Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: October 31, 2014

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: For the risk adjustment program, can issuers submit encounter claims for services provided by registered nurses and physicians assistants instead of medical doctors?

Answer: Encounters and claims from registered nurses are not allowed. Since each State determines licensing requirements for medical providers, please check with your State. Our business rules require a medical claim; therefore, medical providers licensed by the State to practice medicine and can bill for services that generate a medical claim or encounter would be appropriate. For additional information, please review the EDGE Server Business Rules (ESBR), located under the Distributed Data Collection (DDC) program area at https://www.REGTAP.info in the REGTAP Library.

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