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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: For the standard methodology, natural order - for claims from different sources, specifically pharmacy and medical claims - is there an order to processing for those received on the same day, or for those received on different days, or can they all be re-adjudicated in the order received regardless of claim type/source?

Answer: As discussed in November 2014 guidance from the Centers for Medicare & Medicaid Services (CMS) on re-adjudication of claims for the purpose of cost-sharing reduction reconciliation, all issuers must set all accumulators to zero and, if using a third party administrator (TPA), first re-process all medical claims in their natural order and then all pharmacy claims in their natural order. If not using a TPA, claims for any type of EHB service should be processed in the order received. https://www.regtap.info/uploads/library/APTC_Claims_Readjudication_Guidance_110314_5CR_111714.pdf

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