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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: If claims are pended during the plan year, should those claims be re-adjudicated in the original order they occurred during the plan year, or when resolved?

Answer: Pended claims should be re-adjudicated in the order that best approximates the initial adjudication of the claims. Thus, if the issuer's practice is to adjudicate a pended claim upon resolution (and not to retroactively adjudicate the pended claim as if it had occurred when originally incurred), the pended cost-sharing reduction reconciliation should similarly be re-adjudicated based on date of resolution.

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.