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Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server FAQ

Guidance for FAQ regarding Edge Server Operations and Policy

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

Question: How should issuers address mother-baby bundled claims if the baby is never enrolled in a plan within the same issuer and the baby will not have a Unique Enrollee ID?

Answer: CMS requires issuers to unbundle mother-baby claims and submit individual enrollment records and claims under separate Unique Enrollee IDs for the mother and the baby. Issuers should adopt and adhere to a consistent policy for unbundling claims. If the issuer is mandated to cover a newborn, a separate enrollment record and Unique Enrollee ID must be created for the baby*. Even if the baby is not enrolled, issuers must submit an enrollment record for time the issuer is required to cover the baby and the issuer must submit any claims incurred during that time for the baby under the baby's Unique Enrollee ID. As a reminder for Risk Adjustment (RA) purposes: RA has separate adult, child and infant models and requires assignment to the correct model for an enrollee based on age. If claims are not unbundled, then the RA software code will only produce a risk score for the masked Unique Enrollee ID that is successfully matched to an enrollee record. As a reminder for Reinsurance (RI) purposes: All claims are aggregated based on the Unique Enrollee ID submitted on the claim. If claims are not unbundled, then claim costs will not be aggregated to each unique enrollee. Please see the EDGE Server Business Rules for further information on creating enrollment records for mandated coverage, guidance on Enrollment Period Activity Indicators (EPAI) and examples of creating separate enrollment records for mother and baby, and for guidance on unbundling mother and baby claims. *5.10 Mandated Enrollment Coverage-Table 29: Mandated Enrollment Coverage (EDGE Sever Business Rules)

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

Issue Date: February 19, 2015

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