Medicare Advantage Risk Adjustment Validation audit in April 2026

The Centers for Medicare and Medicaid Services (CMS) is conducting a Risk Adjustment Data Validation audit from April 2026 through September 2026 to review the data provided to CMS for 2019 dates of service.

Authority to audit

Federal regulations require Medicare Advantage organizations and their providers and practitioners to submit medical records for the validation of risk adjustment data (42 CFR § 422.310).

What is Blue Cross NC required to do?

The CMS payment year 2019 RADVCON audit requires Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to collect medical records for the CMS selected sample population whose claims were submitted to CMS for calculations of Risk Adjustments. For Blue Cross NC to comply with this requirement, we must retrieve the medical charts for the members that are in the sample.

What we need from you

Blue Cross NC may contact your practice to obtain medical charts. If so, please provide a timely response to the request. The audit process began in April, following CMS’s release of the RADV member sample.

If you have any questions about this program, please email the Blue Cross NC Provider Outreach department.

Thank you for helping us fulfill these CMS requirements.