2019 HHS-Risk Adjustment Data Validation Program (RADV)

May 2, 2019

In 2019, the Centers for Medicare and Medicaid Services (CMS) will conduct another Initial Validation Audit (IVA), now known as Department of Health and Human Services (HHS) Risk Adjustment Data Validation Program (RADV), to validate the data used when assessing the payment transfers for the Affordable Care Act (ACA). Your role is essential to the success of the HHS-RADV audit. Therefore, if any of your patients are selected to be included in the audit, Blue Cross and Blue Shield of Oklahoma (BCBSOK) is asking for your cooperation and participation to fulfilling the requirements of the HHS-RADV.

The HHS-RADV is expected to begin in June of 2019. As BCBSOK providers, you are required to provide medical records to validate diagnosis codes used in the ACA Risk Adjustment risk score calculation. If you are selected to participate in the HHS-RADV audit you will be notified by mail and receive a follow-up phone call from our network representatives.

Please respond to these requests in a timely manner. It is important to have a successful audit to improve the healthcare delivery system.

Medical Record Submission Standards for the HHS-RADV program Must include the following documents for ALL visits for the 2018 year:

  • Demographic/Face sheet, ER notes, history and physical, progress notes, discharge summary, consultation reports, anesthesia reports, radiology reports, interventional radiology reports, and operative/procedure notes. Nephrology providers must include DIALYSIS notes.
  • Pathology reports, physician orders, medication list and radiology may substantiate a diagnosis and be submitted, but only in conjunction with other medical documentation

The requested medical records must be signed and credentialed within 180 days of the date of service. Please Note: If the credentialed signature is missing or is ineligible if handwritten, BCBSOK will contact you for a Signature Statement Attestation.

HHS-RADV will be performed on a sample of members enrolled in ACA-compliant individual and small group plans, both on and off-exchange. The HHS-RADV team will validate medical claims of the sampled members from the previous calendar year. We are requesting ALL medical records tied to the 2018 calendar year for the selected members. For example, this HHS-RADV will be conducted in 2019, but will review claims with dates of service in 2018.

We understand that this is a very busy time; however, in an effort to comply with CMS' requirements, we appreciate your full support and cooperation as you receive requests from BCBSOK and deliver the requested medical record(s) in a timely manner.

If you have any questions, please contact your Provider Network Representative.