Risk Adjustment Initial Validation Audit of ACA medical records starting July 2025

The Centers for Medicare & Medicaid Services (CMS) has launched the annual mandatory Risk Adjustment Validation Audit (RADV) audit. The U.S. Department of Health and Human Services (HHS) has the authority to conduct the Risk Adjustment Validation Audit (RADV) in the Affordable Care Act (ACA) model based on Section 1343 of the ACA establishes a permanent Risk Adjustment (RA) program, which is intended to provide payments to health insurance issuers that attract higher-risk populations.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) must submit medical record documentation supporting a mandatory Initial Validation Audit (IVA). This audit improves risk-adjusted payment integrity and accuracy and provides a more complete and accurate clinical profile of Blue Cross NC members to help support initiative-taking care management programs.

Blue Cross NC will begin requesting medical records for these CMS audits in July 2025. The chart requests for these audits will include provider dates of service between January 1, 2024, and December 31, 2024.  Blue Cross NC will reach out directly to notify providers with specific details on members, dates of service, and documents to send.

Your compliance and assistance with this mandatory audit are very much appreciated.