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

Issue Date: May 11, 2016

Program Area: CSR Reconciliation (CSR)

Question: With regard to REGTAP FAQ ID 15573, does this example only pertain to hospital stays or does this include primary care physician (PCP) visits as well? If it includes PCP visits, how are we to break up multiple PCP visits that occur in a single month to appropriately record the allowed amount if the Per Member Per Month (PMPM) rate is supposed to be included in the allowed amount for that claim?

Answer: REGTAP FAQ 15573 applies to any encounter from a capitated provider. As stated in updated FAQ 15573 (May 3, 2016), and FAQ 15107, issuers should report a total allowed cost and plan paid amounts using their internal pricing system or a reasonable method for estimating these amounts, which may include per-member-per-month costs. In the case where the issuer charges a PMPM fee and the enrollee incurs cost-sharing for multiple services during multiple visits in a month, the issuer should not report total allowed costs equal to the PMPM amount. Instead, the issuer should apportion PMPM costs, if applicable and the costs of the services across visits using a reasonable method that is applied consistently for all members, regardless of their cost-sharing variation.

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