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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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Categories: Health Plan