RADV Audit Preparation Checklist: How MA Plans Can Prepare in 2026

Why RADV Preparation Matters

RADV audit preparation is the structured process by which Medicare Advantage plans proactively verify that every submitted HCC diagnosis is supported by compliant medical record documentation, ensuring that risk-adjusted payments survive CMS scrutiny and that the organization is equipped to respond to an audit notification with minimal disruption and financial exposure.

RADV audit preparation through pre-submission scrubbing catches documentation issues before they become audit findings. Risk Adjustment Data Validation (RADV) audits are CMS's primary mechanism for ensuring Medicare Advantage plans receive only the payments their enrollees' clinical documentation supports. In 2026, the stakes have never been higher.

The 2023 RADV final rule confirmed that CMS will apply extrapolation to RADV findings for payment year 2018 and forward. This means audit errors found in a sample of beneficiaries are projected across the entire contract, turning small documentation gaps into multi-million-dollar recoveries.

• Financial Exposure: A plan with 80,000 members and a 12% unsupported HCC rate in the audit sample could face extrapolated recoveries exceeding $25 million, depending on the average RAF score impact per unsupported condition
• Expanded Scope: CMS has steadily increased the number of contracts selected for RADV each cycle, and OIG has recommended further expansion of audit coverage
• V28 Complexity: The transition to 100% CMS-HCC V28 introduces new mapping rules and documentation expectations that legacy compliance processes may not address

Documentation Requirements

CMS requires that every HCC submitted for risk adjustment payment be supported by medical record documentation meeting specific criteria. Understanding these requirements is the foundation of RADV preparation.

• Face-to-Face Encounter: The diagnosis must originate from an in-person visit with a qualified healthcare provider. Telehealth visits are accepted when they meet CMS telehealth requirements, but lab results, radiology reports, or ancillary service records alone do not qualify.
• Qualified Provider: The rendering provider must be an MD, DO, PA, NP, or other CMS-recognized provider type. Diagnoses documented solely by non-qualified personnel (medical assistants, intake staff) are not RADV-supportable.
• Definitive Diagnosis: The condition must be stated as a confirmed, active diagnosis. Terms like "suspected," "probable," "rule out," or "possible" do not meet RADV documentation standards. The diagnosis must be clearly present and under active management.
• Clinical Indicators: The medical record must contain clinical evidence supporting the diagnosis — lab values, examination findings, imaging results, or symptom documentation that substantiates the condition's presence.
• Treatment or Monitoring Plan: Documentation should show that the provider is actively managing the condition through medication, therapy, monitoring, or a documented clinical rationale for watchful waiting.
• Date of Service: The encounter must fall within the applicable payment year. Documentation from prior years does not support current-year HCC submissions, even for chronic conditions.
• Provider Signature: The record must be authenticated by the rendering provider with a signature and date. Unsigned notes are non-compliant regardless of content quality.

The Pre-Audit Checklist

This 10-item checklist provides a structured framework for RADV readiness. Each item addresses a specific vulnerability that CMS auditors evaluate.

• 1. HCC-Level Documentation Validation: For every HCC submitted, confirm that a corresponding medical record exists with a face-to-face encounter, definitive diagnosis, and provider signature from the payment year. This is the single most impactful preparation step.
• 2. Chart Retrieval Infrastructure: Establish retrieval agreements with all contracted provider groups. Plans that cannot produce medical records within the CMS-specified timeframe (typically 45-90 days) automatically fail those HCCs.
• 3. Coding Accuracy Review: Conduct internal audits using certified coders to verify ICD-10 code assignment accuracy. Confirm that codes map correctly to HCCs under V28 rules, not legacy V24 mappings.
• 4. Provider Attestation Compliance: Verify that attestation-based submissions (where providers confirm previously documented conditions) meet CMS attestation requirements and are supported by original clinical documentation.
• 5. Chronic Condition Recapture Verification: Confirm that every chronic condition HCC has been re-documented in the current payment year through a qualifying encounter. Conditions not recaptured are audit vulnerabilities.
• 6. Supplemental Data Validation: If the plan uses chart reviews or health risk assessments as supplemental data sources, ensure each submission traces back to a qualifying encounter and meets all documentation standards.
• 7. Delete File Reconciliation: Verify that previously submitted and later deleted HCCs have been properly removed from the risk adjustment submission. Unreconciled deletes are a common audit finding.
• 8. High-RAF Member Review: Prioritize documentation review for members with RAF scores in the top 10% of the plan. These members contribute disproportionate revenue and face heightened audit scrutiny.
• 9. Provider Education Documentation: Maintain records of provider training on documentation requirements, specificity coding, and RADV compliance. This demonstrates organizational commitment to compliance.
• 10. Mock Audit Execution: Conduct at least one internal mock RADV audit annually using CMS methodology — random sample, independent coding review, and error rate calculation with extrapolation modeling.

Common Documentation Failures

Analyzing published RADV findings and OIG reports reveals consistent patterns in documentation failures. These are the areas where plans most frequently lose HCCs during audit.

• Diagnosis Without Clinical Support: The most prevalent failure. A diagnosis code appears on the claim, but the medical record lacks objective clinical evidence — no lab values, no exam findings, no imaging to corroborate the condition. This accounts for approximately 35-40% of RADV-unsupported HCCs.
• Chronic Condition Not Addressed: The condition appears in the problem list or medical history, but the encounter note for the payment year does not reference, evaluate, or manage it. Passive carry-forward of diagnoses without active encounter documentation fails RADV review.
• Specificity Mismatch: The ICD-10 code submitted requires a level of specificity (laterality, type, stage) that the documentation does not provide. Under V28, specificity requirements have tightened for several condition categories.
• Missing Provider Signature: Complete, clinically accurate notes that lack a provider signature are non-compliant. Electronic signature requirements vary by state, and plans must verify signature compliance across their provider network.
• Date of Service Discrepancy: The encounter falls outside the applicable payment year, or the documentation date does not align with the submitted date of service. This is especially common with chart review supplemental submissions.
• Non-Qualifying Provider Type: The encounter was conducted by a provider type not recognized by CMS for risk adjustment purposes, or the supervising physician did not co-sign the record as required.

Technology for RADV Preparation

Manual chart-by-chart review is neither scalable nor sufficient for modern RADV preparation. Technology platforms address the volume and complexity challenges that manual processes cannot.

• Pre-Submission Scrubbing: Automated validation engines screen every HCC submission against documentation rules before data reaches CMS. This catches unsupported diagnoses, specificity gaps, and mapping errors at the point of submission — not months later during audit.
• Risk-Prioritized Review Queues: A risk adjustment analytics platform identifies which members and which HCCs carry the highest financial and audit risk, allowing compliance teams to focus limited review resources where exposure is greatest.
• V28 Mapping Validation: With the transition to 100% V28, technology that validates ICD-10-to-HCC mappings against current CMS crosswalks prevents submission of codes that no longer map to HCCs or that map differently than under V24.
• Extrapolation Modeling: Simulation tools that model potential RADV outcomes based on internal audit findings help plans quantify financial exposure and prioritize remediation efforts.
• Chart Retrieval Tracking: Workflow platforms that manage chart requests, track retrieval timelines, and flag overdue records ensure plans can produce documentation within CMS deadlines.
• Audit Trail Maintenance: Technology that maintains a complete audit trail — from original encounter to code assignment to submission — provides the documentation chain CMS expects during RADV review.

Building a Continuous Compliance Process

RADV preparation is not a once-a-year activity. Plans with the lowest audit exposure treat compliance as a continuous operational process embedded across the organization.

• Quarterly Internal Audits: Conduct statistically valid sample audits every quarter using the same methodology CMS employs. Track error rates over time and set organizational targets for improvement.
• Real-Time Submission Monitoring: Implement dashboards that track submission quality metrics — unsupported HCC rates, specificity compliance, chart retrieval success rates — as data flows rather than in retrospective batches.
• Provider Feedback Loops: Share audit findings with individual providers and practice groups. Providers who understand which documentation gaps trigger RADV failures improve their documentation at the source.
• Cross-Functional Ownership: RADV readiness requires coordination across coding, compliance, provider relations, and IT. Designate a RADV readiness team with representatives from each function and executive sponsorship.
• Annual Mock RADV: Execute a full-scale mock audit annually that mirrors CMS methodology, including sample selection, independent coding review, error rate calculation, and extrapolation modeling. Use results to drive targeted remediation.
• Regulatory Monitoring: Track CMS rulemaking, OIG work plans, and published RADV findings for changes in audit methodology, documentation standards, or enforcement priorities that require process adjustments.

The organizations that perform best under RADV are those that have eliminated the distinction between "audit preparation" and "normal operations." When every submission is audit-ready by default, RADV becomes a validation of existing quality rather than a crisis to manage.