The U.S. Department of Health and Human Services and Massachusetts Health Connector (the federal and state agencies administering the Affordable Care Act’s risk adjustment program) are required to annually validate the accuracy of claims data submitted by health insurance companies for risk-adjustment-covered-plans through the validation of members’ medical records. This process is known as the Risk Adjustment Data Validation (RADV) program.
In support of the program, beginning in June 2017, you may receive a medical chart request pertaining to services provided to your Harvard Pilgrim patients during the 2016 calendar year, as part of the annual RADV audit. Please keep in mind that:
- Medical chart requests may be for a regular patient of yours or someone who was only seen once in your office
- Medical charts must have the patient’s name and date of birth, the date of service, the provider’s signature and credentials, and date of the provider’s signature
- Medical charts must be provided within 14 days to meet Harvard Pilgrim’s audit timeline requirements
- Member authorizations are not required
- Medical chart request materials will include contact information for the entity collecting charts, as well as a Harvard Pilgrim phone number and email for any additional assistance
If you have questions regarding a RADV medical chart request, please contact Kathryn Roach, Program Manager, at 617-509-2199.