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Audit Services

Optum provides comprehensive data validation and support services to health plans for CMS and HHS risk adjustment data validation (RADV) audits.

Deep expertise, flexible options

The Centers for Medicare & Medicaid Services (CMS) and Department of Health & Human Services (HHS) are required to audit diagnosis data submitted by health plans. Preparing for and undergoing a CMS or HHS RADV audit can be a massive task. We provide support every step of the way.

CMS- or HHS-targeted risk adjustment data validation:

  • Analyze data and identify targeted medical records
  • Retrieve, code and score records 
  • Prioritize records and submit to CMS or HHS
  • Determine and collect attestations
  • Report on audit results

National sample RADV audit support: 

  • Optional service is a subset of the CMS- or HHS-targeted RADV service
  • Includes same services offered for the CMS- or HHS-targeted RADV service listed above 

Key benefits

  • Flexible options based on client needs
  • Dedicated project management and RADV audit team
  • Client-focused and communicative throughout engagement

Other audit services

Optum Claims Verification service is a process to: 

  • Review accuracy of hierarchical condition categories (HCC) submitted by claim data
  • Compare to coding results from Optum Chart Review service

The service allows both prospective and retrospective charts to be evaluated for eligibility.  

For clients performing a self-audit, we offer internal data validation review services.

See how Optum can drive better risk and quality outcomes for members, health plans and providers