May 2026 Top of Mind

What to know about the Medicare Risk Adjustment Chart Review Program

Have you received a letter requesting medical records for Medicare Risk Adjustment?

With the various requests for medical records you receive, it can be challenging to understand why patient information is being reviewed and by whom. Here’s insight into the annual Medicare Risk Adjustment Chart Review Program, why it’s important and the critical role you play. With clear information about the program, process and expectations, you can prepare accordingly to minimize any disruption to your already busy staff.

The Medicare Risk Adjustment Program

The purpose of this Centers for Medicare & Medicaid Services (CMS) program is to ensure covered Medicare Advantage plans receive appropriate payments based on the health status of their members. CMS requires plans to submit diagnostic data annually, reflecting services provided in the previous calendar year.

Optum administers behavioral health benefits for UnitedHealthcare Medicare Advantage plans. The diagnostic data that we gather through medical record reviews is shared with UnitedHealthcare to include as part of its annual submission to CMS. Learn more about the Chart Retrieval process.

Here’s what you need to know

When will I receive a letter ?	Medical record request letters will be sent various times throughout the year.
Who will contact me?	You may receive a request letter and telephone outreach from either OIR (formerly known as Episource) or Datavant (formerly Ciox Health/Ciox). Both work on behalf of Optum to compile information.
Do I have to participate?	Yes. Your contract with Optum outlines that you must provide patient medical records when requested. UnitedHealthcare tracks provider compliance with record requests. If you don’t respond, it could be considered a violation of your contract.
How many records will be requested?	The request letter will provide the patient names being requested. The total number will vary by provider.
How quickly do I need to respond?	The request letter will outline the deadline. We encourage you to respond within a week so this doesn’t get overlooked with other items on your busy schedule.
What are the options to submit the records?	The request letter will outline the options and give additional instructions. Options generally include: Electronic medical record access: The fastest and least expensive option is to allow OIR/Datavant to access your EMR. Email or the vendor’s submission portal: Either of these options allow you to submit without having to print the medical records Mail: If remote EMS access or other electronic submission is not possible, an address will also be included for records to be mailed.
How can I prepare for these reviews?	You can verify that the contact information we have for you is up to date. The easier it is to reach you, the fewer calls your practice will receive. Here’s how: Log in to the Provider Express secure portal with your One Healthcare ID and password. Select Practice Management (upper right corner), then My Practice Profile from the drop down list. Verify that the selected TIN and Organization is correct, then click View and Edit Profile. Key information to review Confirm contact information on the Practice Profile tab. Add new practice addresses, modify existing address attributes, or delete addresses where you no longer see patients, if needed. If it’s a group practice, check the Group Roster Tab to confirm the list of clinicians who currently provide direct service to patients is accurate. If you add or update a clinician listing, complete all fields for contact information, availability, licenses, ID and personal details. When making changes, be sure to Save and Submit and then attest so that it will be processed. Once you’ve confirmed or updated all clinician data, click the “I So Attest” button to complete the review.
What if I have questions?	Chart retrieval questions: The request letter will include additional contact information if you have further questions. Updating your provider information: Please call 1-866-842-3278 (option 1).

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