Continuing our 2019 reporting Commercial Risk Adjustment (CRA) updates, Anthem Blue Cross and Blue Shield (Anthem) requests your assistance with respect to our reporting processes.


The Centers for Medicare & Medicaid Services (CMS) is conducting a Risk Adjustment Data Validation (RADV) Audit beginning June 2019 through January 2020. This audit is in accordance with the provisions of the Patient Protection and Affordable Care Act (PPACA) and its risk adjustment data validation standards.


For this audit, CMS will select a statistically valid sample of Anthem’s members enrolled in an Affordable Care Act (ACA) compliant plan. Providers whose patients during the benefit year 2018 were selected for this audit will receive requests and must provide copies of medical record(s)/chart(s). This audit is to verify that diagnosis codes, which have been submitted on claims and reported to CMS, are accurate, properly documented, and coded with accurate levels of specificity.


In the event your patients are selected for this RADV audit, please note that Anthem is working with several vendors to collect the needed medical records and signature attestations (if applicable). Representatives from Anthem or our vendors may reach out to you to request the required medical records and signature attestations.  We appreciate your assistance and patience during this process.


Be advised that Anthem is not requesting copies of “psychotherapy notes” as defined by the Health Insurance Portability and Accountability Act (HIPAA).  Under HIPAA, psychotherapy notes are defined as “notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual’s medical record.  However, any data excluded from the definition of psychotherapy notes must be provided where applicable and pursuant to this request. 


The following list of items are not included in the definition of “Psychotherapy notes” and therefore, can be included pursuant to HIPAA:

  • Medication prescription and monitoring
  • Counseling session start and stop times
  • Modalities and frequencies of treatment furnished
  • Results of clinical tests; and
  • Summary of the following:
    • Diagnosis
    • Functional status
    • Treatment plan
    • Symptoms
    • Prognosis; and
    • Progress to date


If you have any RADV audit questions/concerns, please contact


If you have any questions regarding our reporting process, please contact our CRA Network Education Representative


Featured In:
September 2019 Anthem Provider News - Ohio