What MMR is

The MMR, or Monthly Membership Report, is the file the Centers for Medicare and Medicaid Services (CMS) sends each month to every Medicare Advantage (MA) contract. It lists every enrollee CMS attributes to the plan, the final Risk Adjustment Factor (RAF) score CMS used for that member, and the resulting per-member-per-month (PMPM) payment.

It is the plan's authoritative record of who CMS believes is enrolled and at what risk score. Because it is issued monthly, it also carries retroactive adjustments: members added or removed for prior months, premium corrections, and RAF restatements all land here. A single file can therefore hold more than one record per member when retroactive changes apply.

Why MMR matters

The MMR is where risk-adjustment work becomes money. A diagnosis captured at the point of care only matters if it raises the RAF score CMS recognizes, and the MMR is the report that confirms whether it did. Plans that do not reconcile the MMR against their own enrollment and submission records pay twice: once in lost revenue when RAF does not land, and again in audit exposure when payment rests on records they never verified.

Operationally, the MMR is the close-the-loop step for the whole risk-adjustment cycle. It answers three questions a finance and risk team need every month: who is CMS paying us for, what risk score is each member carrying, and does that match what we submitted and expected.

How MMR is used

Reconciling the MMR is a comparison exercise across three sources: the MMR itself, the plan's internal enrollment system, and the diagnoses the plan submitted to CMS. The reconciliation catches several distinct failure modes.

  • Enrollment mismatches. Members CMS shows as enrolled that the plan does not, or the reverse. These drive direct payment discrepancies and have to be resolved before they compound month over month.
  • Retroactive enrollment changes. Adds, deletes, and disenrollments applied to prior months appear as new records in the current file. Each one moves the PMPM total and has to be traced.
  • RAF that did not land. When the recognized RAF is lower than expected, the diagnoses behind it either were rejected, are still inside the CMS sweep window, or were never submitted. The MMR surfaces the gap; the MAO-004 and the MOR explain the cause.

The MMR pairs with the MOR (Model Output Report). The MMR tells you the final RAF score and the payment. The MOR tells you which Hierarchical Condition Categories (HCCs) drove that score. Read together, they let a team move from "the payment is wrong" to "this specific HCC is missing, and here is why."

Common mistakes teams make with MMR

  • Treating the MMR as a payment receipt instead of a reconciliation input. Filing it without comparing it to internal enrollment and submitted diagnoses lets discrepancies accrue silently.
  • Ignoring retroactive records. Teams that only read the current payment month miss prior-period adjustments that change the running total and the per-member RAF.
  • Reading the MMR without the MOR. The MMR shows the score but not the HCCs behind it, so a RAF gap cannot be diagnosed from the MMR alone.
  • Not tying MMR gaps back to MAO-004. A RAF that did not land often traces to a diagnosis rejected at MAO-004 that was never reworked or resubmitted.
  • Manual, quarterly reconciliation. By the time a quarterly spot-check finds a problem, several submission windows may have closed, making recovery harder or impossible.

How Pelica handles MMR

Pelica's Risk Adjustment Copilot reconciles the MMR against internal enrollment and submitted diagnoses on the same canonical record, then traces every RAF gap through the MAO-004 and MOR cycles so the cause is visible, not inferred. Across Pelica deployments, customers have lifted RAF by roughly +0.4 in two quarters with no new headcount.

Related terms

The MMR sits inside the CMS payment and submission cycle alongside several related terms: the MOR (Model Output Report), which explains which HCCs drove each RAF score; the RAF (Risk Adjustment Factor) score the MMR reports per member; and the MAO-004 report, which confirms which submitted diagnoses CMS accepted or rejected.

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