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 the definition of the Paid Amount field? Are issuers permitted to include surcharges as part of claims submissions?

Answer: Under 45 CFR 153.230 (c), Reinsurance (RI) payments are calculated based upon the claims costs for an individual enrollee's covered benefits under a RI-eligible plan. The issuer's claims costs for an individual enrollee's covered benefits under a RI-eligible plan should include the full claims costs paid by the issuer, including any non-medical costs assessed by the provider that are included as part of the provider's standard billing practices, including provider administrative fees, taxes, and claims-based surcharges assessed by states. However, issuers may not include in the Plan Paid Amount incentive or performance payments to providers, interest due to late payments or any other payments made to providers outside of the standard provider payment rates or based on the timing of payments or volume of payments or services. Issuers should not deduct payment hold backs such as risk withholds from the Paid Amount. For example, if an issuer applies a $5 hold back on a $100 claim to address the possibility of overpayment's to the provider under the overall issuer-provider relationship, the issuer should enter $100 in the Plan Paid Amount for this claim.

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