CMS Conducts Risk Adjustment Data Validation Audit - Medicare Advantage Members with 2018 Dates of Service

Sep 16, 2026

CMS is conducting a contract-level Risk Adjustment Data Validation (RADV) audit for Medicare Part C (Medicare Advantage) data to ensure payment integrity and accuracy. The audit targets the 2019 payment year and applies to Florida Blue BlueMedicare HMO and PPO plans for 2018 dates of service. Between July and September 2025, providers may receive medical records requests for diagnosis validation, with responses due within set business-day timelines and HIPAA-aligned handling.

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July 2025 CMS Conducts Risk Adjustment Data Validation Audit

What to Expect

Medical Records Requests

Recent CMS Fraud Alert

July 2025 CMS Conducts Risk Adjustment Data Validation Audit For Medicare Advantage Members with 2018 Dates of Service The Centers for Medicare & Medicaid Services (CMS) is conducting a contract-level risk adjustment data validation (RADV) audit for Medicare Part C (Medicare Advantage) data. This is a standard compliance process to ensure the integrity and accuracy of payments in the Medicare Advantage program. The audit is focused on the 2019 payment year and will apply to patients with Florida Blue BlueMedicareSM HMO and PPO plans with 2018 dates of service. What to Expect • Between July and September of 2025 , we may request medical records from providers for our BlueMedicare HMO and PPO members with 2018 dates of service. This is to validate the accuracy of diagnosis data submitted for risk adjustment purposes. • CMS will review medical records you provide to us to validate the accuracy of diagnosis data previously submitted for risk adjustment purposes. Medical Records Requests We will send a medical records request letter with a member list and details for providing the records to providers included in this audit. We ask for providers’ timely support in retrieving and submitting patient medical records with progress notes. Providers who receive our request are urged to respond with the requested medical records per our instructions within 10 business days. All records must be received no later than 45 days from the date of our original request. We appreciate your continued collaboration and commitment in complying with this CMS contract audit. Please be on the lookout for our RADV audit request for medical records and be sure to email us at [RPMChartProcurement@FloridaBlue.com](RPMChartProcurement@FloridaBlue.com) if you have questions. Note: The collection of risk adjustment data and medical records for this audit aligns with the Health Insurance Portability and Accountability Act (HIPAA) guidelines. For information about risk adjustment, visit the Florida Blue Risk Adjustment Process webpage at [FloridaBlue.com](FloridaBlue.com). Important: Recent CMS Fraud Alert CMS recently issued an alert to providers and payers of a Medicare fraud scheme involving phishing fax requests. The requests include language demanding information within 72-hours. Please note, Florida Blue regularly conducts audits where medical records are requested and will always identify specific Medicare beneficiaries, time periods, and encounters or prescription drug event records involved. We will also provide ample time to return medical records and include contact information for questions.

FAQs

What audit is CMS conducting and what is its purpose?

CMS is conducting a contract-level Risk Adjustment Data Validation (RADV) audit for Medicare Part C (Medicare Advantage) data. The purpose is to validate the integrity and accuracy of payments by checking the diagnosis data used for risk adjustment.

Which plans and dates of service are included in this RADV audit?

The audit focuses on the 2019 payment year and applies to Florida Blue BlueMedicare HMO and PPO plans with 2018 dates of service.

How long do providers have to respond to medical records requests?

Providers are urged to respond within 10 business days. All records must be received no later than 45 days from the date of the original request.

What should providers know about recent CMS fraud alerts related to medical record requests?

CMS issued an alert about a Medicare fraud scheme involving phishing fax requests that demand information within 72 hours. Florida Blue notes that its audits request medical records regularly, allow ample time to return them, and will include specific beneficiary and encounter details, along with contact information for questions.

Sep 16, 2026

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