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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: If a service was provided in September 2015, but the claim is lost or not presented until June 2016, in which benefit year reconciliation cycle should the issuer report the Cost-sharing Reduction (CSR) provided? Is this a CSR provided in 2015, or in 2016?

Answer: This is a CSR provided in 2015 but which could not be re-adjudicated and reconciled with other 2015 claims on the same policy because the issuer did not get the bill for service until after the data submission deadline. In such a case, the issuer would adjudicate and re-adjudicate all claims on the 2015 policy again, and restate 2015 CSRs for that policy during the 2016 reconciliation cycle (April 2017). The Centers for Medicare & Medicaid Services (CMS) intends to provide guidance on the CSR restatement process for previous year claims.

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.