What the MOR is

The MOR, or Model Output Report, is a member-level file CMS produces for each Medicare Advantage payment year. For every enrollee, it lists the Hierarchical Condition Categories (HCCs) and demographic factors that contributed to that member's Risk Adjustment Factor (RAF), the score that drives capitated payment.

Where a submitted diagnosis enters the system through claims and encounter data, the MOR sits at the end of the pipeline. It reports the diagnoses CMS recognized and scored, not the diagnoses a plan submitted. That distinction is the entire reason the report exists: submission and acceptance are not the same as payment.

Why the MOR matters

A risk adjustment program can do everything right at the point of care, capture the diagnosis, document it cleanly, submit it inside the sweep window, and still see no payment for it. The MOR is where that gap becomes visible. Without it, a plan is trusting that every accepted code became revenue, which is rarely true.

Operationally, the MOR closes the loop on capture. Financially, it is the difference between believing your RAF and knowing it. A plan that reconciles its captured-and-submitted records against the MOR can quantify exactly how much submitted acuity failed to score, and route those members back into the workflow before the window closes.

Per member
The MOR reports scored HCCs and demographic factors at the individual enrollee level
Scored, not sent
It lists only diagnoses CMS recognized for payment, so a missing HCC is a signal to investigate
Pairs with MMR
The MMR gives the final score per member; the MOR explains how that score was built

How the MOR is used

The MOR is how plans confirm that a captured diagnosis actually translated into a higher RAF, after CMS applied trumping and constrained-group logic. Two mechanics explain most of the gap between what a plan submits and what the MOR shows:

  • Trumping. Within an HCC hierarchy, a more severe condition trumps a less severe one in the same family. A diagnosis can be submitted and accepted, yet contribute nothing to RAF because a higher-weighted condition in its hierarchy already scored. Only the trumping condition appears on the MOR.
  • Constrained groups. V28 places certain related conditions into constrained groups that share a single coefficient. Submitting more conditions inside a constrained group does not raise RAF; only the group's coefficient counts. The MOR reflects the constrained outcome, not the raw list of submitted codes.

The practical workflow is reconciliation. A plan takes its own ledger of captured-and-submitted diagnoses, maps each expected HCC, and diffs it against the MOR. Every expected HCC that is absent from the MOR is either trumped, constrained, or never scored, and each case has a different remediation. The MOR pairs with the MMR (Monthly Membership Report), which carries the final score and payment per member: the MMR is the number, the MOR is the breakdown behind it.

Common mistakes teams make with the MOR

  • Treating acceptance as payment. A clean MAO-004 response confirms a diagnosis was accepted, not that it scored. Teams that stop at acceptance never see the trumped and constrained HCCs that dropped out by the time the MOR is produced.
  • Reconciling only at year end. By the time the final MOR lands, the submission window for many members has closed. Plans that reconcile against interim runs can still act; plans that wait cannot.
  • Reading the MOR without the submission ledger. The MOR lists what scored. It does not list what failed to score. The gap is only visible when the report is diffed against the plan's own record of submitted diagnoses.
  • Ignoring the MMR-to-MOR link. A RAF on the MMR that does not reconcile to the HCCs on the MOR is an unexplained discrepancy that should be investigated, not assumed away.
  • Not retaining evidence for scored HCCs. Every HCC on the MOR is a condition CMS paid on, which means it is a condition a RADV audit can challenge. Each should have a retrievable evidence packet behind it.

How Pelica handles the MOR

Pelica's Risk Adjustment Copilot tracks every submitted diagnosis through the full lifecycle and reconciles the plan's captured-and-submitted ledger against the MOR automatically, flagging HCCs that were trumped, constrained, or dropped before they cost a payment year. Across Pelica deployments, customers have lifted RAF by roughly +0.4 in two quarters with no new headcount, in part by closing the gap the MOR exposes.

Related terms

The MOR sits inside a small family of risk adjustment reports and concepts. Its closest pair is the MMR (Monthly Membership Report), which carries the final risk score per member. The factors it reports are built from HCCs (Hierarchical Condition Categories), and the score they produce is the RAF (Risk Adjustment Factor).

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