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: Would denied procedure codes at the claim level be used for risk scores and should denied claims line diagnoses be included in the EDGE Server Medical Claim Submission (ESMCS) Extensible Markup Language (XML) header?

Answer: If the procedure is denied because it is part of a more inclusive service, then it should be submitted to the EDGE server for consideration in the Risk Adjustment (RA) and Reinsurance (RI) programs. If the procedure is denied because it is not covered or authorized, then it is not eligible for consideration and must not be submitted.

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