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May 19, 2026
Some of your patients could be included in the U.S. Department of Health and Human Services Risk Adjustment Data Validation Audit, conducted by the Centers for Medicare & Medicaid Services. The HHS-RADV audit is expected to begin in June.
How you can help: If you have patients included in the audit, you’ll receive a letter from CMS and should expect a medical records request from us. It’s important to respond to this request by the date listed on the request. As a contracted provider, you’re required to provide medical records to validate diagnosis codes used in the Affordable Care Act Risk Adjustment risk score calculation.
What the data is used for: The HHS-RADV audit validates the data used when assessing payment transfers for the ACA. The audit is performed on a sample of members enrolled in ACA-compliant individual and small group plans. It validates medical claims of the sampled members and requests all medical records tied to 2025.
If you have questions, contact our RADV department for individual and family plans.