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raf score

raf_scr
clinical·Updated Jun 23, 2026

Definition

ISO-11179 Definition

Risk Adjustment Factor score — a numeric value calculated by CMS representing a Medicare Advantage member's predicted healthcare costs relative to the average Medicare beneficiary. A RAF score of 1.0 represents average predicted cost. Scores above 1.0 indicate higher than average predicted costs.

CMS multiplies the health plan base payment rate by the member RAF score to determine monthly capitation payments. RAF scores are calculated from two components: demographic factors including age, gender, and enrollment status, plus diagnosis components from HCC categories mapped from submitted ICD-10 codes. Higher RAF scores generate higher monthly payments to Medicare Advantage health plans to account for higher expected member utilization.

The CMS-HCC V28 model is the current standard for payment year 2026. Healthcare data engineers store RAF scores as DECIMAL(10,3) values in member risk score tables, used in risk adjustment pipelines processing CMS RAPS and EDPS submissions.

Standard Abbreviation

raf_scr

Category

clinical

Production DDL — FACT_CLINICAL_EVENT

FACT_CLINICAL_EVENT.sql
CREATE OR REPLACE TABLE FACT_CLINICAL_EVENT (
    clin_evt_key  INTEGER        NOT NULL  -- surrogate key,
    mbr_key       INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    prvdr_key     INTEGER        NOT NULL  -- FK to DIM_PROVIDER,
    diag_cd       VARCHAR(10)              -- ICD-10 diagnosis code,
    hcc_cd        VARCHAR(10)              -- HCC category code,
    proc_cd       VARCHAR(10)              -- procedure code,
    svc_dt        DATE                     -- service date,
    pos_cd        VARCHAR(2)               -- place of service,
    raf_scr       DECIMAL(10,3)            -- RAF score,
    admit_dt      DATE                     -- admission date,
    dsch_dt       DATE                     -- discharge date,
    drg_cd        VARCHAR(10)              -- DRG code,
    los_days      SMALLINT                 -- length of stay,
    readmt_ind    CHAR(1)                  -- readmission indicator,
    load_dt       TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical clinical table. Convert to BigQuery or Databricks →

Why This Term Matters

Clinical terms are the building blocks of risk adjustment, quality measurement, and value-based care analytics. A data engineer who understands this terminology can design schemas that correctly capture patient conditions, procedures, and encounters — enabling accurate HCC scoring, HEDIS measure attribution, and CMS reporting. Misclassifying clinical fields in a data warehouse cascades into incorrect RAF scores and failed regulatory submissions.

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