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Insurers Required by CMS to Conduct (HHS- RADV) Program/Initial Validation Audit IVA (2019)

May 6, 2019

In 2019, the Centers for Medicare & Medicaid Services (CMS) will conduct another Initial Validation Audit (IVA) to validate the data used when assessing the payment transfers for the Affordable Care Act's (ACA) HHS-Risk Adjustment Data Validation (RADV) program/IVA. The provider's role is essential to the success of the RADV/IVA. Therefore, if any of your patients are selected to be included in this audit, Blue Cross and Blue Shield of New Mexico (BCBSNM) is asking for your cooperation and commitment to fulfilling this CMS mandate. The IVA is expected to begin in June of 2019. Our IVA auditor requires medical records to validate the sampled member's risk score calculation, which is based on the diagnosis codes submitted on a member's claims, as well as through supplemental diagnosis submissions based on medical record review. As BCBSNM providers, you may be asked to provide medical records to validate the diagnosis codes used in the ACA RA risk score calculation. It is of utmost importance that you respond to these requests in a timely manner.

The IVA will be performed on a sample of members enrolled in ACA-compliant individual and small group plans, both on- and off-exchange. Our IVA auditor will validate medical claims of the sampled members from the previous calendar year. For example, this IVA will be conducted in 2019 but will review claims with dates of service in 2018. Please be aware some of these claims may have been paid in 2019 and are likely to be included in the IVA sample.

Medical Record Submission Standards for the HHS-RADV program/IVA

CMS considers the following documentation types as acceptable for purposes of this 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 listed above
  • Records must be signed and credentialed within 180 days of the date of service. (If the credentialed signature is missing or illegible, BCBSNM will contact you for a Signature Statement Attestation.)

We understand that this is a very busy time; however, in an effort to comply with CMS' requirements, we appreciate your full support and cooperation as you receive requests and deliver the requested medical record(s) in a timely manner.
If you have any questions, please email the IVA team directly at NMACAIVA@bcbsnm.com.