As the 2017 submission year kicks off, a quick note about a couple of CMS changes that may affect your submissions. First, CMS has substantially altered the ECS XML report (Orphan claims). They’ve changed the structure of the file, adding more detailed breakdowns by market. This change could cause your existing code or tooling to fail or miss important data, depending on how those tools are configured and coded. Check with your IT staff or EDGE TPA to ensure they are making the appropriate changes to avoid losing data. The ECS/ECD reports are important because they show CMS how many claims you have submitted, if those claims are orphans (have no proper coverage periods), and whether the claims are flagged for risk-adjustment. Therefore it’s very important for you, the Plan, to know what is being reported to CMS. If the numbers in the ECS report indicate that there are submission problems or are out-of-line with your baseline numbers, CMS will contact you by telephone or email, and ask for justification or corrections.
CMS has released version 7.0 of the EDGE Business Rules document, in which they have made substantial changes. This is the go-to document defining the rules under which enrollment, claims and supplementals are accepted. The Babel SMEs are analyzing the changes to determine if any substantial changes have been made to the rules themselves.
Lastly, CMS has added a validation zone to the EDGE servers, to test future releases of the EDGE server software. They advise strongly that no plan should submit to the validation zone unless instructed to do so by CMS. As always, questions can be sent to CMS.
– Chris Bladon, Director of Risk Analytics