Risk Adjustment Data Validation Audit – June 2023 through November 2023

The Centers for Medicare and Medicaid Services (CMS) will be conducting an Initial Validation Audit (IVA) from June 2023 through November 2023 to review the data provided to CMS for ACA 2022 dates of service. 

Authority to do the Audit 

The United States Department of Health and Human Services (HHS) has the authority to conduct a Risk Adjustment Data Validation Audit (RADV) in the Affordable Care ACT (ACA) market based on the following: 

“Section 1343 of the Affordable Care Act (ACA) establishes a permanent Risk Adjustment (RA) program which is intended to provide payments to health insurance issuers that attract higher-risk populations.  
The Premium Stabilization Final Rule requires states, or HHS on behalf of states, to validate a statistically valid sample of data for all issuers that submit for risk adjustment every year and provide an appeals process.” 

The Secretary of HHS has designated the CMS to implement the HHS-RADV program. 

CMS requires issuers to hire an independent auditor to perform an IVA for those members in the sample they choose. 

What is Blue Cross NC required to do? 

The IVA requires Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to collect medical records for the CMS selected sample of population whose claims were submitted to CMS for purposes of calculations of Risk Adjustments. In order for us to comply with this requirement, we must retrieve the medical charts for the members that are in the sample; and provide them to the IVA auditor. The IVA auditor will report to CMS any discrepancies between the chart and the claims Blue Cross NC submitted to the Edge Server.  

What we need from you 

Once an employee of Blue Cross NC contacts you to obtain medical charts, please provide them within a few days of the initial request. The audit process will begin in January after CMS has given Blue Cross NC the sample of members on whom they want the IVA performed. It is important that the chart collection occurs over the first months of the audit to allow time for them to be read and the results reported to CMS. In the event that the chart requested does not support the HCC submitted to CMS, we will need time to request additional charts when possible. 

Thank you for supporting us in this effort.  

If you have any questions about this program, please contact George Taylor at 919-765-2750 or George.Taylor@bcbsnc.com and/or Kiera McCloud at 919-765-4729 or Kiera.McCloud@bcbsnc.com. 

Release Date: May 27, 2023