Risk Adjustment Data Validation

The Centers for Medicare & Medicaid Services (CMS) and Health & Human Services require medical documentation to support the review of medical encounter(s) for our commercial members.

What you need to know

The Risk Adjustment Data Validation Audit for benefit year 2019 resumes in January 2021 (paused due to COVID-19). The 2020 audit is scheduled to be completed in May 2021.

  • Enrollees will be randomly selected by CMS
  • Members covered under individual and/or small group plans are included
  • You will be contacted in February 2021 if your patient has been selected
  • CIOX Health, our chart retrieval vendor, will request medical records to support the audit. You can find a video tutorial to learn about electronic submission of medical records at cioxlink.com

What could be requested from you

CIOX Health will contact you if your patient has been selected. The auditor will ask for the following information. Please include required HIPAA documentation.

  • Demographic sheet
  • Progress notes for face-to-face and virtual office visits
  • Consultation reports
  • Discharge summary
  • Emergency room records
  • History and physical exam
  • Medication list
  • Operative/procedure notes
  • Prescription for laboratory services
  • Problem list
  • Radiology reports
  • Pathology services

Questions?

Contact CIOX Health with any questions.