What Is the RADV Appeals Process?
The Risk Adjustment Data Validation (RADV) audit process is part of CMS's oversight responsibilities to ensure the accuracy of risk adjustment data submitted by Medicare Advantage Organizations (MAOs). If CMS determines overpayments were made based on invalid diagnoses, MAOs may face financial recoupments. However, CMS provides an appeals pathway to challenge certain findings through a structured process involving the CMS Hearing Officer.
This process is critical for any MAO seeking to dispute RADV audit results and protect its financial integrity.
Who Oversees the Appeals?
Appeals related to RADV audit findings are reviewed by a CMS Hearing Officer. This individual acts independently and is not part of the RADV audit team or the Office of the Actuary.
The CMS Hearing Officer evaluates whether CMS properly applied its rules and procedures when determining a payment error based on medical record review.
What Can Be Appealed?
Medicare Advantage Organizations may request reconsideration for RADV audit findings that lead to payment adjustments. This typically applies to:
Important: The appeals process does not cover general policy disagreements or procedural complaints that do not directly affect the audit outcome.
Key Steps in the RADV Appeals Process
Let’s walk through the major steps involved when a Medicare Advantage Organization initiates an appeal:
1. Request for Reconsideration
MAOs must submit a written request for reconsideration within the timeframe specified in CMS’s final RADV audit findings notice.
Format: The request must clearly state the basis for the appeal and reference supporting evidence.
Deadline: The timeframe is typically short, so MAOs must act promptly.
2. Review by CMS Hearing Officer
Once the request is received, the CMS Hearing Officer will conduct an independent and objective review of the materials. This includes:
The hearing officer will then issue a reconsideration decision, which either upholds or overturns the original CMS audit decision.
What Happens After the Hearing Officer Decision?
The decision issued by the CMS Hearing Officer is considered final at the administrative level. There is no second-level administrative appeal for RADV audit determinations. However, MAOs may pursue further review through judicial proceedings if desired.
Required Documentation
To support a strong appeal, MAOs should prepare and submit:
A detailed explanation of each disputed finding
The specific supporting documentation or corrected records
Any evidence demonstrating CMS misapplied policy or used incorrect methodology
References to CMS guidelines or prior decisions (when applicable)
Where to Access Official Resources
CMS provides detailed information about the RADV appeals process on its official site. Visit:
👉 CMS RADV Appeals Process Page
Here, you’ll find:
Description of the hearing officer's responsibilities
Reconsideration request guidelines
Contact details for submitting appeals
Tips for a Successful Appeal
If your organization is preparing to challenge a RADV audit result, here are a few best practices to consider:
Act quickly – Don't miss the submission deadline.
Be thorough – Include detailed reasoning and evidence for every contested item.
Stay organized – Structure your request in a clear, professional format.
Use CMS references – Support your case with CMS manuals, memos, or prior rulings.
Consult legal or compliance experts – Especially for high-stakes findings or complex issues.
Frequently Asked Questions (FAQs)
Q: Can I appeal every RADV audit finding?
A: Only those findings that result in a payment adjustment and are tied to medical record discrepancies may be appealed.
Q: Is the CMS Hearing Officer independent?
A: Yes, the hearing officer operates independently from the RADV audit and CMS program teams.
Q: Is there a deadline to submit the appeal?
A: Yes, the deadline is defined in CMS’s audit result notice. Delayed submissions are generally not accepted.
Q: Can the hearing officer's decision be appealed?
A: No administrative appeals follow the hearing officer’s decision. However, MAOs may pursue judicial review.
Q: Can I get help drafting an appeal?
A: Yes, most MAOs engage compliance teams, legal counsel, or third-party RADV specialists.
Final Thoughts
The RADV appeals process is an essential safeguard for Medicare Advantage Organizations facing potential financial impacts from CMS audit determinations. By understanding the role of the CMS Hearing Officer and adhering to the structured procedures, MAOs can ensure fair consideration of disputed findings and uphold compliance with risk adjustment guidelines.
If your organization receives a RADV audit result that raises concerns, don’t delay—begin reviewing the findings, collecting documentation, and preparing your appeal with precision.
