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

Issue Date: July 01, 2016

Program Area: ACA Financial Appeals (ACA FA)

Question: Does the Centers for Medicare & Medicaid Services (CMS) recommend that issuers file discrepancies based on what is published in the June 30, 2016 final Risk Adjustment (RA) and Reinsurance (RI) payment reports or should issuers wait until after CMS determines the value of submitted discrepancies?

Answer: CMS recommends that issuers file a Request for Reconsideration if a discrepancy is identified on the June 30, 2016 final RA and RI payment reports. However, CMS will update the final RA and RI payment reports once all overlapping claims discrepancies are validated and completed. Once CMS reissues the report, CMS will conduct an additional appeals process for overlapping claims discrepancies only. If an issuer discovers that a discrepancy is resolved after the report is released with the updated overlapping claims information, the issuer can withdraw the Request for Reconsideration.

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