Here’s What You Need to Know About HHS-RADV Audits
The MAC office has gotten calls regarding medical record requests from Datavant for Medicare Plus Blue patients. Datavant, formerly CIOX Health, conducts audits under the Health and Human Services-Risk Adjustment Data Validation (HHS-RADV) program, the Centers for Medicare and Medicaid Services’ (CMS) primary way to address overpayments to Medicare Advantage Organizations (MAOs). CMS requires all insurers participating in the HHS-RADV program to perform an annual HHS-RADV audit of a random sample of members enrolled in a participating individual or small group plan.
Historically, these medical records requests have been more of an audit of the MAO, making sure they are following all requirements, rather than an examination of the provider. If the MAO does not perform well, they could face significant repayment penalties.
During an RADV audit, CMS confirms that any diagnoses submitted by an MAO are clinically supported in the enrollees’ medical records. If diagnoses are unsupported by the medical records, CMS may collect overpayments from the MAO. However, it is possible that the MAO could attempt to claw back any overpayments from the provider to mitigate their own financial exposure.
Typically, the organization being audited requests records for the full calendar year being targeted in the audit.
Medicare Plus Blue
In June 2026, Datavant began mailing notification letters to provider offices for 2025. For each member selected for the audit, the letter includes identifying information, record submission guidelines, and relevant deadlines. The audits are time sensitive, so Blue Cross asks that providers submit the requested records as soon as they are received.
Sources / More Information
- Blue Cross Record Article, “2025 benefit year HHS-RADV Initial Validation Audit begins May 2026,” May 2026
- gov, “Medicare Advantage Risk Adjustment Data Validation Program,” updated March 4, 2026
- OfficeAlly Article, “CMS Expands Audits on Medicare Advantage Overpayments: What Providers Need to Know,” June 2025
