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Horizon BCBS NJMedicare Advantage · Documentation · Medical PolicyHigh impact

Risk Adjustment Data Validation Audits to Resume in 2026

Effective date
Jan 1, 2026
Identified
Oct 3, 2026

Summary

CMS will resume Risk Adjustment Data Validation (RADV) audits in 2026, beginning with payment year 2020 claims dating back to 2017. These audits verify that submitted diagnoses are supported by complete, signed medical record documentation. Providers must ensure timely submission of requested medical records to avoid diagnosis disallowance, financial penalties, and potential program exclusion from Medicare Advantage, ACA, or Medicaid.

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What to do

Action · 6 steps
01By end of 2025.
02Billing and clinical teams must establish a process to respond promptly to RADV medical record requests from Horizon's Risk Adjustment team.
03Contact RiskAdjustment@HorizonBlue.com to evaluate direct collection relationship options (EMR access, on-site collection, or chart-collection assistance) to streamline medical record submission.
04Conduct internal audit of diagnosis coding accuracy for dates of service 2017-2020 to identify and correct unsupported diagnoses before CMS audits begin.
05Ensure all clinical documentation includes complete provider credentials, signatures, and dates for all applicable dates of service.
06Develop escalation protocol for urgent medical record requests to meet CMS timelines.
If missed: Failure to provide timely, complete documentation will result in diagnosis disallowance, repayment obligations, and potential loss of participation in Medicare Advantage, ACA, and Medicaid programs.

Original notice

Risk Adjustment Data Validation Audits to Resume in 2026
horizonblue.com · Always check the source before changing claims.
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