Publication Date

Publication Date: 

The Centers for Medicare and Medicaid Services (CMS) will conduct a contract-level risk adjustment validation audit, starting September 2016 and going through February 2017. The audit will review the data provided to CMS for 2012 dates of service.


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


What is Blue Cross NC required to do?
The contract-level audit 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 to CMS for purposes of calculations of risk adjustments. In order for Blue Cross NC to comply with this requirement, we need to retrieve the medical charts for members in the sample.


What do we need from you?
If our vendor, Inovalon, contacts you to obtain medical charts, please respond to their requests in a timely manner. The audit process begins this month, once CMS gives us the sample members they want included in the audit.


If you have any questions about this program, please contact Monica Sleap at 336-408-3257.