See what matters
Bring source data, processing outcomes, and risk insights into a shared operational view.
Meet Confianza · Healthcare technologyComplex healthcare.
Complex healthcare.
Clearer possibilities.
We connect data, technology, and operational insight to help health plans move forward with confidence.
Confianza builds solutions for Medicare Advantage and ACA Marketplace programs—bringing submission, reconciliation, risk intelligence, and audit support into a connected experience.
Purpose-built forMedicare Advantage/ACA Marketplace
C+Connected insight.Confident action.
Risk intelligenceSee the full picture
Connected operationsFrom data to resolution
Clarity at every step
Who we areTechnology with a clear purpose.
Technology with a clear purpose.
Make healthcare operations easier to understand.
We bring a practical approach to the complexity health plans face every day. Our solutions connect fragmented information, make results traceable, and help teams turn the next question into the next action.
Follow the full story
Trace results back to the records and evidence behind them, across each stage of processing.
Move work forward
Give teams clear priorities, ownership, and visibility into what happens next.
Our solutionsTwo programs.
Two programs.
A connected set of solutions.
Explore the capabilities that fit your team—from risk intelligence to submission operations and audit readiness.
Risk intelligence01
MA Risk Compass
Understand HCCs, RAF, payment results, and risk opportunities with reconciliation and prioritized work queues.
Medicare Advantage↗
Marketplace insight02
ACA Risk Compass
Connect payer and EDGE data with HHS risk scores, gap analysis, and transfer-payment visibility.
ACA Marketplace↗
Submission operations03
MA encounter submission
Create and validate encounter files, track CMS responses, and manage corrections through resolution.
Medicare Advantage↗
EDGE operations04
ACA EDGE submission
Prepare enrollment, medical, pharmacy, and supplemental files, with validation and response tracking.
ACA Marketplace↗
Audit readiness05
MA RADV support
Organize supporting evidence, track review work, and maintain traceability for audit preparation.
Medicare Advantage↗
What would a clearer view mean for your team?
Let’s explore your program, your workflows, and where you need better visibility.
Talk to ConfianzaInside the platformFrom the first record
From the first record
to the next informed decision.
Explore how Risk Compass connects submission, reconciliation, and operational follow-through.
Medicare Advantage
- Submit
- 837P, 837I, 837D, DME and chart-review submissions
- Reconcile
- 999, 277CA, MAO, MOR and MMR reconciliation
ACA Marketplace
- Submit
- Enrollment, medical, pharmacy and supplemental EDGE XML
- Reconcile
- EDGE validation, disposition, summary and risk reports
Risk & financial intelligence
- Measure
- HCC, RAF, HHS risk score and transfer-payment visibility
- Act
- Prioritized work queues and financial projections
Explore platform capabilities Submission · Reconciliation · Analytics · Workflows ＋
The problem
Risk-adjustment value leaks between systems
Submission data, response files, risk scores, payment reports, coding results and operational work usually sit in separate systems. When they do, nobody can say with confidence what was submitted, what was accepted, what counted toward risk, or where revenue was lost.
- SourceDiagnosis never submitted
- 999 / 277CAFile or claim rejected
- MAO-002Encounter or line rejected
- MAO-004Accepted, but not risk eligible
- MOR / MMRHCC missing from the payment result
One platform from submission through financial outcome
Risk Compass brings submission operations and risk-adjustment intelligence together in one place. The platform:
- Creates and validates Medicare Advantage and ACA submission files
- Reconciles submitted records against CMS and EDGE outcomes
- Connects accepted diagnoses to HCCs and risk scores
- Identifies rejected, missing, deleted and disallowed diagnoses
- Quantifies RAF, payment and transfer impact
- Converts exceptions into prioritized work
- Tracks each issue through correction, resubmission and closure
Every diagnosis stays traceable from the payer's source data through submission, acceptance, risk-score contribution and financial outcome.
Core value
Submission operations that know what each record is worth
submit
Submit clean, compliant files
Create program-specific submission files using configurable validation, mapping and business rules.
reconcile
Reconcile every response
Compare payer source data, submitted records, CMS or EDGE responses, accepted diagnoses and downstream risk results.
recover
Find lost risk-adjustment value
Find diagnoses that were never submitted, rejected, deleted, excluded from risk scoring, or accepted without the expected financial result.
prioritize
Work the highest-value fixes first
Rank exceptions by HCC impact, risk-score contribution, financial exposure, submission deadline and likelihood of resolution.
trace
Trace every diagnosis end to end
Follow each member, claim, encounter, diagnosis, response, correction and action through a single audit trail.
Program capabilities
Built for the rules of each program
Medicare Advantage encounter submission and reconciliation
Manage the complete encounter lifecycle, from claims intake through CMS acceptance, risk-score reconciliation and payment analysis.
837P · 837I · 837D
Encounter generation
- 837P, 837I, 837D generation
- Original, replacement and void submissions
- Linked and unlinked chart-review encounters
- Add and delete diagnosis submissions
- Supplemental and provider-submitted encounter support
- Configurable plan, submitter, provider and contract rules
X12 · NPI · ELIGIBILITY
Pre-submission validation
- X12 structural and situational validation
- Member eligibility and enrollment validation
- Provider and NPI validation
- Diagnosis and procedure validation
- Risk-eligibility checks
- Duplicate and sequencing detection
- Plan-defined business edits
- Correction and resubmission controls
999 · 277CA · MAO-001/002/004
CMS response reconciliation
- 999 acknowledgment processing
- 277CA claim and service-line reconciliation
- MAO-001 and MAO-002 reconciliation
- MAO-004 diagnosis and risk-eligibility reconciliation
- Accepted, rejected, deleted and disallowed diagnosis tracking
- Original-to-adjustment encounter linkage
- Unmatched and orphan-response identification
CMS-HCC · RAF · MOR · MMR
HCC, RAF and payment intelligence
- CMS-HCC model support with hierarchy and interaction processing
- Claim vs. submitted vs. accepted HCC comparison
- Preliminary vs. final allowed HCC tracking
- Actual, current and projected RAF
- Recapture-gap and rejected-HCC analysis
- MOR reconciliation against accepted diagnoses
- MMR payment, leakage and recapture analysis
- Contract and benefit-package analysis
ACA EDGE submission and reconciliation
Manage ACA enrollment, medical, pharmacy and supplemental submissions while connecting EDGE processing results to HHS-HCC risk scores and transfer-payment analytics.
EDGE XML
EDGE file generation
- Enrollment, medical claims and pharmacy claims XML
- Supplemental diagnosis submission XML
- Benefit-year and environment-specific processing
- Issuer, state, market, plan and enrollee validation
- XML schema and business-rule validation
- Submission control totals and batch tracking
ACK · DISPOSITION · SUMMARY
EDGE response processing
- File and header acknowledgment processing
- System-error processing
- Enrollment, medical, pharmacy and supplemental dispositions
- Accepted and rejected record reconciliation
- Error-code and rejection-reason analytics
- Duplicate, orphan and unmatched-record detection
- Submission-summary reconciliation
- Correction and resubmission monitoring
RACSD · RACSS · RARSD · RARSS
ACA risk-adjustment reconciliation
- RACSD and RACSS analysis
- RARSD and RARSS reconciliation
- Enrollee-level calculation-detail analysis
- Accepted diagnosis and HHS-HCC reconciliation
- Demographic, HCC, RXC and interaction-factor visibility
- Enrollment-duration and model-factor analysis
- EDGE-calculated vs. plan-calculated risk scores
- Preliminary vs. final risk-result trending
PLRS · HCRP · TRANSFER
Risk-transfer and financial intelligence
- Plan liability risk-score visibility
- State, market, metal, rating-area and plan analysis
- Geographic cost factor and induced-demand factor visibility
- Statewide average premium and billable-member-month analysis
- High-cost risk-pool charge and payment visibility
- Preliminary and final transfer-payment analysis
- Transfer projections and scenario modeling
Closed-loop reconciliation
Know what happened to every submitted record
Risk Compass reconciles data across the full processing chain for both programs.
Medicare Advantage
- Claim or Chart Review
- 837 Submission
- 999 / 277CA
- MAO-002
- MAO-004
- MOR / MMR
- RAF & Payment
ACA Marketplace
- Enrollment, Medical, Pharmacy, Supplemental
- EDGE XML
- Disposition & Summary
- RACSD / RARSD / ECD
- Risk Score
- Transfer Outcome
At every stage, the platform identifies:
EXPECTED · NOT SUBMITTEDRecords expected but not submitted
SUBMITTED · NO ACKRecords submitted but not acknowledged
REJECTEDRecords rejected by CMS or EDGE
ACCEPTED · NOT RISK ELIGIBLEDiagnoses accepted but not risk eligible
MISSING DOWNSTREAMAccepted diagnoses missing from downstream risk reports
SCORE VARIANCERisk factors that did not produce the expected score
FINANCIAL VARIANCEFinancial results that differ from internal projections
ACTION REQUIREDCorrections requiring operational action
The result is a single, governed reconciliation trail from payer source data to financial outcome.
Financial intelligence
Connect submission performance to financial exposure
Technical acceptance alone does not confirm that a diagnosis affected risk or payment.
Risk Compass measures the financial meaning of submission and reconciliation outcomes. Leaders can move from an enterprise-level result to the exact record behind it.
Drill path
- Enterprise result
- Member
- HCC
- Claim
- Encounter
- Response
- Source record
MEDICARE ADVANTAGE
- Actual, current and projected RAF
- Member and HCC-level RAF contribution
- Annualized payment impact
- Rejected-diagnosis exposure
- Recapture opportunity
- Payment leakage
- CMS payment reconciliation
ACA MARKETPLACE
- Member and plan-level risk scores
- HHS-HCC and RXC contribution
- Plan liability risk-score analysis
- Transfer-payment projection
- High-cost risk-pool impact
- Market and metal-level performance
- Preliminary-to-final transfer movement
Work management
Turn every exception into accountable work
Risk Compass converts submission errors, reconciliation differences and risk opportunities into structured operational workflows. Each work item shows what needs to happen next, who owns it, its financial importance, and whether the correction ultimately reached CMS or EDGE.
Work queues can support
QSubmission rejectsQUnmatched response recordsQEnrollment discrepanciesQMissing medical or pharmacy recordsQHCC recapture gapsQRejected or disallowed diagnosesQInternal editsQPayment leakageQACA risk-score variancesQProvider documentation follow-upQCoding and clinical validationQAudit and compliance initiatives
Workflow capabilities
- Configurable priority scoring
- User and team assignment
- Due dates and service-level targets
- Member and HCC-level work items
- Evidence and documentation tracking
- Pend and escalation controls
- Notes and disposition reasons
- Correction and resubmission tracking
- Duplicate-work prevention
- Complete action history
- Productivity and backlog reporting
- Closure based on downstream acceptance
Operational dashboards
One operational view for every stakeholder
Encounter and EDGE operations
Monitor file generation, validation, submissions, acknowledgments, rejects, corrections and submission deadlines.
Risk adjustment leadership
Track captured, submitted, accepted, risk-eligible, allowed and missing HCCs across the population.
Coding and clinical review
Receive prioritized member-HCC opportunities with supporting evidence, recommended action and submission status.
Finance and actuarial teams
Understand RAF, CMS payment, ACA risk score, risk-transfer movement and financial exposure.
Compliance and audit teams
Trace each diagnosis from source evidence through submission, acceptance, risk-score contribution and financial outcome.
Executive leadership
View population performance, submission health, risk-score position, financial opportunity, backlog and unresolved exposure from one command center.
Complex cases
Complex submission scenarios, managed within the same workflow
Replacements, voids and deletes
Maintain the relationship between the original record and every subsequent correction.
Orphan responses
Hold and investigate response records that cannot be matched to the original submission.
Retroactive enrollment changes
Reprocess affected claims, encounters and risk results when member eligibility changes.
New-to-plan members
Separate risk contributed by prior issuers or plans from risk documented and submitted by the current plan.
Duplicate and overlapping submissions
Identify duplicates across source systems, vendors, submission cycles and supplemental feeds.
Plan and member identifier changes
Preserve historical crosswalks so records stay traceable across plan, issuer, contract and enrollee changes.
Late-arriving data
Process late claims and corrections while protecting the original submission and reconciliation history.
Preliminary and final risk results
Maintain separate result versions and explain changes between reporting cycles.
Differentiators
Why Risk Compass
Most tools stop at file acceptance or start at the risk score. Risk Compass covers the whole path in between, and explains every number it reports.
One platform for MA and ACA
A common operational experience that preserves each program's distinct rules, file formats, models and financial methodologies.
Submission and risk intelligence together
Connect technical processing outcomes directly to HCC, RAF, HHS risk-score, payment and transfer impact.
Closed-loop reconciliation
Confirm what CMS or EDGE accepted and whether it appeared in the expected downstream risk and financial result.
Financially prioritized operations
Rank corrections and opportunities by their potential risk and financial effect.
Configurable rules
Authorized analysts maintain validation, prioritization and workflow rules with controlled versioning and approval.
Explainable results
See the source data, applicable model, rule, coefficient, evidence and processing history behind every reported value.
Complete audit trail
Retain the original source, submission event, response, correction, user action, model version and final disposition.
Modular adoption
Start with submission and reconciliation, then add risk analytics, financial projections, coder workflows and audit capabilities without replacing the core platform.
Business impact
Outcomes your team can measure
Cleaner submissions
Improve completeness and accuracy before records reach CMS or EDGE.
Faster reconciliation
Reduce manual comparison of claims, submission files, response reports, risk results and financial outputs.
Earlier intervention
Identify missing and rejected risk-adjustment data while corrective action is still possible.
Better prioritization
Direct teams toward issues with the greatest risk, financial and deadline impact.
Stronger financial visibility
Connect operational submission performance to RAF, CMS payment, ACA risk score and transfer results.
Better audit readiness
Maintain traceability from source data and supporting evidence through submission and downstream acceptance.
FAQ
Frequently asked questions
Does Risk Compass support Medicare Advantage and ACA?
Yes. The platform provides a common submission, reconciliation, analytics and workflow experience while applying program-specific rules and data models for Medicare Advantage and ACA Marketplace risk adjustment.
What Medicare Advantage transactions are supported?
The platform can support 837 professional, institutional, dental, DME and chart-review encounter processing, including original, replacement, void, add and delete scenarios. It reconciles downstream 999, 277CA, MAO, MOR and MMR results.
What ACA data can the platform process?
Risk Compass can process enrollment, medical, pharmacy and supplemental data along with the related EDGE acknowledgments, dispositions, summaries, claim-selection reports, risk-score reports and enrollee calculation details.
How does the platform prove that a diagnosis affected risk adjustment?
Risk Compass follows the diagnosis from the source claim or clinical evidence through submission and acceptance, then verifies whether the corresponding HCC or risk factor appears in downstream CMS or EDGE risk results.
Does technical acceptance mean the diagnosis affected payment?
No. A record may pass structural processing but still fail risk eligibility, be excluded by hierarchy or model logic, or fail to appear in the applicable downstream risk result. Risk Compass reconciles across all of these stages.
Can exceptions create work automatically?
Yes. Configurable rules can generate member, claim, encounter, diagnosis or file-level work items and route them to the correct team with priority, evidence, due date, recommended action and financial context.
Can Risk Compass integrate with existing submission or coding vendors?
Yes. The platform can operate as the submission system of record or receive data from existing submission, claims, coding, clinical-review and actuarial systems for reconciliation and analytics.
Does the platform support audit readiness?
Yes. It preserves traceability from source data and clinical evidence through coding, submission, response, risk-score contribution, correction and final disposition.
See it in action
Let’s bring clarity to your next challenge.
Tell us about your program and the workflows you want to improve. Explore how Confianza can support your risk intelligence, submission operations, reconciliation, or audit readiness needs.
Your program. Your priorities. A clearer path forward.