Payment Year

Birth Date (MM/DD/YYYY) or AgeGender

Demogragphic Risk Factors

InstitutionalMedicaid
Current Medicare Eligibility due to
Original Medicare Eligibility due to Disablility


HCC
Description
Override
Score
DX1    
DX2    
DX3    
DX4    
DX5    
DX6    
DX7    
DX8    
DX9    
DX10