The Centers for Medicare and Medicaid Services (CMS) uses diagnostic information (ICD-9) from original Medicare claims and from Medicare Advantage provider claims to determine the appropriate risk adjusted payment rate to be paid to Medicare Advantage Plans for each member. As a Medicare Advantage Plan, Blue Medicare PPO is responsible for ensuring the accuracy of the data submitted to CMS for payment purposes.

Blue Cross and Blue Shield of Texas (BCBSTX) internal data validation activities will include identification of a sample group of Blue Medicare PPO members for data validation purposes. BCBSTX will submit a written request for medical records, with detailed instructions, to those providers that have treated the selected sample of Blue Medicare PPO members. The provider will return a copy of the medical records requested to BCBSTX. The medical record review is being conducted by BCBSTX to confirm the accuracy of the diagnostic information listed on the member’s claims and ultimately submitted by the Blue Medicare PPO Plan to CMS for payment purposes.
NOTE: this internal data validation project, conducted by BCBSTX, is not sponsored by CMS. 

We would like to thank you in advance for your valuable time and appreciate your cooperation with our internal data validation efforts. If you have any questions about this process, please contact your local Network Management office. For more information regarding the BCBSTX data validation project, visit http://www.bcbstx.com/provider/medicare/index.htm.

posted 12/2008