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: Some issuers have pharmacy claims processed by a third party. The issuer sends an original claim, and the third party sends back either a reversal or an adjustment, but not a new claim. Should the issuer aggregate both the claim and adjustment to get the net cost and make a new claim out of the individual actions?

Answer: Issuers may submit the original claim and then submit a replacement claim when the adjustment is received from the third party vendor. Issuers may, alternatively, submit one (1) claim with the aggregation of both the initial claim and any adjustment performed by the third party.

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