May 2019

The Department of Health and Human Services Risk Adjustment Data Validation (HHS-RADV) Program/Initial Validation Audit (IVA) Begins in June

As an insurer participating in the Affordable Care Act's (ACA) HHS-RADV program/IVA, Blue Cross and Blue Shield of Illinois (BCBSIL) needs your participation in the Centers for Medicare & Medicaid Services (CMS) required HHS-RADV program/IVA. 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. CMS mandates that BCBSIL provide the full 2018 medical records from the physician’s office and hospital records for those members selected to be audited. 

A key component of the HHS-RADV program is a calculation based on enrollee risk. As a reminder, enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental codes captured through medical record review. As a BCBSIL independently contracted provider, 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 may include the following documents for the audit:

• 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.
• 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 you receive notification letters listing the enrollees selected for the audit. BCBSIL will begin mailing the letters containing member names for the HHS-RADV program/IVA in early June 2019.