Risk Adjustment (RA) FAQ
Guidance for FAQ regarding Risk Adjustment Operations and Policy
Program Area: Risk Adjustment (RA)
Question: Regarding supplemental diagnosis codes, if an issuer rejects a claim and the provider re-submits the claim with additional diagnosis codes, and the issuer adjudicates that claim and the diagnosis code is on the adjusted claim, is it necessary for the issuer to also include this information on the Supplemental Diagnosis File?
Answer: Based on this scenario, it is not necessary for the issuer to submit a supplemental diagnosis record if the diagnoses are part of the issuer's final paid claim or accepted encounter. Reminder: Only final, paid claims or encounters must be submitted to the External Data Gathering Environment (EDGE) server.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 25, 2019
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