Empire BlueCross BlueShield’s (“Empire”) Prospective Risk Adjustment program works to improve risk adjustment accuracy and focus on performing appropriate interventions for patients with undocumented Hierarchical Condition Categories (HCC), in order to help you close your patients’ gaps in care.  This program involves:
  • Member outreach encouraging primary care physicians (PCP) visits
  • Provider outreach sharing previously coded and suspected conditions, and encouraging member visits
  • PCP alternatives to complete Health Assessments


Due to our partnership, we expect and encourage you to participate in the Risk Adjustment initiatives.


Inovalon Requests

Consistent with 2019, we have again engaged a vendor, Inovalon – an independent company that provides secure, clinical documentation services – to help us comply with the provisions of the Affordable Care Act that require us to assess members’ relative health risk levels.  In the coming weeks and months, Inovalon will begin sending letters to providers as part of a new risk adjustment cycle, asking for your help with completing Health Assessments for some of our members.


If you worked with Inovalon in 2019, many thanks for your help. This year will bring a new round of assessments because chronic conditions must be assessed and coded each and every year. As always, if you have questions about the requests you receive, you can reach Inovalon directly at 1-877-448-8125.


Prospective Program ask of Providers:

Empire network providers – usually PCPs – receive letters from Inovalon, requesting that they:

  1. Schedule a comprehensive visit with patients identified by Inovalon to confirm or deny if previously coded or suspected diagnoses exists, and;
  2. Submit a Health Assessment documenting the previously coded or suspected diagnoses (also called SOAP Notes - Subjective, Objective, Assessment and Plan).


Incentives for properly submitted Health Assessments (these incentives are in addition to the office visit reimbursement):

  • $150 for each Health Assessment properly submitted electronically
  • $50 for each Health Assessment properly submitted via fax


Submit electronically via Inovalon’s ePASS tool:

  • Inovalon ePASS® Training Webinars
    • Every Wednesday - 3:00 - 4:00 PM EST
  • Join an ePASS webinar:


Alternative Engagement

ePASS® is our preferred method for submission. However to improve engagement and collaborate with our providers who are not submitting via ePASS®, we have identified other tools which may be helpful. If in 2019 your practice utilized some of these alternative options for prospective member outreach, we thank you for continuing on these alternative forms of program participation into 2020. 


For those providers not familiar with our alternative options, they are listed below. Any questions your office has on these can be directed to either your local Provider Representative, or the Empire CRA Network Education Representative listed below.


  • EPHC Providers using PCMS - Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool to schedule members for comprehensive visits. PCMS does have a link to take you directly to the Inovalon ePASS® tool where completed Health Assessments will result in a $150 incentive payment per submitted Health Assessment.
  • List of Members to be scheduled - Empire CRA provides member/patient reports for providers to schedule members for comprehensive visits. Providers use normal gap closure through claims submission.  No Health Assessment needed. Not eligible for additional incentive.
  • EPIC Patient Assessment Form (PAF) - Providers with EPIC as their electronic medical record (EMR) system can fax the EPIC PAF to Inovalon at 1-866-682-6680 with a coversheet indicating "see attached Empire Progress Note,” which is eligible for a $50 incentive payment.
  • Providers Existing Patient Assessment Form (PAF) - Utilize providers existing EMR system and applicable PAF. Must be submitted to Inovalon at 1-866-682-6680 with coversheet indicating, "see attached Empire Progress Note,“ which is eligible for a $50 incentive payment.


Please contact our Commercial Risk Adjustment Network Education Representative, Alicia.Estrada@anthem.com if you have any questions: 


Thank you for your continued efforts with our CRA Program.




Featured In:
May 2020 Empire Provider News