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

Issue Date: October 02, 2018

Program Area: Risk Adjustment (RA)

Question: Does risk adjustment require the submission of pharmacy claims?

Answer: Yes. Beginning with 2018 benefit year RA, as finalized in the 2018 Payment Notice (81 FR 94058 at 94074), adult enrollees' risk scores will incorporate some drug classes (Prescription Drug Categories [RXCs]) and those RXCs' interactions with Hierarchical Condition Categories (HCCs), if applicable, in States where the Department of Health and Human Services (HHS) operates the RA program. Therefore, all pharmacy claims should be submitted to an issuer's External Data Gathering Environment (EDGE) server not only for inclusion in calculating RA risk scores and ultimately transfers for a benefit year, but also for inclusion in the enrollee-level recalibration dataset and RA data validation. We also note that beginning for the 2018 benefit year EDGE data submissions, we will be collecting "days' supply" on pharmacy claims for evaluation as part of the enrollee-level recalibration dataset.

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