Medical Record Requests for CMS Risk Adjustment Validation Program

Medical Record Requests for CMS Risk Adjustment Validation Program

6/5/2017

Last fall, BlueCross BlueShield of South Carolina and BlueChoice HealthPlan sent medical record requests to selected providers for Risk Adjustment Data Validation (RADV). Our plans will again conduct outreach in support of this federally-mandated program. The Centers for Medicare and Medicaid (CMS) and the U.S. Department of Health & Human Services validate the accuracy of risk adjustment data submitted by health plans in the Individual and Small Group markets.

Just as before, we will require participating providers to respond timely to medical record requests for members identified as part of the random sample audit. We will review those members’ progress notes, hospital notes and correspondences from services provided during calendar year 2016. 

All providers will not be required to participate in this audit process. For those providers that are chosen, you will receive this notice beginning June 1. Find the letter here and follow the instructions closely, making sure to respond in a timely manner to the requests for patient information. 

As a reminder, we do NOT pay for fees for your practice to supply medical records to our health plans. If your practice contracts with a vendor that manages the release of patient information on your behalf, please work with your vendor to forward the data to us as a non-billable event. Ensure your vendor understands that you permit our health plans or our designated business partner to inspect, review and acquire copie provider.education@bcbssc.coms of records upon request at no charge. 

Providers that do not send the requested patient information timely — or send an invoice for payment — will be contacted by a Provider Advocate to facilitate release of medical records.

For questions about this bulletin, please contact Provider Relations and Education by submitting the Provider Education Contact Form. Providers may also send inquiries to provider.education@bcbssc.com or call 803-264-4730