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

Issue Date: May 03, 2016

Program Area: CSR Reconciliation (CSR)

Question: Please clarify 'natural order' for retroactively processed Cost-sharing Reduction (CSR) claims, since REGTAP FAQ 15458 and 15460 seem contradictory?

Answer: The guidance from the Centers for Medicare & Medicaid Services (CMS) on the re-adjudication of claims (November 17, 2014) applies to the retroactive adjustment of CSR amounts for enrollees who were not provided correct amounts of reduced cost-sharing. The purpose of retroactive re-adjudication is to correct accumulators and refund enrollees, if applicable. Therefore, when subsequently re-adjudicating re-processed claims for the purpose of CSR reconciliation, issuers must follow the corrected order of claims and accumulators, (when cost-sharing should have been incurred) and not the date when the issuer reprocessed the claims to correct errors.

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