2018 ACA Risk Adjustment Program Audit

May 30, 2018

In 2018, the Centers for Medicare and Medicaid Services (CMS) will conduct another Initial Validation Audit (IVA) to validate the data used when assessing the payment transfers for the Affordable Care Act's (ACA) Risk Adjustment (RA) program. The provider's role is essential to the success of the IVA. Therefore, if any of your patients are selected to be included in the IVA, Blue Cross and Blue Shield of Oklahoma (BCBSOK) is asking for your cooperation and commitment to fulfilling the requirements of the IVA.

The IVA is expected to begin in June of 2018. As BCBSOK providers, you may be asked to provide medical records to validate diagnosis codes used in the ACA RA risk score calculation. Please respond to these requests in a timely manner. It is important to have a successful audit to improve the healthcare delivery system.

Medical records may include the following documents:

  • Progress notes, history and physical, discharge summary, consultation reports, and operative/procedure notes
  • Pathology reports, physician orders, medical list and radiology may substantiate a diagnosis and be submitted, but only in conjunction with other medical documentation

Every service date with a patient must be signed and credentialed within 180 days of the date of service. Please Note: If the credentialed signature is missing, BCBSOK will contact you for a Signature Statement Attestation.

The IVA will be performed on a sample of members enrolled in ACA-compliant individual and small group plans, both on and off-exchange. IVA will validate medical claims of the sampled members from the previous calendar year. For example, this IVA will be conducted in 2018, but will review claims with dates of service in 2017. Please be aware some of these claims may have been paid in 2018 and are likely to be included in the IVA sample.

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.