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

Issue Date: April 19, 2016

Program Area: CSR Reconciliation (CSR)

Question: We receive encounters from capitated providers and process them through our system just like fee-for-service claims. For example, if the hospital stay is capitated $1,200 for the member, the claim is processed through our system to show an allowed amount of $10,000 with a member pay of $100 on the CSR plan and a plan pay of $9,900. Since this is an encounter, we do not actually pay the $9,900. Should issuers report on the 03 record an allowed amount of $10,000, a plan pay of $9,900, a member pay of $100, a member would have paid (assume $5,000 in the standard plan) and then a CSR provided of $4,900? Or do issuers report an allowed amount of $1,300?

Answer: In the case of capitated or discounted services, issuers should report a total allowed costs and plan paid amount using their internal pricing system or a reasonable method for estimating these amounts. Total allowed costs should be the same in the plan variation and the standard plan. Of course, enrollee paid amounts should reflect the amounts the enrollee did pay under the plan variation, and the amounts they would have paid under the standard plan.

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.