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: How will the Centers for Medicare & Medicaid Services (CMS) identify a denied claim line?
Answer: Denied claims are identified when the allowed amount at the header equals $0. Any claims with an allowed amount of $0 at the header will be rejected. The same logic cannot be applied at the line level as claim lines may have a $0 allowed amount if they are part of a more inclusive service. Issuers may include a service that was denied because it was covered as part of another service that was paid. Issuers must not submit claim lines that were denied because the claims were not covered nor authorized as these services are not considered incurred by the issuer, and therefore, not eligible for consideration under risk adjustment or reinsurance.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: November 26, 2014
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