciliation, and prior authorization, all built to the rules those programs are actually measured on. It reads from the same claims and encounter data as HealthOS CAPS, so risk scores and quality measures update from what's actually happening, not a quarterly extract.
Same Record as CAPS
Risk adjustment and quality measures update from live claims and encounters, not a monthly file.
AI PASS Finds the Gaps
HCC and care gaps are surfaced while there's still time in the plan year to close them.
Platform Foundation
Government Program Accuracy, Built In From the Start.
Medicare Advantage and Medicaid MCO operations carry a compliance and accuracy burden that generic claims software wasn't built for. HealthOS Plan runs on the same secure, audited core as every HealthOS workspace, with the specific logic government programs are measured on wired in natively.
Immutable Security & Audit
Every risk adjustment and Star Ratings decision is logged, supporting HITRUST and SOC 2 Type II obligations by default.
Shared Data Core
Risk scores and quality measures are built from the same claims and encounter record used across HealthOS.
AI PASS Embedded Intelligence
HCC gap prediction and Star measure forecasting run continuously, not just at year-end reporting.
Inside Plan
Five Modules. Everything a Medicare or Medicaid Operation Runs On.
Pick a module to see what your team actually touches inside it.
Risk Adjustment
HCC gaps surface directly from claims and encounter data, so coding accuracy improves during the plan year instead of showing up as a surprise at RAF submission.
HCC Gap IDRAF TrackingSuspectingCMS Submission
HCC Capture87.3%
Open Gaps1,204
RAF Score Avg1.42
Member #55214Diabetes HCC suspected
ReviewMember #55098HCC confirmed & submitted
CompleteBatch RAF-0619Submission processed
ProcessedHow Work Moves
From Encounter to Star Rating.
How a single visit flows through risk adjustment and quality reporting.
A member visit generates a claim or encounter, captured on the same core CAPS uses.
AI PASS scans the encounter for documented conditions and flags likely HCC gaps for review.
Verified diagnoses roll into the member's risk score and CMS risk adjustment submission.
Enrollment and payment data reconcile against CMS's MARx system automatically.
The same encounter updates relevant HEDIS measures, feeding directly into Star Ratings.
The Intelligence Layer, Inside Plan
AI PASS Finds the Gap Before the Audit Does.
AI PASS scans claims and encounter data continuously for undocumented HCCs and Star measure risk, ranked by RAF and quality impact, so outreach teams work the list that actually moves the numbers.
Learn more about AI PASSLive decision intelligence● Active
Member #55214HCC Gap01 / Review
Analysis completeEncounter history shows documented diabetes management · No corresponding HCC coded this plan year · RAF impact estimated at 0.31.
RecommendationRoute to coding review with the supporting encounter documentation attached.
Confidence 94%
Why HealthOS Plan?
The Numbers Behind the Console.
What Medicare Advantage plans, Medicaid MCOs, and government programs typically see after moving onto Plan.
45%Faster Claim Cycle
28%Lower Admin Cost
40–70%Faster Claims
90%+Data Accuracy
Why Plan
What Changes When Risk Adjustment Runs on Plan.
The difference shows up before the numbers lock for the year, not after.
The Old Way
- HCC gaps surface in a year-end audit, when there's no time left to close them.
- Star Ratings performance is a report you read after the measurement year closes.
- MARx reconciliation means exporting files and manually matching them by hand.
- Risk adjustment runs on a separate system from claims, so the data never quite matches.
On Plan
- AI PASS surfaces likely HCC gaps from claims data while the plan year is still open.
- HEDIS measures update continuously, so quality teams know where Stars stand in real time.
- MARx transactions reconcile automatically against enrollment and payment records.
- Risk adjustment reads from the same claims and encounter core as HealthOS CAPS.
Security & Compliance
Built to the Standards Your Compliance Team Already Holds You To.
Role-based access control, encryption in transit and at rest, and a complete audit log across every module — the same baseline for every HealthOS workspace.
HITRUSTSOC 2 Type IINCQAHL7 FHIR R4CMS Interoperability RuleEDI 837 · 835 · 270 · 271
FAQ
Frequently Asked Questions.
Does HealthOS Plan support both Medicare Advantage and Medicaid MCOs?
Yes. Risk adjustment, Star Ratings and HEDIS tracking, and MARx reconciliation are configurable to the specific rules of Medicare Advantage, Medicaid managed care, and other government programs.
How does HCC gap identification work?
AI PASS analyzes claims and encounter data for patterns consistent with documented but uncoded chronic conditions, then surfaces those gaps for coding and clinical teams to verify.
Can HealthOS Plan run independently of HealthOS CAPS?
Yes, though the biggest gains come from sharing a claims and encounter record with CAPS, since risk adjustment and Star measures are built directly from that data.
Does Plan handle MARx reconciliation automatically?
Yes. Enrollment, disenrollment, and payment transactions reconcile against CMS's MARx system as part of the standard workflow.
Is HealthOS Plan secure and compliant?
Yes. Plan aligns with HIPAA, HITRUST, SOC 2 Type II, and CMS requirements, with a complete audit log across every module.
One Console, One Suite
Six Workspaces. One Record.
Every HealthOS workspace reads and writes to the same core. Start with Plan, connect the rest whenever your team is ready.
Get Started
See HealthOS Plan in the context of your operations.
Bring your line of business and your hardest workflow — we’ll show you how it runs on one intelligent platform.
