Complete Story
 

07/21/2025

Health Alliance Plan

Health Alliance Plan Managed Care Committee Member

April Danish

April Danish, CHONC - Newland Medical Associates

Medical Record Review Projects
HAP partners with vendors to conduct medical record reviews. They contact offices directly and provide the review details, including due dates and submission requirements.

The table below outlines our current and upcoming medical record review projects. All reviews are conducted by our vendors, Optum/Episource, LLC, and Cognisight, unless otherwise noted. Provider offices could be contacted more than once due to different regulatory projects, dates of service, and membership.

Medical Record Review Project Description Timeframe HAP Members Dates of Service
Commercial Risk Adjustment Review of diagnoses in HAP member medical records for information not submitted on claims Nov 1, 2025 -
Mar 31, 2026		 Commercial 2025

Commercial Risk Adjustment Data Validation (RADV) Audit

Vendor - Cognisight

 CMS audit to validate the accuracy of diagnoses submitted on a claim and included in a member’s risk score calculation Jun 1, 2025 -
Dec 31, 2025		 Commercial 2024
Medicare Risk Adjustment Review of diagnoses in HAP member medical records for information not submitted on claims July 1, 2025-
Jan 31, 2026		 Medicare Advantage 2024

Medicare Advantage Risk Adjustment Data Validation (RADV) Audit

Vendor - Cognisight

 CMS Audit to validate the accuracy of diagnoses submitted on a claim and included in a member’s risk score calculation Jun 20, 2025 -
Sept 15, 2025		 Medicare Advantage 2018


Vendors will contact provider offices by letter if they are part of the medical record review. The letter will include:

If you are not contacted, there is nothing you need to do. 

Per your HAP contract and HAP policy, failure to respond to these requests is subject to potential recovery of paid claims. We appreciate your cooperation. We will work with you to minimize disruptions in patient care activities.

If you have any questions, please reach out to your Provider Services representative.

HAP CareSource Monthly Updates – June 2025
Below are updates from the HAP CareSource Newsroom & Announcement pages for each HAP CareSource plan.

Marketplace

Medicaid

MI Health Link

Henry Ford Infusion – Preferred Provider for Home Infusion of Specialty Medications for HAP Commercial Members
Effective August 1, 2025, HAP Commercial members residing in Macomb, Oakland, and Wayne counties must receive specialty medications professionally administered at home from our preferred specialty provider – Henry Ford Home Infusion. We will contact members affected by this change.

These medications are marked with SPC in the Key column on our Services that Require Prior Authorization List. When submitting a request via our online authorization application for any HCPCS codes that are designated with SPC, you will be alerted that the medication must be provided by our preferred specialty provider.

If you are providing specialty medication home infusion services to members outside of Macomb, Oakland, and Wayne counties, please complete our HAP Infused Medication Form.

This change does not affect services administered in the clinic or infusion center. We will update our Home Infusion Policy. You can find the policy when you log in at hap.org and select Benefit Admin Manual under More.

 

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