July 19, 2018
As part of the Affordable Care Act (ACA), The Centers for Medicare and Medicaid Services (CMS) conducts an annual audit of health plans in the U.S. Premera Blue Cross participates in this audit for a sample of members both on and off the Exchange.
You may receive a request to submit all medical records for some of your patients for the 2017 calendar year. The request for these medical records will come from Cognisight LLC, our contracted audit vendor. Cognisight is contractually bound to preserve the confidentiality of health plan members’ protected health information (PHI) obtained from the medical records, in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations. The request will come by fax and includes the following information:
- A list of members for submitting medical records
- Key information the medical records should include and document requirements for successful submission
- Detailed instructions on how to submit the medical records
- Submission deadline
- Where to ask questions about the audit
The purpose of the audit is to promote confidence in accurate risk adjustment data that issuers submit to the Department of Health and Human Services (HHS), including validating medical record documentation for each sample member selected. This audit isn’t specific to providers or provider groups and isn’t designed to monitor practices or billing or coding patterns.