Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server FAQ
Guidance for FAQ regarding Edge Server Operations and Data Submission - Other
Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server
Question: Can the yearly amount Issuers pay providers, under capitated plans, be submitted to the Edge Server for the purpose of risk adjustment and reinsurance?
Answer: Capitated claims are acceptable for submission to the edge server. Issuers will need to derive (or estimate) a paid amount for these services as outlined in 45 CFR 153.710. As indicated in the Edge Server Business Rules, the Derived Amount Indicator is a data element that allows issuers to identify claims that have capitated provider arrangements instead of fee-for-service arrangements and to reflect the derived costs associated with the capitated services in the Derived Amount Field. If a medical claim includes both derived and paid amounts, then the header should include the derived indicator value of "Y". At the line level, each line should include the appropriate value which indicates whether the value is derived.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: November 20, 2013
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