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

Issue Date: January 22, 2019

Program Area: Risk Adjustment (RA)

Question: How will bundled Mother/Baby claims be calculated in terms of Risk Adjustment (RA)?

Answer: Each claim or encounter submitted to the External Data Gathering Environment (EDGE) has only one (1) enrollee ID. If mother/baby claims are bundled, only the claims information for the enrollee ID on the claim may be eligible for risk score calculation if an associated plan enrollment record exists. Mother/baby claims should be unbundled to separate claim for the mother and for the baby, so the appropriate diagnosis codes can be assigned to each unique enrollee ID. For more information, please see the current benefit year HHS-Developed Risk Adjustment Model Algorithm Software located under Premium Stabilization on the CCIIO website (http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html). For additional guidance, the Distributed Data Collection (DDC) program area has published the EDGE Server Business Rules document located here https://www.regtap.info/ddc.php in the REGTAP library.

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