February 2021

The 2019 HHS-RADV Initial Validation Audit (IVA) Begins January 2021

Typically, the Department of Health and Human Services Risk Adjustment Data Validation (HHS-RADV) program/IVA runs from June through December, but the Centers for Medicare & Medicaid Services (CMS) delayed the 2019 audit due to the COVID-19 public health emergency.

The 2019 HHS-RADV program/IVA will run from January through September 2021.

The 2020 HHS-RADV program/IVA will run from May 2021 through January 2022.

Therefore, both the 2019 and 2020 HHS-RADV program/IVA will run simultaneously May through September 2021.

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 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. BCBSIL is requesting the full years 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 substantiate the eligible diagnosis. 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 2019 HHS-RADV program/IVA in early March 2021.