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By Truven Staff

Appealing the CMS Risk Adjustment and Reinsurance Calculations: Making Sense of the Discrepancy Regulations

On March 16, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to all Edge server issuers, titled Technical Guidance for FORMAL Discrepancy Reporting Procedures Regarding Edge Server Outbound Risk Adjustment and Reinsurance Program Estimate Reports

This technical guidance reminded issuers that if they want to appeal CMS’s risk adjustment and reinsurance calculations, two windows are available to file a formal discrepancy. (A formal discrepancy is a required action to preserve the issuer’s rights to appeal these calculations.)

The first formal discrepancy reporting window allowed issuers to use either the Risk Adjustment & Reinsurance (RARI) reports that CMS triggered in March, 2015, or the RARI reports they triggered on April 3, 2015. This first formal discrepancy reporting window closed on April 14.

The second—and final—formal discrepancy reporting window for issuers who wish to preserve any calculation appeal rights opens on May 4th and closes 15 days later, on May 18th. Because this final formal window is extremely brief and the process is detailed and complex, issuers are naturally looking for a way to gain more time.

The compressed timeline, combined with CMS’s recent decision to trigger RARI reports weekly until April 30, has led to some confusion on which CMS reports may be used to support the second and final formal discrepancy process. Issuers now have so many CMS-triggered RARI reports and so little time that some are planning to use April-triggered reports, but the regulations dictate that the May reports must be used.

Truven Health Analytics encourages issuers to review CMS’s guidance, and ensure they use their May 1–3 CMS-generated RARI reports in any formal discrepancy process. In tandem, we have reached out CMS to ask them to consider publishing an FAQ reminding issuers that only this report may be used in the second and final discrepancy reporting process. To learn more about this issue or other Edge processes, contact us.

Brian Breigel
Director, Operations

Categories: Health Plan