Payment Validation for Part C and D Programs
Guidance for payment validation information relating to the Medicare Advantage (Part C) and Prescription Drug (Part D) Programs.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 14, 2020
The purpose of this page is to share payment validation information relating to the Medicare Advantage (Part C) and Prescription Drug (Part D) Programs.
Payment validation ensures the accuracy of Medicare Part C and Part D program payments, and protects the Medicare Trust Fund.
Medicare Advantage (Part C)
The Improper Payments Information Act of 2002 (IPIA; Public Law 107-300), as amended by the Improper Payments Elimination and Recovery Act of 2010 (IPERA; Public Law 111-204), requires government agencies to identify, report, and reduce erroneous payments in the government's programs and activities. In the process of implementing IPIA/IPERA requirements, CMS has reported a Part C composite payment error estimate since FY 2008.
CMS conducts Medicare Advantage (MA) risk adjustment data validation activities for the purpose of ensuring the accuracy and integrity of risk adjustment data and MA risk adjusted payments. Risk adjustment data validation (RADV) is the process of verifying that diagnosis codes submitted for payment by an MA organization are supported by medical record documentation for an enrollee.
Prescription Drug (Part D)
For compliance with IPIA/IPERA under the Part D Program, CMS has prepared and is implementing a systematic plan for identifying, measuring, and reporting erroneous payments for the Medicare Part D program.
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.