Reinsurance (RP) FAQ

Guidance for FAQ regarding Other and Other

Program Area: Reinsurance (RP)

Question: How should subrogation claims be presented to the Edge Server for purposes of reinsurance?

Answer: Issuers must submit paid claims net of any reduction in liability due to subrogation payments made with respect to those claims (whether or not received directly by the issuer) as of April 30 of the year following the applicable benefit year. We recognize that at the time a claim is first loaded to the edge server it may be difficult to know whether future subrogation payments will reduce an issuer's liability for that claim. Therefore, if an issuer's liability is reduced due to a subrogation payment that is received prior to the end of the data collection period, an issuer must submit a new version of the claim to adjust for the subrogation payment. The void and replace process should be used to submit these changes to the edge server, just as it should be used to report adjustments for a change to diagnosis, services or issuer's paid amount. Consider an issuer that pays $1,500 for a claim from March, 2014. The issuer would submit this paid claim to the Edge Server. If the issuer receives a $500 subrogation payment in September, 2014, then the issuer would submit a replacement claim to the edge server with the new version of the claim with a paid amount of $1,000. If the issuer later receives another $1,000 subrogation payment on this claim in January, 2015, the issuer would submit a void of the $1,000 claim to the edge server, reversing the entire claim, resulting in a $0 claims paid amount.