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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: If claims involving coordinated benefits cannot be properly handled before submission, is it acceptable to filter out Coordination of Benefits (COB) claims and not include them for Cost-sharing Reduction (CSR) reconciliation?

Answer: Issuers may wait to re-adjudicate complex claims until the complete cost of the benefit has been accounted for; however, in such a case, the issuer must re-state claims for the entire policy, including the complete COB claim, reducing total allowed costs for EHB by the amount paid by another issuer, as applicable, in both the standard plan and the plan variation, to ensure correct re-adjudication of CSR provided for that policy. See also REGTAP FAQ 15101 and 15106.

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