Insurers Required by CMS to Conduct ACA Risk Adjustment Program Audit

March 28, 2017

In 2017, the Centers for Medicare and 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) Risk Adjustment (RA) program. The provider's role is essential to the success of the IVA. Therefore, if any of your patients are selected to be included in the IVA, Blue Cross and Blue Shield of Texas (BCBSTX) is asking for your cooperation and commitment to fulfilling the requirements of the IVA.

The IVA is expected to begin in June of 2017 and BCBSTX will be working with Tactical Management Incorporated (TMI) to retrieve the requested medical records that we have to submit to our IVA auditor. Our IVA auditor requires medical records in order 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 BCBSTX providers, you may be asked to provide medical records directly to TMI in order to validate all of 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 2017, but will review claims with dates of service in 2016. Please be aware some of these claims may have been paid in 2017 and are likely to be included in the IVA sample.

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 from TMI and deliver the requested medical record(s) in a timely manner.

If you have any questions, please contact your Network Management Representative.