As part of the Affordable Care Act (ACA), Cigna Healthcare^® Individual & Family Plans must comply with the ACA risk-adjustment program. The program’s aim is to prevent adverse selection and promote an equitable environment in the individual health care marketplace. The program runs on a calendar-year cycle, recurring every January.

What is the risk-adjustment program?

This is a government program administered by the Centers for Medicare & Medicaid Services (CMS). Risk adjustment ensures resources are available to cover complex patients who have costly conditions. It allows payers like Cigna Healthcare and Evernorth^® Behavioral Health to support patients through clinical and quality programs, while providing a valuable offering in the marketplace.

As part of the risk-adjustment program, CMS requires payers to report patient diagnoses annually via claims and medical record diagnoses abstraction (coding).

To comply with the program, we will request patient medical records as part of a risk-adjustment request or a risk-adjustment data validation (RADV) audit.

What this means for patients

Patients cannot be denied coverage or be charged a higher premium by payers based on their health status or preexisting conditions.

What this means for providers

Providers that receive a request to submit one or more patient medical records as part of a risk-adjustment request or an RADV audit are required to respond.

Please note:

• Subjective therapeutic notes are not required. Sensitive data can be omitted and, in many cases, a basic objective assessment plan – a SOAP note minus the “S” (“subjective”) – will suffice. Our request is for your professional diagnoses and treatment plan documentation. We will work with your office to obtain appropriate documents.
• This is not an audit of your work, claims, or financial agreements. The request is being made in compliance with the CMS requirements to audit risk-adjustment data.
• Requests for medical records may be made twice annually and will recur annually.
• All payers that offer Health Insurance Marketplace plans are subject to the same mandatory requirements.

For more information

To learn more about the risk-adjustment program or medical record review process, visit the Cigna Healthcare Individual & Family Plans web page or refer to the Evernorth Behavioral Administrative Guidelines.