May 22, 2023
As an insurer participating in the Affordable Care Act's HHS-operated Risk Adjustment Data Validation (HHS-RADV) program, the Centers for Medicare & Medicaid Services is requiring Blue Cross and Blue Shield of Illinois to perform the required HHS-RADV program/Initial Validation Audit (IVA). As a provider who provides medical services to BCBSIL members enrolled in the ACA, your participation in the IVA is required.
The IVA will be performed on a random sample of members enrolled in ACA-compliant individual and small group plans, including plans that are available on and off the exchange. BCBSIL is requesting a full year’s medical record documentation for clinical hospital inpatient treatment, outpatient treatment and professional medical treatment for the respective audit year.
A key component of the HHS-RADV program is a calculation based on enrollee risk. Enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental codes captured through medical record review. Through its review, BCBSIL must provide sufficient documentation (documentation of disease process and/or treatment plan of care), to verify the eligible diagnosis. As a provider who provides medical services to BCBSIL members enrolled in the ACA, you may be asked to provide medical records for a member to validate all the diagnosis codes submitted on claims, which are then used in the Risk Adjustment calculation.
Medical Record Submission Standards for the HHS-RADV Program/IVA
You should include the following documents for the audit:
- Progress notes, history and physical, discharge summary, consultation reports and operative/procedure notes.
- Pathology reports, physician orders, medication list and radiology may substantiate a diagnosis and be submitted, but only in conjunction with other medical documentation.
- Records must be signed and credentialed within 180 days of the date of service. (If the credentialed signature is missing, we will contact you for a Signature Statement Attestation.)
To comply with the precise timeline requirements of the CMS HHS-RADV program IVA, we appreciate your support in submitting the requested medical records as soon as you receive notification letters listing the enrollees selected for the audit. BCBSIL will be reaching out to providers to confirm contact information and method of submission of medical records prior to the start of the audit.
If you have any questions, please email the BCBSIL Initial Validation Audit team.