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

Issue Date: May 25, 2016

Program Area: ACA Financial Appeals (ACA FA)

Question: Should an issuer with only a single claim in the individual market identified by the Overlapping Claims Summary Count query report that claim as a discrepancy, even if that enrollee is not eligible for Reinsurance (RI)?

Answer: Yes, issuers must report all results of the Overlapping Claims Summary Count query. The Centers for Medicare & Medicaid Services (CMS) is developing an updated query that excludes overlapping claims for enrollees who do not qualify for RI. Once the new query is complete, issuers can use that query and report those results, which may report fewer overlapping claims than the current query. If an issuer runs the query and it returns zero (0) results, then the issuer does not need to submit a discrepancy.

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