Risk Adjustment Data Validation Audit

June 28, 2019
Risk Adjustment Data Validation Audit

HHS has recently initiated audits of health plans subject to risk adjustment under the Affordable Care Act (ACA). QualChoice is included in this audit and we, along with our contracted providers, are required to fully comply.

The audit validates medical record documentation in support of 2018 ACA risk adjustment data that QualChoice has submitted to HHS about our members. QualChoice and medical providers receiving payment for services rendered to an ACA plan member must submit the required charts.

QualChoice is contracting with Optum® to assist with chart collection. Optum will contact providers to coordinate medical record retrieval. The following documentation is being requested:


  • Progress notes from face-to-face office visits
  • History and physical notes
  • Consultation notes
  • Demographics sheet
  • Problem list
  • Signature log


  • Progress notes
  • Consultation reports
  • Radiology reports
  • Prescriptions for laboratory services
  • History and physical exam/annual physical exam notes
  • Discharge summary
  • Emergency room (ER) records


Letters detailing the record collection process will soon be sent to affected providers.