Medical records needed for an important CMS RADV audit.

What is a RADV audit?

We need your help!

The Centers for Medicare & Medicaid Services (CMS) conducts Risk Adjustment Data Validation (RADV) audits to make sure the diagnoses reported for our members for risk adjustment payments are supported by documentation in their medical records. This is a regulatory requirement for all Medicare Advantage health plans.

As part of the current audit process, CMS selects a random sample of member records from the health plan for each calendar year from 2019 through 2024. CMS is planning to conduct yearly audits for successive calendar years thereafter.

Martin’s Point Generations Advantage is required to provide CMS with copies of the medical records for the selected members. CMS then reviews the records to confirm that each reported diagnosis is supported by documentation in the medical record.

If a reported condition is not supported by documentation in the medical record, CMS will disallow that diagnosis for payment purposes, which can result in retrospective payment adjustments to the health plan.

What does this mean for you?

You may be contacted by Generations Advantage to provide medical records for a member included in the audit, so that the medical records can be provided to CMS.

If you receive a request, please send the complete medical records as soon as possible. Your timely response and support are important to helping us meet CMS audit requirements.

Thank you for your partnership and for helping us make sure our members' medical records accurately reflect the care they receive!