Annual Risk Adjustment Data Validation (RADV) Audits

As part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) conducts an annual Risk Adjustment Data Validation (RADV) audit of health plans. The Department of Health and Human Services requires Premera Blue Cross to participate in this audit for a sample of members who purchased plans on and off the Washington Health Benefit Exchange.  

The RADV audit for 2025 date(s) of service is now in process: 

• Provider offices may receive a request for medical records from Datavant or directly from Premera.  

• Premera will only reimburse copy cost fees for the allowed amount within your contract. You can validate allowed copy cost fees in sections 5.01 and 5.02 of your contract agreement with Premera.  

• If you don’t receive a letter, you don’t need to do anything. 

Reminder: Medicare Advantage RADV audits continue to be announced: 

• Provider offices may receive a request from Datavant or directly from Premera for historical medical record information regarding patients selected by CMS for each payment year reviewed.  

• Payment year 2021 retrieval is expected to start July 2026.  

• Requests will be small in volume from Premera or Datavant, but urgent due to the compressed review period set by CMS.  

• Premera will only reimburse copy cost fees for the allowed amount within your contract. You can validate allowed copy cost fees in sections 5.01 and 5.02 of your contract agreement with Premera.  

• If you don’t receive a letter, you don’t need to do anything. 

We appreciate your support as Premera works through this intense audit cycle.