Enrollment and Eligibility (ENR) FAQ
Guidance for FAQ regarding Reconciliation and Business Rules
Program Area: Enrollment and Eligibility (ENR)
Question: Please provide guidance to the below EDI scenarios describing Issuers assumptions for inbound transactions and what Issuers are expected to provide for reconciliation. In the case of a deceased subscriber, will FFM send a full TERM for the entire policy? Would this transaction go on both the full file audit and supplemental file?
Answer: 'Per 45 CFR 155.430(d)(7), termination due to death is effective on the date of death. If there are other family members on the policy receiving financial assistance, their eligibility will be redetermined. The reconciliation process is separate from the process for transmitting terminations. If a termination is transmitted and processed during the reconciliation period, it should be reported on the supplementary file for that reconciliation period. If the enrollee is not active as of the pull date of the audit files, the enrollee will not appear on the full 'snapshot' audit file.'
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 27, 2014
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