CMS expands Medicare Advantage RADV audits to all eligible plans

Aug. 2025What's New

On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a substantial expansion of its Risk Adjustment Data Validation (RADV) audit program for Medicare Advantage plans.

Beginning in June 2025, CMS will audit all eligible Medicare Advantage contracts for payment years 2019 through 2023, a significant increase from the previous scope of approximately 60 plans annually. This expansion includes UPMC Health Plan.

 As part of this initiative, CMS will also increase the number of medical records reviewed per plan—from a standard 35 records annually to 35 to 200 records per plan per year, depending on the plan’s size. This enhanced sampling methodology is designed to improve the statistical validity of audit findings and support extrapolation in accordance with the RADV Final Rule.

 UPMC Health Plan began requesting medical records for this expanded CMS audit starting in June 2025. Record requests will cover dates of service from 2018 through 2023. Affected providers will be contacted directly with detailed instructions, including member information, relevant dates of service, and documentation requirements.

Thank you in advance for your prompt attention to such requests.

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