By Brad Marks, General Manager, Risk Adjustment Products
During the second annual EDGE Server submission, participating organizations prepare CMS submissions that are used for interim reinsurance payment calculation and interim risk adjustment summary reporting. The submission process entails cleansing and submitting data, correcting errors, analyzing a myriad of de-identified XML files and filing discrepancy reports. The 15-day extension that was given to insurers in 2015 was not provided in 2016, requiring issuers to meet the May 2 submission deadline.
Once the initial EDGE Server submission is complete, participating health insurance issuers must attest to the accuracy and completeness of the data for the 2015 benefit year. This attestation must be conducted between 12:01 a.m. ET May 3, 2016 and 11:59 p.m. ET May 31, 2016. Attestation allows for reporting of discrepancies for one or more Health Insurance Oversight System (HIOS) IDs.
Submitting an Attestation
Once health insurance issuers determine if the EDGE Server submissions were complete and accurate or contained discrepancies, they need to report their findings to CMS through the EDGE Server web form by selecting one of two options: (1) Submit attestation with no discrepancies; (2) Submit attestation with at least one discrepancy.
Complete and Accurate Attestation
If a health insurance issuer has no discrepancies to report, indicating that all of the data submitted for the relevant HIOS IDs is complete and accurate, the user will be asked to confirm each relevant HIOS ID. Once the HIOS IDs are confirmed, the EDGE Server submission process is complete.
If the health insurance issuer indicates that they have one or more discrepancies, the EDGE Server web form will begin a series of prompts related to each discrepancy, process and health insurance issuer. Supporting documentation for each discrepancy may be required. After each of the discrepancies has been reported, the user can attest to the submission, including the noted discrepancies, and complete the EDGE Server submission process.
Application of Discrepancy Data
It is important to understand that discrepancies reported during the attestation period will not decrease charges or increase payments for the health insurance issuer, even if the discrepancy filing provides additional data or corrects inaccurate data. The only exception would be if a discrepancy was due to a CMS error, such as: (1) A CMS processing error; (2) An incorrect application of the relevant methodology by CMS; (3) A CMS mathematical error.
Importance of Attestation
Although health insurance issuers put significant emphasis on meeting the May 2 EDGE Server submission deadline, it is equally important that the attestation is completed within the specified attestation and discrepancy reporting period. Once the health insurance issuer has attested to the accuracy or discrepancies, the EDGE Server submission process is complete. Risk Adjustment and Reinsurance program results are scheduled to be released June 30, 2016.