Publication Date: 

May 20, 2021 Update: This communication has been updated to include a link to the Medical Records Risk Adjustment FAQs. The original communication was posted on March 16, 2021.

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).


Summary: In 2021, Blue Cross NC will work with Optum, who works with Ciox Health, to request medical records with dates of service for the target year 2020 through present day for Medicare risk adjustment (MRA).

MRA refers to the process by which CMS adjusts Part C payments made to Medicare Advantage plans to account for expected costs of care based on factors associated with member demographics and health. The goals of risk adjustment are:

  1. To collect accurate and complete diagnosis information to ensure proper treatment, care management, and care coordination services.
  2. To submit accurate and complete diagnosis data to CMS to ensure appropriate payment to both the Medicare Advantage plan and providers — in support of appropriate management of a members’ health.


Jaime Marcotte, Medicare Retrospective Risk Program Lead, is managing this project. If you have any questions regarding this program, please contact Jaime at or 1-843-666-1970.


To review the full details on this update, please see the Medical Records Risk Adjustment FAQs. 


Note: Optum and Ciox Health are independent companies providing medical record review services on behalf of Blue Cross and Blue Shield of North Carolina.