ACA HHS-RADV Knowledge Guide — Health Data Max
ACA HHS-RADV · Knowledge Guide

HHS-RADV: the complete reference for your team.

Program rules, audit workflow, sampling logic, medical record standards, business rules, and deadlines for BY2024 and BY2025 — in one place.

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BY2024 audits active · BY2025 EDGE locked Apr 30, 2026
The Program
200
enrollees sampled per issuer — standard IVA sample
Audit cycleAnnual
Validation layersIVA → SVA → Error Est.
PLRS adjustmentBoth ± directions
Coder QAIRR required
Annual
audit cycle — every eligible issuer, every benefit year
200
enrollees sampled per issuer (standard IVA sample)
Both ±
outlier issuers receive RA transfer adjustments
3 layers
IVA → SVA → Error Estimation before payment impact
The Fundamentals

What is HHS-RADV?

CMS's annual audit program that verifies the diagnoses issuers submit to the EDGE server are actually supported by medical records.

HHS Risk Adjustment Data Validation (HHS-RADV) is CMS's annual audit program that verifies the accuracy of the diagnoses issuers submit to the EDGE server — the same diagnoses that drive risk scores and determine how much each issuer receives or pays through ACA Risk Adjustment.

Risk adjustment redistributes funds among issuers in the same state market risk pool based on relative member health risk. Issuers with sicker-than-average enrollees receive transfers; those with healthier-than-average enrollees pay charges. RADV audits the data quality behind those transfers.

Because payment follows diagnosis, CMS validates a sample of those diagnoses against the underlying medical records. An unsupported HCC fails, the issuer's Plan Liability Risk Score (PLRS) is adjusted, and RADV-adjusted RA transfers are applied.

How a diagnosis becomes an audit target

1
Provider documents & codesICD-10 diagnosis from a face-to-face or telehealth encounter.
2
Issuer submits to EDGEDiagnosis accepted on EDGE, maps to an HCC.
3
HCC raises risk scoreHCC coefficient increases enrollee risk score; PLRS determines RA transfer.
4
RADV samples enrolleesMedical records must support each sampled HCC.
5
Unsupported HCC failsSuper HCC failure rate rises for that issuer.
6
Outlier issuer identifiedError rate adjustment applied to PLRS.
Why This Matters Now

The audit cycle runs every benefit year

RADV isn't a periodic spot-check — it's a structural part of every issuer's annual RA settlement.

// SCOPE

Individual + small group markets

Non-grandfathered individual and small group (including merged) market RA-covered plans, inside and outside the Exchange, in states where HHS operates risk adjustment.

// STAKES

RA transfer is at risk

An issuer with a high Super HCC failure rate may be identified as an outlier, resulting in an adjustment to its enrollees' HCC-associated risk scores — and therefore its RA transfer — for that benefit year.

// TIMING

Audits run on locked prior-year data

EDGE data locked April 30 → RA cycle runs → CMS deploys the sampling command and releases sample reports (~May) → IVA conducted (~Jun through Jan) → Package 1 due ~early Jan → SVA (~Jan–Mar) → Final Results Memo (~Jun of the next year). Submission-time accuracy decides the audit outcome.

Two-Layer Validation

IVA and SVA: independent audits at every level

Two separate entities review the same enrollees — one contracted by the issuer, one contracted by CMS — and their results are statistically reconciled.

Initial Validation Audit — IVA

Issuer-contracted, CMS-approved

The issuer selects a CMS-approved IVA Entity to review medical records for each of the 200 sampled enrollees. The IVA Entity validates D&E data, RXC categories, and every EDGE-submitted HCC against source documentation, submitting findings via the CMS RADV Audit Tool.

DeliverablesPackage 1, 2 & 3
Coder requirementInter-Rater Reliability
Submission systemCMS RADV Audit Tool
BY2025 deadlineJan 7, 2027
Second Validation Audit — SVA

CMS-contracted, nationally uniform

A single CMS-designated SVA Entity independently re-abstracts a subsample of IVA records with no access to IVA findings. A statistical comparison of the two entities' results determines whether the IVA or SVA findings feed error estimation.

Conducted byCMS-designated entity
ScopeSubsample of IVA records
MethodIndependent re-abstraction
Access to IVA resultsNone
Markets covered

Non-grandfathered individual and small group (including merged) market risk adjustment covered plans, inside and outside the Exchange.

Regulation

Established under the Affordable Care Act and implemented through HHS regulations and annual CMS Payment Notice rulemaking.

HCC model

Diagnoses are validated against the HHS-HCC risk adjustment model version that applies to the benefit year being audited.

End-to-End Process

From EDGE submission to RADV-adjusted RA transfer

The RADV lifecycle runs from the benefit year's EDGE data cutoff (April 30 of the following year) through to the final adjusted RA transfer. EDGE accuracy during the benefit year is what determines audit outcomes — the RADV command audits data that was locked months earlier.

1
EDGE Submission
→Issuer submits enrollment (ESES), medical claims (ESMCS), pharmacy claims (ESPCS), and supplemental diagnoses (ESSFS) to EDGE server throughout the benefit year.
→Enrollment files use full replacement; claims files are incremental — previously accepted claims are not re-submitted.
→April 30 cutoff — final date for any claim submission or correction that counts toward RA.
2
RA Calculation Cycle Closes
→CMS runs the risk adjustment model on locked EDGE data (~May of the following year).
→Plan Liability Risk Score (PLRS) is calculated per issuer; transfer amounts are set.
→The RADV command runs on each issuer's EDGE server and the HHS-RADV sampling reports are generated.
3
IVA Sample Selected
→200 enrollees selected via a stratified allocation method across the strata (by age group and risk level).
→Stratum 10 (no EDGE HCCs) is excluded from the IVA sample for recent benefit years.
→The sampling report lists the sampled enrollees with demographics and EDGE HCCs.
4
IVA Entity Designated
→Issuer selects and contracts a CMS-approved IVA Entity before the published deadline.
→IVA Entity must be reasonably free of conflict of interest, such that it can conduct the audit impartially and independent of the issuer.
→IVA Entities conduct Inter-Rater Reliability (IRR) review of their Primary Coders' work as a quality-assurance step.
5
Medical Record Collection & IVA Packages
→IVA Entity retrieves medical records for all 200 sampled enrollees from providers.
→Package 1: submission of IVA audit findings (including mapping documentation) with Issuer Senior Official sign-off.
→Package 2: submission of the medical records and associated workpapers, with Issuer Senior Official sign-off.
→Package 3 (if requested by CMS): submission of medical records for sample enrollees not submitted during Package 2.
→All packages submitted through the HHS-RADV Audit Tool by published deadlines.
6
SVA — Independent Re-Abstraction
→CMS SVA Entity selects a representative subsample of the issuer's IVA sample.
→SVA re-abstracts records independently — no access to IVA findings at any point.
→A statistical comparison of IVA and SVA results determines which findings are used in error estimation.
→The SVA subsample is reviewed in stages and can be expanded — up to the issuer's full IVA sample — if agreement or precision is insufficient.
7
Error Estimation & Final Results
→Accepted results (IVA or SVA) are used to calculate Super HCC failure rates across the failure rate groups.
→Issuers whose failure rates fall outside the expected range are identified as outliers.
→An adjustment factor for outlier issuers is applied to the HCC-associated portion of affected enrollees' risk scores.
→Final Results Memo issued; RADV-adjusted RA transfers applied to the benefit year settlement.
Key timing insight

The RADV sample is drawn from data already locked on the EDGE server. By the time a RADVIVAS report lands, an issuer has no ability to correct the underlying submission. Continuous EDGE data quality monitoring during the benefit year is the only effective RADV preparation.

Sample Selection

How CMS selects the 200 enrollees your IVA will audit

The IVA sample is not a random draw from an issuer's full enrollment — CMS uses a stratified sampling method.

CMS uses a stratified sampling method that distributes the sample across strata based on each stratum's share of the issuer population and its risk-score variability.

For recent benefit years, Stratum 10 (enrollees with no HCCs) is excluded from the IVA sample. For issuers whose eligible population (enrollees with at least one HCC) is smaller than the standard sample size, all eligible enrollees are selected.

Strata 1–3
Age 0–17
Low / Mid / High RS
Strata 4–6
Age 18–64
Low / Mid / High RS
Strata 7–9
Age 65+
Low / Mid / High RS
Stratum 10 — EXCLUDED
Enrollees with no EDGE HCCs
How the SVA subsample works

CMS selects a representative subsample of the issuer's IVA sample for the SVA. Review proceeds incrementally — starting with a smaller subsample and expanding in stages based on how closely the SVA results agree with the IVA results. If agreement or precision remains insufficient, CMS can expand the SVA to the issuer's full IVA sample.

Standard IVA sample

200

Standard IVA sample size per issuer. For issuers whose eligible population is smaller, all eligible enrollees are selected. CMS allocates the sample across strata using a stratified allocation method.

Error Rate Estimation

How RADV findings translate into payment adjustments

CMS turns accepted medical-record findings into risk-score adjustments for outlier issuers through failure-rate grouping, outlier detection, and group- and enrollee-level adjustment factors.

Error estimation process

1
Compare IVA and SVA resultsA statistical comparison determines whether the IVA or SVA findings are used in error estimation, based on agreement and precision.
2
Group the findingsHCCs are aggregated into Super HCCs and categorized into failure rate groups.
3
Identify outlier issuersIssuers whose failure rates fall outside the expected range for a group are identified as outliers.
4
Calculate the adjustmentAn adjustment factor is calculated for outlier issuers and applied at the enrollee level.
5
Adjust risk scoresThe adjustment is applied to the HCC-associated portion of affected enrollees' risk scores, feeding the final RA transfer.
How the adjustment is applied
For outlier issuers, CMS calculates an adjustment factor at the group level and applies it at the enrollee level, to the HCC-associated portion of each affected enrollee's risk score. CMS then estimates the issuer's HCC-associated error rate.
Adjustments work in both directions — depending on whether the audit finds an issuer's HCC-associated risk scores were overstated or understated relative to the validated records.
Medical Record Standards

What makes a record valid — and what disqualifies it

Each audited HCC must be supported by a qualifying medical record linked to an RA-eligible claim in the RADVMCE Report. The IVA Entity submits records through the Audit Tool; the SVA Entity re-abstracts the same records independently.

✓ Valid record requirements
✓Documentation generated during a face-to-face or telehealth visit dated within the benefit year
✓Records authenticated by a provider credentialed to diagnose in the state of practice
✓Records with a valid provider signature and credentials
✓Records authenticated after the date of service by a valid provider attestation (including attestation by a Medical Director or Supervisor licensed to diagnose in the state if the original provider is unavailable)
✗ Cannot substantiate a diagnosis alone
✗A medication list alone, used to abstract a diagnosis
✗A diagnosis abstracted from the past medical history without substantiating that the condition coexists at the time of service
✗Records from a provider not licensed to diagnose in the applicable state
✗Records where neither a signature nor a valid attestation can be obtained
✗Conditions that were previously treated and no longer exist (per Outpatient Coding Guidelines)
Coding Standards

ICD-10 & diagnosis validation rules

ICD-10-CM coding guidance

IVA Entities follow the conventions in the ICD-10-CM manual and the ICD-10-CM Official Guidelines for Coding and Reporting when abstracting diagnoses.

HCC model version

A diagnosis must map to a valid HCC under the HHS-HCC risk adjustment model version that applies to the benefit year being audited in order to contribute to the risk score.

Diagnosis must coexist at service

A diagnosis cannot be abstracted from the past medical history without the provider substantiating that the condition coexists at the time of service. Conditions previously treated and no longer existing should not be abstracted.

Cannot substantiate alone

Certain auxiliary information cannot substantiate a diagnosis alone — for example, a diagnosis cannot be abstracted solely from a medication list.

Provider credentials

For HHS-RADV, CMS defines an acceptable provider as a licensed physician or other qualified provider licensed to diagnose in the state in which they practice.

Signature or attestation required

If neither a valid provider signature nor a valid attestation can be obtained, the record is invalid and no diagnoses are abstracted; such diagnoses are excluded from the IVA Audit Results Submission XML.

Business Rule Repository

Mandatory requirements from CMS guidance

A plain-language summary of the key requirements that shape an HHS-RADV audit, organized by area. These are descriptive overviews, not a substitute for the official CMS HHS-RADV Protocols and related guidance.

Eligibility3 rules
HHS-RADV applies to non-grandfathered individual and small group (including merged) market risk adjustment covered plans, inside and outside the Exchange, in states where HHS operates risk adjustment. Issuers that received an RA transfer for the benefit year being audited are required to participate unless they qualify for an exemption.
An issuer may qualify for an HHS-RADV exemption in defined circumstances — for example, very low enrollment, being at or below the materiality threshold and not selected by CMS, being in liquidation, offering only small group carryover coverage, being the sole issuer in the state market risk pool, or receiving a Risk Adjustment Default Charge due to insufficient EDGE data.
A sole issuer in a state market risk pool is not subject to HHS-RADV for that pool because there are no RA transfers; sampling is performed for issuers in state market risk pools in which the issuer received an RA transfer.
Sampling3 rules
The standard IVA sample is 200 enrollees per issuer. For issuers whose eligible population (enrollees with at least one HCC) is smaller, all eligible enrollees are selected.
Enrollees with no EDGE HCCs (Stratum 10) are excluded from the IVA sample for recent benefit years.
CMS uses a stratified allocation method to determine how the sample is distributed across the strata, based on each stratum's size and risk-score variability.
IVA Process3 rules
Each year the issuer must complete a Conflict of Interest (COI) Attestation in the IVA Designation form in the Audit Tool, attesting to a documented process ensuring the IVA Entity is reasonably free of conflict of interest.
The IVA Entity must submit its audit packages by the CMS-published deadlines via the HHS-RADV Audit Tool.
IVA Entities are required to conduct Inter-Rater Reliability (IRR) review of their Primary Coders' work; coders that do not meet the required consistency measure have their records re-reviewed by a Senior Coder.
Medical Record4 rules
Certain auxiliary types of medical information cannot substantiate a diagnosis alone — for example, a diagnosis cannot be abstracted solely from a medication list, or from the past medical history without substantiating that the condition coexists at the time of service.
Medical record documentation must be generated during a face-to-face or telehealth visit (telehealth includes real-time audio-visual and real-time audio-only communications) and must be authenticated by a provider credentialed to diagnose in the state.
CMS accepts provider attestations to authenticate documentation that was not authenticated at the date of service. If neither a valid signature nor a valid attestation can be obtained, the record is determined invalid and no diagnoses are abstracted from it.
For HHS-RADV, CMS defines an acceptable provider as a licensed physician or other qualified provider, licensed to diagnose in the state in which they practice.
Diagnosis2 rules
A diagnosis must map to a valid HCC under the HHS-HCC model version applicable to the benefit year being audited in order to contribute to the risk score.
The medical record must be linked to an RA-eligible claim and must independently substantiate the diagnoses being audited.
SVA2 rules
CMS selects a representative subsample of the issuer's IVA sample for the SVA, reviewed in stages; if agreement or precision is insufficient, the SVA can be expanded up to the issuer's full IVA sample.
The SVA Entity conducts the SVA independently and re-abstracts records without access to the IVA findings.
Error Rate2 rules
Issuers whose failure rates fall outside the expected range for a group are identified as outliers; issuers with too few Super HCCs in a group are not treated as outliers in that group.
For outlier issuers, CMS calculates an adjustment factor and applies it at the enrollee level, to the HCC-associated portion of affected enrollees' risk scores. The adjustment can move risk scores in either direction.
EDGE3 rules
Enrollment files are submitted as full replacement files; claims and supplemental files are submitted incrementally — previously accepted claims are not re-submitted as complete replacements.
April 30 following the applicable benefit year is the last date to submit and correct claims data counting toward the RA calculation. If April 30 falls on a weekend, the deadline moves to the following business day.
Issuers are required to retain their EDGE data for an extended retention period defined by CMS, including a period maintained on the active EDGE server.
Appeals1 rule
CMS administers an SVA Findings attestation and discrepancy reporting process and an Error Rate Calculation attestation and discrepancy reporting process, followed by a Request for Reconsideration and an Appeal to the Administrator.
Master Timeline

Key dates and deadlines — BY2024 & BY2025

Apr 30
Annual cutoff

EDGE data submission cutoff — the hard deadline

April 30 following the applicable benefit year is the last date for any claim submission or correction counting toward the RA calculation; if April 30 falls on a weekend, the deadline moves to the following business day. After this date, the benefit year's data is locked. Enrollment files use full replacement; claims are submitted incrementally. Issuers are required to retain their EDGE data for an extended retention period set by CMS.

BY2024 Benefit Year 2024 — Active
DateMilestoneResponsible Party
Mar 19 – Apr 10, 2025IVA Entities elect to participate in BY2024 HHS-RADVIVA Entity
Apr 14, 2025Issuers begin designating IVA Entities in the HHS-RADV Audit ToolIssuers
Apr 30, 2025BY2024 EDGE server data cutoffIssuers
Nov 2025Audit Tool opens for IVA Audit Results SubmissionIVA Entity
Jan 8, 2026Package 1 submission deadline (8:00 PM ET)IVA Entity
Jan 15, 2026Package 2 submission deadline + IRR submission dueIVA Entity
Jan–Mar 2026SVA review windowSVA Entity
Mar 2026Summary of Final Results releasedCMS
FollowingSVA Findings Attestation & Discrepancy Reporting windowIssuers
Jun 2026Final Results Memo publishedCMS
FollowingError Rate Calculation Attestation & Discrepancy Reporting windowIssuers
Jul 2026Summary Report of BY2024 HHS-RADV Adjustments to RA Transfers publishedCMS
BY2025 Benefit Year 2025 — In Progress
DateMilestoneResponsible Party
Mar 18 – Apr 15, 2026IVA Entities elect to participate in BY2025 HHS-RADVIVA Entity
Apr 13, 2026Issuers begin designating IVA Entities in the HHS-RADV Audit ToolIssuers
Apr 30, 2026EDGE data cutoff — last day for claim correctionsIssuers
Nov 2026Audit Tool opens for IVA Audit Results SubmissionIVA Entity
Jan 7, 2027Package 1 submission deadline (8:00 PM ET)IVA Entity
Jan 14, 2027Package 2 submission deadline + IRR submission dueIVA Entity
Jan–Mar 2027SVA review windowSVA Entity
Mar 2027Summary of Final Results releasedCMS
FollowingSVA Findings Attestation & Discrepancy Reporting windowIssuers
Jun 2027Final Results Memo publishedCMS
FollowingError Rate Calculation Attestation & Discrepancy Reporting windowIssuers
Jul 2027Summary Report of BY2025 HHS-RADV Adjustments to RA Transfers publishedCMS

After the SVA findings and the error rate calculation are released, CMS opens defined attestation and discrepancy reporting windows for issuers. Dates are based on published CMS HHS-RADV activities timelines and are subject to change.

Reference Glossary

Key terms and acronyms used in HHS-RADV

Key terms and acronyms used throughout HHS-RADV, in plain language.

ACA
Affordable Care Act — 2010 law establishing the ACA Health Insurance Marketplaces and the risk adjustment program.
D&E
Demographics & Enrollment — IVA audit category validating age, gender, enrollment period, and plan information against issuer source systems.
DDVC
Default Data Validation Charge — a charge an otherwise-required issuer may elect to receive, via the HHS-RADV Issuer Participation Status and Exemption Web Form, in lieu of participating in HHS-RADV.
EAF
Enrollee Adjustment Factor — derived from an outlier issuer's Group Adjustment Factor and applied to the HCC-associated portion of an enrollee's EDGE risk score.
GAF
Group Adjustment Factor — the adjustment factor calculated for an outlier issuer within a Failure Rate Group, used to derive enrollee-level EAFs.
EDGE Server
External Data Gathering Environment — issuer-operated server environment to which issuers submit enrollment, claims, and prescription drug data used in RA calculations.
ESES
EDGE Server Enrollment Submission — inbound EDGE enrollment file type. Enrollment files are submitted as full replacement.
ESMCS
EDGE Server Medical Claims Submission — inbound EDGE medical claims file type. Submitted incrementally.
ESPCS
EDGE Server Pharmacy Claims Submission — inbound EDGE pharmacy claims file type. Submitted incrementally.
ESSFS
EDGE Server Supplemental File Submission — inbound EDGE supplemental diagnosis file type; references previously accepted medical claims.
HCC
Hierarchical Condition Category — diagnosis-based risk factor in the HHS-HCC model that contributes to an enrollee's risk score.
HHS-RADV
HHS Risk Adjustment Data Validation — CMS's program that validates issuer EDGE data (D&E, RXC, and health status) used in risk adjustment.
HHS-HCC
HHS Hierarchical Condition Category risk adjustment model. CMS uses a defined model version for each benefit year.
IRR
Inter-Rater Reliability — a consistency check comparing a Primary Coder's substantiated HCCs against a Senior Coder's, used as a quality-assurance measure during the IVA.
IVA
Initial Validation Audit — first audit performed by the issuer's designated IVA Entity.
IVA Entity
The CMS-approved organization contracted by the issuer to conduct the IVA.
PLRS
Plan Liability Risk Score — the issuer's risk score used in determining RA transfers.
RA
Risk Adjustment — the ACA program that transfers funds among issuers in a state market risk pool based on the relative health risk of their enrollees.
RADC
Risk Adjustment Default Charge — a charge applied when an issuer has insufficient EDGE data; receiving a RADC can result in an HHS-RADV exemption for the affected risk pools.
RADVDE
RADV Detailed Enrollee Report — EDGE-generated report used in the audit (enrollee-level detail).
RADVIVAS
RADV Initial Validation Audit Statistics Report — an HHS-RADV sampling report.
RADVMCE
RADV Medical Claim Extract Report — contains the RA-eligible and RXC-eligible medical claims to which medical records are linked.
RXC
Prescription Drug Category — categories mapped from prescription drug data used in the RA adult models.
Super HCC
A grouping of HCCs sharing the same coefficient estimation group, used to calculate failure rates and categorize HCCs into Failure Rate Groups.
SVA
Second Validation Audit — independent re-abstraction of a subsample of IVA records by a CMS-designated entity.
SVA Entity
The CMS-contracted organization performing the SVA.
The Health Data Max Approach

One platform. Continuous audit readiness.

HDM doesn't wait for the RADVIVAS reports to land. EDGE submissions, accepted claims, RA outputs, and source enrollment are reconciled in one database — so every HCC is traceable to the chart that has to support it before CMS samples.

01

Reconcile EDGE data

Enrollment, claims, RA outputs, and RADV reports linked per issuer and benefit year.

→
02

Flag audit risk

Mirror Super HCC failure rate signals and D&E/RXC anomaly patterns before the sample drops.

→
03

Surface evidence

For each sampled enrollee-HCC, surface the strongest linked medical record and claim chain.

→
04

Validate or correct

Confirm defensible HCCs, route unsupported diagnoses for correction — accurate RA transfer.

✓
One source of truthClaims, encounters, RADV reports, risk scores, and charts in a single linked database.
✓
CMS- & EDGE-aligned flaggingSuper HCC failure rate signals and D&E/RXC anomaly patterns run continuously against your data.
✓
Best-chart selection per HCCFor every flagged enrollee, surface the record most likely to support the diagnosis before audit.
✓
Encounter ↔ chart reconciliationEvery submitted code tied back to source documentation — gaps found before CMS does.
✓
Pre-sample risk prioritizationFocus on the HCCs whose failure rate would drive outlier status, before the sample drops.
✓
Clean audit submissionsRADV Audit Tool–ready XML packages with every flag and decision logged and defensible.
Accuracy in both directions. The goal isn't to maximize codes — it's to make every submitted HCC defensible. HDM flags potential over-coding and unsupported diagnoses for correction just as it surfaces supporting evidence, so your risk capture is accurate, compliant, and able to withstand the SVA's independent re-review.
Get Ahead of Your Benefit Year

Be ready before the RADVIVAS lands.

With BY2024 audits active and BY2025 on the calendar, the window to get ahead of your IVA cycle is now.

Request a Consultation → Start a 30-Day Trial