Information Regarding Requests for Risk Adjustment Medical Records
Date: 07/18/25
The Health Plan is committed to improving the quality of care provided to our members. We are required by the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), in accordance with Risk Adjustment guidelines, to submit complete diagnostic data regarding your patients, our Medicaid, Wellcare and Ambetter members. We do so by facilitating medical record reviews.
It is our obligation to ensure accurate and complete data is sent to federal (and, where applicable, state) regulators. Although the request for medical records is not an audit, our intention is to ensure we are aligned with our regulators for complete data accuracies.
We thank you for your participation in prior reviews and want to provide an overview of the programs that will take place over the next 12 months.
| Wellcare | Ambetter | |
|---|---|---|
| Members | MA, MMP and DSNP members with 2024 visits. | Members with 2025 visits. |
| Records Needed | Dates of service/encounters from January 2024 through present day. | Dates of service/encounters from January 1, 2025, through December 31, 2025. |
| Timeline for Active Outreach | June throughDecember 2025. | September 2025 through April 2026; incremental records may be requested after the initial, for the complete encounter year. |
| Outreach Vendors | We contract with several vendors to obtain records on our behalf. You may receive outreach from Datavant, Advantmed, Datafied, Virtix or others. | |
| Turn Around Time to Submit Medical Records | Outreach vendors will request the fulfillment of records within a business week. However, special accommodations canbe considered. | |
| NOT AN AUDIT! | While we do need these records to submit diagnostic data to HHS, CMS and state agencies, this should not be considered an audit or a claims denial exercise. | |
Options for Submitting Records
Vendor: We engage several vendors to conduct reviews. A vendor representative will work with you to provide retrieval options and a list of the requested members’ medical records for services rendered.
Electronic Records: Let us make it easier for you to deliver records! Our team will be happy to help reduce your administrative burden by retrieving records directly from your system. If interested in providing the Health Plan with access to your electronic medical record (EMR) system, please complete the Provider/Centene EMR Connectivity form. If you’ve already established interoperability with us, we will work to obtain the records directly.
Third Party Vendors: If you work with a third-party vendor for fulfillment of charts, please let us know in the Provider/Centene EMR Connectivity form, so we can direct release of information
requests appropriately.
Work With Us Directly: Please contact the Health Plan for options to obtain a request list and send records directly to the health plan.
Start Now
We can obtain charts directly from your EMR. To utilize this service, complete the Provider/Centene EMR Connectivity form and our team will begin the process to establish access.
For questions or concerns, contact your provider engagement account manager in your area or call Provider Services at:
- Iowa Total Care: 1-833-404-1061, Monday – Friday 7:30 a.m. - 6 p.m. CT.
- Ambetter: 1-833-919-3213, Monday - Friday 7 a.m. - 7 p.m. CT.
- Wellcare: 1-855-538-0454, Monday - Friday 8 a.m. - 8 p.m. CT.
Thank you for your partnership in serving our members.