Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: November 18, 2014

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: How does the EDGE application verify that stored data meets the following Risk Adjustment (RA) and Reinsurance (RI) payment requirements: all enrollees provided are tied to at least one (1) claim or encounter; all claim and encounters records are tied to a valid enrollee; and all claims and encounters record were incurred during a valid enrollment period for an enrollee?

Answer: Comparisons of claims and enrollees are done prior to the running of RA and RI calculations. Issuers will be provided with outbound files of claims without enrollees (orphan claims) and enrollees without claims and issuers will have an opportunity to submit additional data to resolve any missing information. Claims are selected, for the appropriate benefit year, using multiple selection criteria which is part of the risk adjustment and reinsurance software. The Centers for Medicare & Medicaid Services (CMS) will provide information on how claims are selected and risk scoring and RI calculations are performed later in 2014.

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