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

Issue Date: November 04, 2019

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: Can the Centers for Medicare & Medicaid Services (CMS) publish a list of reason codes for claims exclusion including reason codes related to Risk Adjustment (RA) program?

Answer: There are 16 reason codes used to identify why a claim is excluded from RA listed below: Code Description R01 Unacceptable bill type for an RA institutional claim. R02 Inpatient institutional claims cannot have the Statement Covers From date prior to 2014. R03 Professional and Institutional Out-Patient claims must have at least one RA eligible service code. R04 Unacceptable discharge status code for an institutional inpatient claim. R05 Active plan record does not exist for the year of the claim coverage from date. R06 Claim not associated to an active enrollment period of an enrollee. R07 Claim statement covers through date does not fall within the payment year. R08 Out-patient or professional cross year claim excluded from RA because the enrollee has no issuer submitted enrollment coverage in an active plan and rating area for the payment year. R09 Supplemental record's associated medical claim is not RA eligible. R10 Supplemental record not associated to an active medical claim. R11 Pharmacy claim prescription fill date does not fall within the payment year R12 Active plan record does not exist for the year of the Pharmacy claim's prescription fill date. R13 Pharmacy claim does not have an NDC that maps to an RXC. R14 Pharmacy claim belongs to an enrollee that does not have enrollment in any active rating areas in the same plan as the claim. R15 Pharmacy claim not associated to an active enrollment period of an enrollee. R16 Medical claim belongs to an enrollee that does not have enrollment in any active rating areas in the same plan as the claim.

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