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: Rule 4 of Table 52 in the EDGE Server Business Rules (ESBR) Version 3.0 states that 'At the claim line, at least one (1) line must include the same Amount Allowed value reported at the claim header; all other Amount Allowed values at the claim line level may be reported with a zero (0).' Does this rule apply when issuers use a default value for the Total Amount Allowed at the claim header or when using a derived value for the Total Amount Allowed?

Answer: The sum of the lines must equal the total amount at the header for both capitated encounters and fee for service claims.

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