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

Issue Date: December 10, 2014

Program Area: Risk Adjustment (RA)

Question: Do risk score calculations exclude pharmacy claims?

Answer: Pharmacy claims data will not be included in the calculation of risk scores. However, we note that issuers should not filter their own claims prior to submitting claims data to the External Data Gathering Environment (EDGE) Server. The risk adjustment filtering process will take place after all claims have been submitted to the EDGE Server. The calculations only include data from medical claims files, enrollment files and supplemental diagnosis files. Pharmacy claims are used for reinsurance. For additional information, please review the EDGE Server Business Rules (ESBR), located under the Distributed Data Collection (DDC) program area at https://www.REGTAP.info in the REGTAP Library.

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