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: How will orphaned claims be handled in the EDGE server? Will it come back on a report or will they be rejected?

Answer: Orphaned claims are not identified during medical or pharmacy claim file processing. Therefore, claims cannot be rejected because they are orphaned. Accepted claims, stored as active records, are compared to the stored active enrollment records when Risk Adjustment (RA) and Reinsurance (RI) commands are executed. The Enrollee (Without) Claims Detail (ECD) Report will list the orphaned claims submitted to the External Data Gathering Environment (EDGE) server. The ECD Report (orphaned claims) includes Enrollee IDs that do not have any associated claims, as well as any Claim IDs that have no associated enrollment record for the Enrollee ID on the claim. The RA and RI programs will not utilize any orphaned claim data for RA and RI calculations. In order for a claim to be accepted for RA and RI calculations, it must be matched to an active enrollee. For more information, please see the Interface Control Document Addendum, located under the Distributed Data Collection (DDC) program area at https://www.REGTAP.info in the Registration for Technical Assistance Portal (REGTAP) Library.

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