Anthem Blue Cross (Anthem) is working with Optum CiOX Health (CiOX) to request medical records for risk adjustment. Risk adjustment is the process by which CMS reimburses Medicare Advantage plans, such as Anthem, based on the health status of their members. Risk adjustment was implemented to pay Medicare-Medicaid Plans (MMPs) more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender), as well as health status.


In 2019, Anthem will work with Optum, using their copy partner CiOX, to request medical records with dates of service for the target year 2018, through present day, then review and code the record.


Jaime Marcotte, Retrospective Risk Program Lead, is managing this initiative. Should you have any questions regarding this program, please contact Jaime at or 1-843‑666‑1970.


History of risk adjustment

As a part of risk adjustment implementation, CMS initially collected hospital inpatient diagnoses for determining payment to MMPs. In 2000, Congress mandated a change to include ambulatory data. This change took place gradually, with full implementation in 2007. CMS selected a payment model that included diagnosis data reported from physician office, hospital inpatient and hospital outpatient settings — the CMS-Hierarchical Condition Category (CMS-HCC) payment model.


Physician’s role

Physician data is critical for accurate risk adjustment as physicians are the largest source of ambulatory data for the risk adjustment model. The CMS-HCC model relies on ICD-10-CM coding specificity.


What is the provider notification process?

Optum using the copy partner CiOX, will initiate the record retrieval process. The process begins with telephonic or fax outreach to the provider, which is followed by a written request, to include:

  • Role of the vendor.
  • Purpose of the medical record retrieval request.
  • Action being requested (for example, submission of the entire medical record).
  • Name of the member.
  • Date rangeof service being requested.


The provider should supply the medical records within two weeks following receipt of the request. If the provider did not see the member during the requested dates of service, the provider should return the request to the vendor with an explanation that no information relative to the request appears on the patient’s medical record


How does risk adjustment impact physicians and members?

It’s important to keep in mind that the risk adjustment process also benefits you and your patients. Increased coding accuracy helps Anthem identify patients who may benefit from disease and medical management programs. More accurate health status information can be used to match healthcare needs with the appropriate level of care.


Risk adjustment also helps you meet your CMS provider responsibilities regarding reporting ICD-10-CM codes, including:

  • Secondary diagnoses, to the highest level of specificity.
  • Maintaining accurate and complete medical records (ICD-10-CM codes must be submitted with proper documentation).
  • Reporting claims and encounter data in a timely manner.


With your help in providing accurate and timely coding for risk adjustment, we can avoid unnecessary and costly administrative revisions, and provide your patients and our members with superior customer service.


Why is medical record documentation important for risk adjustment?

  • Accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding.
  • CMS conducts risk adjustment data validation by medical record review.
  • Specificity of the ICD-10 diagnosis coding is substantiated by the medical record.


Importance of ICD-10-CM diagnosis coding

  • ICD-10-CM is the official diagnosis code set for Medicare and is used for risk adjusted payment.
  • Medical record documentation dictates what code is assigned.
  • Appropriate coding requires use of the most specific code available.


Medical record documentation

  • Documentation should be clear, concise, consistent, complete and legible.
  • Document coexisting conditions at least annually.
  • Use standard abbreviations.
  • Utilize problem lists. (Ensuring they are comprehensive, show evaluation and treatment for each condition relating to an ICD-10 code on the date of service, and are signed and dated by the physician or physician extender.)
  • Identify patient and date on each page of the record.
  • Authenticate the record with signature and credentials.


Major points

Federal regulations require Medicare and its agents to review and validate medical records to avoid underpayments or overpayments.


It is important for the physician’s office to fully code each encounter; the claim should report the ICD‑10‑CM code of every diagnosis that was addressed and should only report codes of diagnoses that were actively addressed.


Contributory (comorbid) conditions should be reported if they impact the care and are therefore addressed at the visit, but not if the condition is inactive or immaterial. It should be obvious from the medical record entry associated with the claim that all reported diagnoses were addressed and that all diagnoses that were addressed were reported.


Requests for medical records

Anthem continually conducts medical record reviews to identify additional conditions not captured through claims or encounter data and to verify the accuracy of coding.


In addition, if CMS conducts an annual Data Validation Audit on the MMP health plan, the provider will be required to assist Anthem by providing medical record documentation for members included in the audit. 


Concerned about HIPAA privacy?

The collection of risk adjustment data and request for medical records to validate payment made to MMP organizations is considered a health care operation and, as such, does not violate the privacy provisions of HIPAA (45 CFR 164.502).


CMS data validation

Data validation ensures the integrity and accuracy of risk-adjusted payment. It is the process of verifying that the diagnosis codes submitted by the MMP organization are supported by the medical record documentation for a member.


MMPs are selected for data validation audits annually.


It is important for physicians and their office staff to be aware of risk adjustment data validation activities because medical record documentation may be requested by the MMP organization. Accurate risk-adjusted payment relies on the diagnosis coding derived from the member’s medical record.


Additional risk adjustment information is available at


Additional information, including frequently asked questions and answers, will be available at > Important Medicare-Medicaid Plan (MMP) Updates.


Featured In:
May 2019 Anthem Blue Cross Provider Newsletter - California