May. 06, 2019
Claims and Eligibility
Standards and Requirements
May. 06, 2019
As an insurer participating in the Affordable Care Act's (ACA) Risk Adjustment (RA) program, Blue Cross and Blue Shield of Montana (BCBSMT) needs your participation in the Centers for Medicare & Medicaid Services (CMS) required Initial Validation Audit (IVA). The IVA will be performed on a random sample of members enrolled in ACA-compliant individual and small group plans, including plans that are available on and off the Exchange. CMS mandates that BCBSMT provide the full 2018 medical records from the physician office and hospital records for those members selected to be audited.
A key component of the RA program is a calculation based on enrollee risk. As a reminder, enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental codes captured through medical record review. As a BCBSMT independently contracted provider, you may be asked to provide medical records for a member to validate all the diagnosis codes submitted on claims, which are then used in the RA calculation.
Medical Record Submission Standards for the IVA
You may include the following documents for the IVA audit:
To comply with the precise timeline requirements of the CMS IVA, we appreciate your support in submitting the requested medical records as you receive notification letters listing the enrollees selected for the audit. BCBSMT will begin mailing the IVA letters in June 2019.
If you have questions, please contact:
Adria Jellum, BCBSMT Unit Manager Quality Improvement