Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server FAQ
Guidance for FAQ regarding Edge Server Operations and Other
Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server
Question: Are claim files edited against stored enrollment records?
Answer: During the initial file load process, medical and pharmacy claim files are not compared to the enrollment files or stored enrollment records. Enrollment and claim files are processed independent of each other. Therefore, an enrollee does not need to be present in the enrollment data table for a claim to be accepted. The process of cross referencing the enrollee and claim data tables for identifying claims eligible for reinsurance and risk adjustment is performed during program specific processing. Issuers will receive outbound data files indicating which stored enrollees do not have corresponding claims and which claims do not have a corresponding enrollee/enrollment period record.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: July 23, 2013
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