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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: For the standard methodology, the natural order of claims was described as temporal order (i.e., when claims are received). Which is it, the date of service or the date that the claim was processed/paid/presented?

Answer: Claims for services provided in a particular benefit year must be re-adjudicated in the benefit year plan structure in which the cost sharing was incurred regardless of when they are presented for payment. Therefore, issuers should adjudicate and re-adjudicate claims in the order that best approximates their natural order, e. g, when cost sharing was incurred for a particular medical service. This may or may not coincide with the actual dates of service, for example, when coinsurance is assessed on a total bill rather than on a per-diem basis.

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.