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

Issue Date: July 18, 2016

Program Area: ACA Financial Appeals (ACA FA)

Question: An issuer partially submitted 10 claims for a member in 2015; however, the issuer determined that the fifth claim had an error in the Cost-sharing Reduction (CSR) Reconciliation calculation and only submitted the first four (4) claims for the member. Can the issuer submit the last six (6) claims for the member even though there is an error in the fifth claim?

Answer: The Centers for Medicare & Medicaid Services (CMS) is aware that restatements to 2015 claims can adjust 2015 payments; however, CMS does not allow issuers to use the discrepancy process to submit 2015 claims adjudications. Issuers should submit 2015 re-adjudicated claims during the 2016 CSR Reconciliation cycle.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.