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

Issue Date: February 05, 2020

Program Area: Payment Policy and Financial Management Group External Audits (PPFMG EA)

Question: For 2014 benefit year audits of SBE issuer submitters (i.e., issuers that submitted on their own behalf) and issuers in SBE submitter states (i.e., states that submitted the EPDW on behalf of the issuers), should the desk audit file be created based on data from the issuer's systems or based on data from the SBE's systems?

Answer: For both SBE issuer submitters and issuers in SBE submitter states, the data reported in the desk audit file should be an extract of the current, effectuated enrollment and payment data from the issuer's systems of record. The issuer can coordinate with the SBE as needed on this data submission. This audit is the first opportunity to review the issuer's data in SBE submitter states. We understand there may be discrepancies between the SBE data and issuer data and coordination with the SBE and issuer may be required to determine root causes and resolution.

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