Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-12-19

The Centers for Medicare and Medicaid Services (CMS) is conducting a targeted Risk Adjustment Data Validation Audit (RADV), from January 2020 - July 2020. The audit will review the data provided to CMS for 2014 dates of service.

Authority to Do the Audit
Federal regulations require Medicare Advantage organizations, their providers, and practitioners to submit medical records for the validation of risk adjustment data (42 CFR § 422.2, 422.310 (e) and 422.311).

What is Blue Cross NC required to do?
The targeted RADV requires Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to collect medical records for the CMS-selected sample population whose claims were submitted for calculating risk adjustments. For Blue Cross NC to comply with this requirement, we must retrieve the medical charts for members who are in the sample.

What do we need from you?
When Blue Cross NC contacts you, please provide the requested medical charts in a timely manner. The audit begins in January, after CMS shares the sample of members on whom they want the RADV performed.

Questions?
Please contact George Taylor at 919-765-2750.

Thank you for helping us fulfill these CMS requirements.