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

Issue Date: April 19, 2016

Program Area: CSR Reconciliation (CSR)

Question: How should issuers report claims where the DRG allowable is greater than the billed amount on a claim? For example, based on our provider contract, we will allow $7,787.34 per the DRG contract for a claim, but the billed amount is $5,785.23. The member cost share is $1,000 per Cost-sharing Reduction (CSR) plan, but changes to $6,000 - or more than the billed amount - under the standard plan. Will this be an issue in the CSR submission?

Answer: The total allowed cost for Essential Health Benefits (EHB) is the actual allowed cost of the claim, not the DRG allowable. If you have a contract with a provider to offer the care at a discount from your DRG allowable then, for CRS reconciliation, the allowed EHB cost for this claim is the discounted rate, $5,785.23, of which the member paid $1,000. The cost of care in the standard plan must be reduced to the equivalent discounted "billed" amount; so issuers cannot use the billed amount in the CSR plan and the DRG allowable in the standard plan when re-adjudicating this claim against the standard plan cost. The benefits and cost sharing structure of the standard plan must be identical to the benefits and cost sharing structure of the associated plan variation. If there is a discount in the CSR plan, there must be an equivalent discount in the standard plan.

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