RAPS vs EDPS: A Simple Guide to CMS Risk Adjustment Submissions in Healthcare

The Centers for Medicare & Medicaid Services (CMS) is rapidly moving from the RAPS (Risk Adjustment Processing System) to the EDPS (Encounter Data Processing System) as the primary method for risk adjustment in Medicare Advantage. This shift changes how plans are evaluated, reimbursed, and monitored for compliance.

Unlike RAPS, which uses summarized diagnosis data, EDPS requires complete encounter details, supporting CMS’s goals of transparency, payment accuracy, and accountability. But as EDPS becomes central to payment calculations, the risks tied to data errors, delays, and compliance gaps increase, leading to potential audit challenges and payment losses.

For Medicare Advantage organizations, the move to EDPS is not merely a technical adjustment. It requires reworking data submission processes, internal systems, and vendor capabilities. As CMS phases out RAPS and fully embraces EDPS, understanding the key differences between the two systems has become essential for maintaining compliance and financial stability for your business.

The question now is not whether health plans need to adapt, but how quickly can they do so. What exactly sets RAPS apart from EDPS and why is it critical for Medicare Advantage plans to close this gap. To fully understand the impact of the shift from RAPS to EDPS, it’s essential to grasp how risk adjustment works in the Medicare Advantage program.

Understanding Risk Adjustment in Medicare Advantage

At its core, risk adjustment is a payment model used by CMS to ensure that MA plans are reimbursed based on the health status and expected care needs of their enrollees. Since members with complex health needs are expected to incur higher costs, MA plans serving these populations receive higher payments. This ensures that plans are adequately compensated for the risk profiles of their members.

Key Stakeholders:

• CMS oversees and enforces risk adjustment rules and methodologies used.
• Medicare Advantage Organizations (MAOs) submit diagnostic and encounter data to CMS to support enrollee risk profiles.
• Providers generate the original clinical data during patient visits, which feeds into the plan’s risk adjustment reporting.
• Third-party vendors and platforms often support MA plans in cleaning, formatting, validating, and submitting encounter data to CMS.

While CMS previously used both RAPS and EDPS to gather diagnostic information, the shift to EDPS as the primary system is in motion. To understand the implications of this change, it’s important to first look at how RAPS works, and why CMS is transitioning away from it. 

Also, read Explore the Power of Mirra's EDPS System for Data Collection

What is RAPS?

In the early 2000s, RAPS was designed to extract and submit diagnosis codes for risk scoring. MA plans would gather relevant diagnoses from provider visits, summarize them, and submit the data in a standardized format for CMS to use in its payment calculations.

How does it Work:

MAOs extract diagnoses that map to Hierarchical Condition Categories (HCCs)*. These diagnoses are submitted via the RAPS format, which contains minimal data beyond the diagnosis itself. CMS calculates risk scores based on accepted HCCs and adjusts payments accordingly.

Pros:

• Established system with a long history of use.
• Simplified data submission process focusing on diagnosis codes and less technical overhead.

Cons:

• Lacks context around the encounter such as, no details on procedures, providers, or timing.
• Higher potential for over-reporting or incomplete validation.

CMS considers it less transparent and difficult to audit, prompting the need for a transition. As a result, EDPS was introduced to provide a more complete and verifiable record of patient encounters for risk adjustment.

What is EDPS?

The EDPS (Encounter Data Processing System) is the advanced data submission platform required by the CMS for Medicare Advantage plans. Unlike RAPS, which only collected summary diagnosis codes, EDPS requires health plans to submit detailed records for every medical service provided to their Medicare Advantage members.

How does it Work:

MAOs submit detailed encounter data similar to traditional FFS Medicare claims, including all services provided during a patient visit, to CMS. These files include diagnosis codes, procedure codes, provider NPIs, service dates, place of service, and more. CMS uses this data to validate diagnoses and calculate risk scores based on real, auditable encounter records.

Pros:

• Enhances the accuracy and transparency of risk adjustment calculations.
• Stronger alignment with fee-for-service standards.
• Supports better oversight, fraud detection, and clinical trend analysis.

Cons:

• Requires more complex data extraction and formatting guidelines.
• Higher likelihood of rejections due to strict data integrity rules.
• Requires additional tools and workflows for error correction and reconciliation.

Why is EDPS Taking Over?

CMS has emphasized this transition for years, with a growing focus on the role of encounter data in risk adjustment. In 2025, EDPS healthcare is the key to how Medicare Advantage payments are determined.

A Timeline of the Transition:

• 2012: CMS introduced the Encounter Data System and began accepting EDPS submissions from MA plans.
• 2016: CMS started using a blend of RAPS and EDPS to calculate risk scores, assigning minimal weight to EDPS.
• 2019–2022: The weight of EDPS in risk score calculation gradually increased year-over-year.
• 2023: CMS announced a 100% transition to EDPS for new enrollees in certain models.
• 2025: EDPS becomes the primary data source for risk adjustment calculations, with RAPS being fully phased out for most purposes.

Current Status:

With EDPS healthcare now serving as the primary source, CMS uses it to calculate risk scores and adjust payments, health plans must meet much higher standards for data quality and accuracy. Each encounter submission has to pass strict format, logic, and content checks to be accepted by CMS. Plans also need robust processes to track rejected encounters, review CMS response reports (e.g., MAO-002, MAO-004), and capture all valid diagnoses. Without these capabilities, health plans face the risk of underpayments, delayed reimbursements, and more audits.

The stakes are high and those who adapt effectively will be better positioned to maintain compliance, improve financial performance, and navigate the increasingly data-driven Medicare landscape.

Implications:

• MAOs must ensure their systems and processes are capable of handling the complexities of EDPS submissions.
• Failure to adapt may result in inaccurate risk scores and financial penalties.

As the shift to EDPS healthcare progresses, health plans face new challenges in managing data accuracy and submission complexities which leads us to the next section.

Common Challenges in EDPS & RAPS Submissions

RAPS:

• Limited data scope can lead to underreported diagnoses.
• Potential discrepancies between submitted codes and actual patient encounters.

EDPS:

• Complex submission requirements increase the risk of errors.
• Higher rejection rates due to stringent data validation rules.
• Necessitates robust data management and quality assurance processes.

Let’s take a closer look at how Mirra helps health plans tackle these challenges. Mirra's EDPS & RAPS Solution reduces rejections, streamline workflows, and maintains compliance with CMS, ultimately helping health plans to boost their operational efficiency.

How Mirra Helps Simplify EDPS & RAPS Submissions?

Health plans managing encounter data for CMS must deal with increasing submission complexity, evolving compliance rules, and growing pressure to minimize rejected encounters. Mirra’s EDPS & RAPS Solution simplifies data management, ensuring timely, accurate, and CMS-compliant submissions.

With a strong focus on automation, reconciliation, and actionable insights, Mirra Health Care empowers Medicare Advantage Organizations to maintain regulatory compliance while improving financial performance. 

Also, read 5 Reasons Mirra’s EDPS is Ideal for Healthcare Data Processing

Key Capabilities That Set Mirra Apart

• Automated data formatting and validation: 

Mirra converts raw plan data into CMS-compliant 837 (v5010) format and performs HIPAA and CMS-specific edits before submission.

• Error classification and prioritization by HCC relevance: 

The platform automatically classifies rejected encounters by type, such as diagnosis, provider, or procedure errors, and prioritizes those linked to Hierarchical Condition Categories (HCCs).

• Integrated data reconciliation across systems: 

Mirra identifies mismatches and gaps between EDPS, RAPS, and CMS response files (MAO-002, MAO-004), while also eliminating duplicate records.

• CMS response automation: 

The system automatically processes response files including TA1, 999, 277CA, MAO002, MAO004, and MAO00, applying corrections and flagging unresolved issues.

• Detailed dashboards and analytics: 

Mirra offers real-time dashboards that track file status, encounter distribution, and error pattern, along with customizable reporting tools.

• User-friendly interface for internal teams: 

The platform features an intuitive web portal where users can upload files, manage plan IDs, and generate reports without requiring specialized technical skills.

Business Benefits of Mirra’s Solution for Medicare Advantage Plans

By adopting Mirra's EDPS and RAPS Solution, health plans can:

• Reduce the number of rejected encounters and minimize revenue loss.
• Accelerate correction and resubmission workflows to avoid payment delays.
• Enhance internal team productivity through automation and user-friendly tools.
• Maintain better control and visibility over risk adjustment submissions.
• Prepare for CMS audits and future reporting transitions.

Mirra not only simplifies EDPS and RAPS but also gives Medicare Advantage plans the agility, accuracy, and transparency needed to succeed in a rapidly evolving regulatory landscape.

Roadmap to Elevate Health Plan Performance 

As EDPS becomes the cornerstone of Medicare Advantage risk adjustment in 2025, health plans must move from reactive compliance to proactive preparedness. A clear, structured action plan can help reduce rejection rates, minimize disruption, and protect revenue.

Start by evaluating your current processes and identifying where operational gaps exist:

• Audit your existing EDPS and RAPS workflows to determine where data loss or delays occur. This includes assessing file formatting, submission success rates, and the timeliness of encounter capture.
• Review CMS response reports (MAO-002, MAO-004) regularly to track rejections, error codes, and missed diagnoses. Developing a feedback loop between CMS reports and internal teams can help close these gaps efficiently.

Equally important is the readiness of your internal teams and technology used:

• Invest in training for encounter data teams, coders, and compliance officers to ensure a solid understanding of EDPS formatting, logic validation, and reconciliation requirements.
• Implement automation tools that streamline file creation, validation, and corrections. Reducing manual intervention can significantly lower human error and improve turnaround times.
• Establish provider engagement protocols to improve the completeness and accuracy of documentation, especially for diagnosis and procedure coding.

To stay ahead of regulatory changes:

• Track CMS updates including technical specifications, policy guidance, and submission deadlines. Staying aligned with CMS priorities helps avoid last-minute mistakes and missed targets.
• Partner with experienced vendors who can provide purpose-built platforms, EDPS/RAPS expertise, and reconciliation support. Vendors like Mirra Health Care not only improve data quality but also reduce operational tasks, enabling faster compliance and higher revenue accuracy.

By following a clear action plan rooted in automation, accountability, and auditability, health plans can turn the EDPS transition from a compliance challenge into a competitive advantage that sets them apart.

Conclusion

With 2025 fast approaching, health plans must act swiftly to optimize their encounter data submission processes and ensure compliance with CMS requirements. Failure to adapt could lead to rejected claims, delayed payments, and missed revenue. On the other hand, proactive investment in data governance, training, and automation will position health plans for future success, ensuring both financial stability and regulatory compliance. 

As a trusted partner for Medicare Advantage plans, Mirra Health Care provides comprehensive solutions that simplify the EDPS and RAPS submission processes. Our Medicare Advantage in a Box offering ensures seamless data submission, automatic reconciliation, and continuous compliance with the latest CMS standards. By working with Mirra, health plans can improve operational efficiency, reduce the risk of rejections, and ensure accurate risk adjustment payments, all while staying ahead of regulatory changes. 

Avoid CMS penalties and streamline submissions with Mirra. Book a no obligation demo today.

Reference

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/hierarchical-condition-category.html