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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


EDGE Server Data Submissions: Do You Need Help?


By Bryan Briegel/Thursday, July 7, 2016



Now that health plans have a couple of years of EDGE server data submissions under their belts, it’s a great time to step back and evaluate how your organization did.

We think a few key questions to ask are:

  • How well did our approach to EDGE work?
  • Did we have clean data to optimize our risk adjustment?
  • Were we able to respond to the changes in CMS requirements in a timely and effective manner?
  • What operational improvements do we need to make?

  • The fact is, many health plans — busy serving their members by providing quality care at a reasonable cost — simply don’t have the proper resources or experience in place to complete the arduous tasks needed to comply with the Premium Stabilization Programs. The EDGE server requirements are challenging — and missteps in meeting them have led to disappointing results, including leaving reinsurance dollars and understated risk scores on the table . Even large health plans with corporate supports in place have been challenged to meet the requirements.

If you think there’s a potential for improvement, now is the time to consider a new plan for your EDGE server submissions. Should you continue to go it alone or stick with your current TPA? Before you decide, consider all the things that a proper EDGE server process should entail.

Your solution should give you:

  • On-time, accurate submissions
  • Dynamic data management services, with constant updating to meet CMS changes
  • At a minimum, quarterly analytic reporting
  • Support staff to keep current with CMS changes and respond to their EDGE server inquiries and mandated server updates
  • Peace of mind and the ability to focus internal resources  attending to your day-to-day responsibilities

If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.


Bryan Briegel, Healthcare Reform Solutions Specialist 
Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations



EDGE Server Data Submissions: Do You Need Help?


By Bryan Briegel/Monday, May 18, 2015


 

Now that the April 30 CMS deadline for submitting EDGE server data – and even the May 15th grace period – has passed, it’s a great time to step back and evaluate how your organization did.

We think a few key questions to ask are:

 ·         How well did our approach to EDGE work?

 ·         Did we have clean data to optimize our risk adjustment efforts?

 ·         Were we able to respond to the constant change in CMS requirements in an effective manner?

 ·         What improvements do we need to make?

 The ACA has made an already complicated, competitive business even harder. And the fact is, many health plans — busy serving their members by providing quality care at a reasonable cost — simply don’t have the proper resources or experience in place to complete the arduous tasks needed to comply with the Premium Stabilization Programs. The EDGE server requirements are challenging — and they will continue to evolve. Even large health plans with corporate supports in place were hard-pressed to meet the 2014 requirements.

If you think there’s need for improvement, now’s the time to consider a new plan of attack for your 2015 submissions. Should you do it on your own? Before you decide, consider all the things that a proper EDGE server process should entail. Your solution should give you:

 ·         On-time, accurate submissions

 ·         Ongoing risk score optimization services

 ·         Data management setup and continuous data management services

 ·         At a minimum, quarterly analytic reporting

 ·         A support staff to keep up with HHS changes and respond to their EDGE server inquiries

 ·         Peace of mind and the ability to focus internal resources  attending to your day-to-day responsibilities

If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.

Bryan Briegel, Director of Operations
Anita Nair-Hartman, Vice President, Payer Strategy and Business Operations




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


By Bryan Briegel/Friday, April 24, 2015


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


New CMS EDGE Server Requirements Challenge Health Plans


By Bryan Briegel/Friday, October 10, 2014
On Wednesday, October 1, Centers for Medicare & Medicaid Services (CMS) hosted a special webinar on EDGE server requirements for issuers of ACA-compliant small group and individual plans on and off the Exchange, subject to the Risk Adjustment and Reinsurance programs. The webinar has left many health plans confused – CMS’s updated enrollment file requirements are a fundamental shift away from specifications issuers have been coding to since May 2013, when CMS announced the enrollment technical and business rules.

What was announced? In short, effective immediately, all enrollment extracts that have been coded to comply with CMS specifications have been rendered incorrect, and will not support the Risk Adjustment Transfer payment calculations – one of the key reasons for submitting data to the EDGE servers. As an EDGE server host and partner with a number of health plans, we at Truven Health Analytics have been working with our clients to handle these changes. 

Here is some background for those new to the game: CMS announced late this summer that it expects issuers to load 2014 enrollment and claims data to their EDGE servers by December 5, 2014, so issuers may receive estimates of their reinsurance payments and risk scores. Since the inception of the program, the enrollment file – and its required structure – has been the most complex and challenging file to produce. Compounding this has been the lack of clarity on how to set a particular field called “Enrollment Period Activity Indicator” (EPAI) and the companion requirement mandating how dependent records must fall within bounds of enrollment start and end dates of their subscriber’s record.

From the October 1 announcement, through the eventual late October 7 release, the CMS shift in requirements left issuers in limbo – suspending any coding activity on enrollment extracts or for those who may have completed coding, and left them considering resourcing a rapid response team to review and revise the extracts. 

Since the October 7 release, the Truven Health EDGE team has reviewed the updated requirements and is working with our issuer partners to re-code their extracts. In helping our issuer partners prepare for the CMS December 5 EDGE data load and initial CMS report run, many have discovered gaps in their billing and rendering provider IDs. CMS has specified that provider IDs are required for claims submitted to the EDGE server and will reject claims with missing IDs. Truven Health has worked with CMS to validate that billing and rendering provider IDs may be used interchangeably on a claim. Additionally, if there is no provider ID information available, issuers may use a proxy or “dummy” ID in its place; for example, a constant string of “333333333333333” while setting the provider ID qualifier as 99. CMS will publish updates to provider ID requirements within the next few weeks via REGTAP, where CMS promulgates business rules and technical requirements for EDGE.

For Truven Health’s part, we’ll continue to monitor these events and share information that impacts your EDGE server work and partner with you to keep in step with CMS.

Bryan Briegel
Director, Operations

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