Centers for Medicare & Medicaid Services (CMS) Audit

Centers for Medicare & Medicaid Services (CMS) Audit

6/26/18

BlueCross and BlueChoice have begun requesting medical records from some providers as part of the U.S. Department of Health and Human Services’ (HHS) annual Risk Adjustment Data Validation (RADV) audit. The review is conducted by the Centers for Medicare & Medicaid Services (CMS). 

CMS identifies a random sample of member medical records needed for the annual audit, which is designed to validate the accuracy of diagnostic information that health plans submit to CMS through claims. The audit involves medical records for members with individual and small-group policies. 

The records required for this year’s audit will be for 2017 dates of service. BlueCross began sending the requests June 1. 

Not all providers will receive a request. The letter will identify the member(s) for whom records are needed. It also includes instructions for mailing or faxing the records. BlueCross Quality Navigators are available to pull the records at your office, if requested.

Providers should return the medical records requested at no cost as part of their contractual agreement with BlueCross. 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. Make sure your vendor understands that you permit our health plans or our designated business partners to inspect, review and acquire copies 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 using the Provider Education Contact Form or by calling 803-264-4730.