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

Issue Date: November 14, 2014

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

Question: What is an orphan(ed) claim?

Answer: An orphaned claim is a claim that was submitted and accepted but cannot be linked to an active enrollment period for an enrollee. Orphaned claims are not identified during medical or pharmacy claim file processing. Claims are compared to the stored active enrollment table when Risk Adjustment (RA) and Reinsurance (RI) commands are executed. Orphan claims appear on the Enrollees (Without) Claims Detail (ECD) Report that is produced when the RA and RI command is executed. The Unique Enrollee ID and Plan ID are used to match active claims to an active enrollment period. If the enrollee does not have an active enrollment period that covers the claim's Statement Covers From date and the Plan ID of the enrollee and claim do not match, then the claim will be orphaned.

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