Skip to contentBuilt for CMS Compliance
RAF (risk adjustment factor), HCC (hierarchical condition category), Star Ratings, and MARx reconciliation are native workflows, not after-the-fact reports.
Medicare & Government Program OperationsRisk Adjustment Software and Star Ratings,
Risk Adjustment Software and Star Ratings,
Without the Quarterly Guesswork
HealthOS Plan is risk adjustment software for Medicare Advantage, Medicaid MCOs, and government programs. It tracks HEDIS and Star Ratings, reconciles MARx, and manages prior authorization on the same record as CAPS, and Aipass™ flags likely HCC gaps and Star measure risk while there is still time to act.
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
CompleteAIAipass™ flagged 42 likely HCC gaps this week and projected two Star measures trending below threshold.
Workspace Overview
What Is HealthOS Plan?
HealthOS Plan is a dedicated workspace within HealthOS for Medicare Advantage, Medicaid MCO, and other government program operations. It covers risk adjustment, Star Ratings and HEDIS, MARx reconciliation, and prior authorization, and reads from the same claims and encounter record as HealthOS CAPS, so risk scores and measures update continuously.
Same Record as the Unified CAPS Core
Risk adjustment and quality measures update from live claims and encounters in CAPS.
Predictive HCC & Care Gap Detection
Aipass™, the embedded intelligence engine in HealthOS, surfaces HCC and care gaps while there is still time in the plan year to close them.
Platform Foundation
Government Program Accuracy, Built In From the Start
HealthOS Plan runs on the same audited core as every HealthOS workspace, with CMS regulatory logic built in.
Audit Log on Every Decision
Every risk adjustment and Star Ratings decision is logged, supporting HITRUST and SOC 2 Type II obligations.
One Shared Record With CAPS
Scores and measures use the same claims and encounter records across HealthOS.
Aipass™ Embedded Intelligence
HCC gap prediction and Star measure forecasting run continuously, to prevent audit vulnerabilities.
Inside Plan
Five Modules for Medicare Risk Adjustment and Government Program Operations
HealthOS Plan is a risk adjustment platform with five modules, one for each part of government program operations. Pick one to see what your team works on inside it.
Risk Adjustment Software
Medicare risk adjustment software that surfaces HCC gaps directly from claims and encounter data, so coding accuracy improves during the plan year instead of appearing as a costly 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
ProcessedStar Ratings and HEDIS Software
Tracks Healthcare Effectiveness Data and Information Set (HEDIS) measures and open care gaps against Star Ratings. The same encounter that feeds risk adjustment updates the measures, so they do not wait for a quarterly extract.
HEDIS TrackingCare Gap ClosureCAHPS SupportMeasure Dashboards
Projected Stars4.2
Open Care Gaps3,140
Gaps Closed MTD612
Colorectal ScreeningOutreach in progress
OpenDiabetes Eye ExamGap closed
CompleteMedication AdherenceBelow threshold
ReviewEnrollment and MARx Reconciliation
Reconciles enrollment, disenrollment, and payment transactions against CMS's MARx system (the Medicare Advantage and Prescription Drug system) as part of the standard workflow. See HealthOS Enrollment for the enrollment workspace.
MARx ReconciliationEnrollmentPremium ReconciliationRetro Adjustments
Active Enrollees112,420
MARx Discrepancies3
Retro Adjustments18
MARx Batch 0619Reconciled, no discrepancies
CompleteDisenrollment DR-441Processed
ProcessedRetro Adjustment RA-092Pending review
ReviewContract Performance
Tracks contract performance, including per member per month (PMPM) trends, network adequacy checks, and contracts nearing expiry. See HealthOS Provider for network management.
PMPM TrackingNetwork AdequacyContract TermsGroup Comparison
Avg PMPM$842
Networks Monitored6
Contracts Expiring (90d)9
Contract CN-3312Renewal review needed
ReviewNetwork Adequacy CheckPassed, all regions
PassedPMPM Trend ReportPublished
ProcessedHow Work Moves
From Encounter to Star Rating
How a single visit flows through risk adjustment and quality reporting.
A member visit creates a claim or encounter on the same core CAPS uses.
Aipass™ scans for documented conditions and flags suspected Hierarchical Condition Category (HCC) gaps for review.
Verified diagnoses feed the member's risk adjustment factor (RAF) score for accurate CMS submission.
Enrollment and payment data reconcile against CMS's MARx system automatically.
The same encounter updates relevant HEDIS measures that feed Star Ratings.
The Intelligence Layer, Inside Plan
Aipass™ Finds the Gap Before the Audit Does
Aipass™ continuously scans claims and encounter data for undocumented HCCs and Star measure risk, ranked by RAF and quality impact. It works in four stages: Observe, Understand, Predict, Recommend.
See how Aipass™ finds HCC gaps.
For the wider context, read agentic AI in healthcare payer operations.
Live 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 Plan
What Changes When Risk Adjustment Runs on Plan
The difference shows up before the numbers lock for the year, not after. Four things change when risk adjustment runs on Plan.
| The Old Way | On Plan |
|---|---|
| HCC gaps used to surface in a year-end audit. | Now Aipass™ surfaces HCC gaps during the plan year. |
| Star performance used to be read after the year closed. | Now HEDIS measures update continuously for active claims. |
| MARx reconciliation used to be manual. | Now MARx transactions reconcile automatically. |
| Risk adjustment used to run on a separate system of claims. | Now it reads from the same CAPS core. |
Security & Compliance
Security and Compliance Standards for Risk Adjustment
Role-based access control, encryption in transit and at rest, and a complete audit log across every module. HealthOS Plan aligns with HITRUST, SOC 2 Type II, NCQA, HL7 FHIR R4, the CMS Interoperability Rule, and EDI 837, 835, 270 and 271.
HITRUSTSOC 2 Type IINCQAHL7 FHIR R4CMS Interoperability RuleEDI 837 · 835 · 270 · 271
FAQ
Frequently Asked Questions
Risk adjustment software helps a health plan find, validate, and submit the diagnosis codes that set each member's risk score, so CMS reimbursements reflect how sick the membership is. HealthOS Plan does this from live claims and encounter data during the plan year.
Yes. Risk adjustment, Star Ratings and HEDIS, and MARx reconciliation can be configured for Medicare Advantage, Medicaid managed care, and other government programs.
Aipass™ analyzes claims and encounter data for patterns that suggest documented but uncoded chronic conditions, then routes those gaps to coding and clinical teams for verification.
The same encounter that feeds risk adjustment also updates the relevant HEDIS measures that feed Star Ratings, so measures update continuously instead of from a quarterly extract.
Yes. Enrollment, disenrollment, and payment transactions reconcile against CMS's MARx system as part of the standard workflow.
Yes. Prior Authorization is one of the five HealthOS Plan modules, alongside Risk Adjustment, Star Ratings and HEDIS, Enrollment and MARx, and Contract Performance.
Yes, but the maximum operational and administrative gains come from sharing a claims and encounter record with CAPS.
HealthOS Plan aligns with HIPAA, HITRUST, SOC 2 Type II, and CMS requirements, with role-based access control, encryption in transit and at rest, and a full audit log.
One Console, One Suite
Six Workspaces. One Record.
CAPS, Plan, Provider, Member, Enrollment, and Sentinel all read and write to the same core. See the full HealthOS platform. Read why health plans are moving to a single operating system.
Get Started
