CSR Discrepancy Process For The 2019 And 2018 Benefit Year .
June 25, 2020Cost-sharing Reduction (CSR) DataSubmission Discrepancy ProcessOverview for Benefit Year 2019 andBY 2018 RestatementsHealth Insurance Exchange ProgramTraining SeriesThis communication was printed, published, or produced and disseminated at U.S. taxpayer expense.The information provided in this presentation is only intended to be a general informal summary of technical legal standards. It is not intended to take the placeHTTPS://WWW.REGTAP.INFO/of the regulations that it is based on. We encourage audience members to refer to the applicable regulations forcomplete and current information about therequirements that apply to them.
Agenda Discrepancy Resolution FileValidations and Record LevelDetails Session Guidelines Cost-sharing Reduction(CSR) Data SubmissionDiscrepancy ResolutionProcess Guidance Question and Answer(Q&A) Resources Discrepancy ReportingRequirements Closing Remarks2
Session Guidelines This is a 90 minute webinar session. For questions regarding content,please submit inquiries to the CSRData Submission team atCSRreconquestions@cms.hhs.gov For questions regarding logistics andregistration, please contact theRegistrar at: (800) 257-9520.3
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Intended Audience The intended audience includes Issuers that willbe submitting data regarding Cost-sharingReduction (CSR) payments for benefit year (BY)2019 and/or Issuers restating CSR payment datafor BY 2018.6
Purpose The purpose of this presentation is to provide an overviewof the CSR data submission discrepancy process. This presentation will address:– Guidance for the discrepancy process– The CSR data submission discrepancy reportingtimeline, and– Requirements for submitting discrepancy files7
Announcements
CSR Data Submission – DiscrepancyResolution Process Guidance CMS has previously released technical specificationson the discrepancy resolution process that issuersmust follow if they have a CSR discrepancy to report. Issuers seeking to file a discrepancy should use the“CSR Discrepancy Inbound Specification” for the 2017Benefit Year and 2016 Prior Year Restatementdocument located on the CCIIO website and REGTAP. CCIIO website link also rting-BY2017.pdf9
CSR Data Submission – DiscrepancyResolution Process CMS will only accept discrepancies for data thatdirectly impacts the issuer's final calculated CSRamounts. Issuers should not file a benefit year 2018restatement discrepancy for an issue for whichthe issuer previously filed a discrepancy.10
CSR Data Submission – DiscrepancyResolution Process (continued) The discrepancy period for issuers that receive a June30, 2020 letter notifying them of their final 2019 and 2018restatement CSR amount(s) will be from June 30, 2020to July 30, 2020 11:59 p.m. ET. The discrepancy period for all other issuers will be 30calendar days from the date of the letter notifying issuersof their final 2019 and 2018 restatement CSR amount(s). Any issuer that is considering filing an appeal must file adiscrepancy in order to file an appeal. The discrepancyprocess also permits CMS to work with the issuer toresolve the dispute prior to an appeal.11
CSR Data Submission Report If you have questions regarding data in yourorganization’s data submission report, please contactCSRreconquestions@cms.hhs.gov. Please indicate in the subject line “2019/2018 CSRDiscrepancy” CMS can provide additional details about thecalculations in your report, which may address anyissue for which you may submit a discrepancy.12
Discrepancy ReportingRequirements
CSR Data Submission – DiscrepancyResolution Process Issuers will submit discrepancy files to CMS. CMS will review and investigate discrepancyfiles on a rolling basis as files are received. CMS will follow up with issuers tocommunicate the discrepancy results.14
CSR Data Submission – DiscrepancyResolution File Naming Convention Since discrepancy files will be submitted via Enterprise FileTransfer (EFT), issuers must follow the EFT required filenaming convention. The file name consists of the following sections:oooooooTrading Partner (TP) Identifier (ID)Application IDFunction CodeDateTimeEnvironment CodeDirection Sample IN15
CSR Data Submission – Discrepancy ResolutionFile Naming Convention (continued) The discrepancy files are being processed by adifferent system than CSR data submission dataand attestation files. Accordingly, please note the differences inApplication ID and Function Code in thediscrepancy file name:– Application ID - OPR– Function Code - CSRDRI16
CSR Data Submission – Discrepancy ResolutionFile Format CSR data submission discrepancy files follow a similarformat as prior year’s discrepancy files. Discrepancy files will need to be submitted in a pipedelimited format, using ASCII text and a CRLF as the lineterminator. The file submitted by the issuer should have only oneHIOS ID.Note: One discrepancy file will include recordsthat apply to multiple benefit years, as applicable. If the issuer is submitting data for multiple HIOS IDs, theissuer will need to create a separate file for each HIOS ID.17
CSR Data Submission – Discrepancy ResolutionProcess Issuers should utilize the discrepancy reporting processfor:– Data discrepancies related to Qualified Health Plan(QHP) ID errors (CSRIFIL67)– Exchange Assigned Subscriber ID errors (CSRIFIL50)– Errors related to the amount of CSRs that an issuerprovided at the policy level Issuers must submit discrepancies in a pipe-delimited fileformat through EFT.18
CSR Data Submission – Discrepancy ResolutionFile Format CSR data submission discrepancy files have threelevels of records:– Issuer Summary (01) Records– Discrepancy Summary (02) Records– Policy Level (03) Records Some data elements in the discrepancy file arethe same as those submitted in the CSR datasubmission data files, while others are uniquedata elements.19
Discrepancy ResolutionFile Validations and RecordLevel Details
Discrepancy File ValidationsCMS will send a rejection report to the issuer’s EFT outbound folder, if the issuer’s filecontains any of the following errors: Across all the record levels, the count of the fields must match to the number specified inthe inbound specifications. The record levels must be in the specified order - i.e. Record level 01 followed by 02 and02 followed by the corresponding 03 records. The length of any single row must not exceed 4000 characters. Rows must end with an alphanumeric character. The Record Code must be 01, 02, or 03, only. Each Discrepancy Reason Type Code must match one of the values listed in thespecifications (01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13). Across all 01 record code rows in one file, if more than one HIOS ID is found, the file willbe rejected. If the HIOS ID is not applicable for the benefit year and state combination or the benefityear is not 2018 or 2019, the file will be rejected.21
Discrepancy Resolution File Format –Issuer Summary (01) Record One record should be created for each issuer andbenefit year. If an issuer is reporting multiple discrepancies fora benefit year, the information must be reported inthe Discrepancy Summary (02) and Policy (03)level records that correspond to the HIOS ID andbenefit year in the Issuer Summary (01) record. Issuer Summary (01) Records must have twelvefields.22
Discrepancy Resolution File Format –Issuer Summary (01) Record (continued) If an issuer is reporting discrepancies for multiplebenefit years, there should be an “01” level record foreach benefit year. Each Issuer Summary (01) record must beimmediately followed by the DiscrepancySummary (02) and Policy Level (03) records thatcorrespond to the HIOS ID and benefit year in thepreceding Issuer Summary (01) record.Note: Highlighted fields represent unique dataelements not included in the CSR data submissionfiles.23
Discrepancy Resolution File Format –Issuer Summary (01) Record (continued)24
Discrepancy Resolution File Format –Discrepancy Summary (02) Record Records with Record Code 02 should bepositioned in the text file immediatelyafter the Issuer Year (01) record they areassociated with. Discrepancy Summary (02) records musthave six fields.Note: Highlighted fields represent uniquedata elements not included in the CSR datasubmission files.25
Discrepancy Resolution File Format –Discrepancy Summary (02) Record (continued)26
D i s c r e p a n c y R e a s o n Ty p e C o d e Appendix 1 in Specification document27
Discrepancy Resolution File Format –Policy Level (03) Record Issuers must populate Policy Level (03)records with the details (for example,QHP IDs or Subscriber IDs) for eachDiscrepancy Summary (02) record thatthe issuer is filing a discrepancy for fromtheir data file(s).28
Discrepancy Resolution File Format –Policy Level (03) Record (continued) Policy level (03) records should be populatedfor each Issuer/Year/Discrepancy Reason thataffects fewer than "All" Exchange AssignedSubscriber IDs. Records with Record Code 03 should bepositioned in the text file immediately afterthe Discrepancy Year (02) record they areassociated with. Policy level (03) records must have eight ornine fields.29
Discrepancy Resolution File Format –Policy Level (03) Record (continued)30
Discrepancy Resolution File Format –Policy Level (03) Record (continued)070809Policy Benefit End DateAmount of CSR Provided Disputed forthe PolicyUpdated Subscriber IDMMOMMODateNumericText8Date that the subscriber’s enrollment in this policy ended.Policy Benefit End Date should be in MMDDYYYY format.Note: CMS does not validate this value but it may be usedin CMS’s investigation of the discrepancy.4-12This is the amount of the discrepancy for CSR providedthat is associated with the specific Discrepancy ReasonType Code (defined in Appendix 1) and this policy recordonly. Can be positive or negative. Positive suggests theissuer is indicating that it provided more valid CSR thanwas accepted by CMS.10Optional field to provide a corrected Exchange SubscriberID. This field should only be used if an incorrect ID wassubmitted in the original CSR Reconciliation submission.Note: Highlighted fields represent unique data elementsnot included in the CSR data submission files.31
CSR Data Submission Discrepancy FileFormat Sample #1 with an Issue01 123456 AA 12345 2015 100 a c abc@gmail.com d 1234567890 last file 201502 R01 "Manual Enrollment" N 2 5003 N 1234567890 1234567890123456 abcdefgh 25.0003 Y 2234567890 1234567890123456 abcdefgd 25.0002 R06 "Lost Claims" N 1 5003 1234567890 1234567890123456 abcdefgh 50.0001 123456 AA 12345 2016 200 a c abc@gmail.com d 1234567890 last file 201602 R12 "Member ID provided instead of subscriber id" N 2 20003 Y 1234567890 1234567890123456 abcdefgh 100.00 123456789103 Y 2234567890 1234567890123456 abcdefgd 100.00 2234567891Issue: The 03 records do not have thecorrect field count. Policy Start and End Datefields are missing from the 03 records.32
CSR Data Submission Discrepancy FileFormat Sample #2 with an Issue33
CSR Data Submission Discrepancy FileFormat Sample #3 with an Issue34
CSR Data Submission Discrepancy FileFormat Sample #4 with an Issue35
CSR Data Submission Discrepancy FileFormat Sample #5 with an Issue36
CSR Data Submission Discrepancy FileFormat Sample #6 with an Issue37
CSR Data Submission Discrepancy FileFormat Sample #7 – No Issues01 123456 AA 12345 2015 100 a c abc@gmail.com d 1234567890 last file 201502 R01 "Manual Enrollment" N 2 5003 N 1234567890 1234567890123456 abcdefgh 01012015 12312015 25.0003 Y 2234567890 1234567890123456 abcdefgd 01012015 12312015 25.0002 R06 "Lost Claims" N 1 5003 1234567890 1234567890123456 abcdefgh 01012014 12312014 50.0001 123456 AA 12345 2016 200 a c abc@gmail.com d 1234567890 last file 201602 R12 "Member ID provided instead of subscriber id" N 2 20003 Y 1234567890 1234567890123456 abcdefgh 01012016 12312016 100.00 123456789103 Y 2234567890 1234567890123456 abcdefgd 01012016 12312016 100.00 223456789138
CSR Data Submission – DiscrepancyResolution Decision CMS will send Discrepancy Resolution Decisions afterinvestigating all discrepancies within a company. Discrepancy Resolution Decisions will include informationabout next steps and how to file a request for reconsideration.– Issuers with certain approved discrepancies* will be asked toresubmit full and complete updated data and attestation files toMIDAS in order for CMS to complete discrepancy processing.– MIDAS will automatically reprocess an issuer’s most recent datafile if the issuer has an approved R01 or R02 discrepancy (andno other approved discrepancies that would require the issuer toupdate and resubmit their data file).– CMS will send revised reports after the above steps arecompleted.*Discrepancy reason type codes R03, 04, 05, 06, 07, 08, 09, 10, 11,12, or 13.39
CSR Data Submission – Requestsfor Reconsideration Issuers may request reconsideration of the calculatedCSR amount within 60 days of the date of thediscrepancy resolution decision. Issuers may contest a processing error made byHHS, an incorrect application of the relevantmethodology by HHS, or a mathematical error madeby HHS. CMS will provide additional guidance at a later dateon the request for reconsideration process of finalcalculated CSR amounts.40
Questions?To submit or withdraw questions byphone: Dial *# (star-pound) on your phone’skeypad to ask a question. Dial *# (star-pound) on your phone’skeypad to withdraw your question.To submit questions by webinar: Type your question in the text boxunder the ‘Q&A’ tab.
Resources
ResourcesResourceResource LinkCenters for Medicare & MedicaidServices (CMS)http://www.cms.gov/U.S. Department of Health & HumanServices (HHS)http://www.hhs.gov/The Center for Consumer Information& Insurance Oversight (CCIIO) webpagehttp://www.cms.gov/cciioConsumer website on Health Reformhttp://www.healthcare.gov/Registration for Technical AssistancePortal (REGTAP) - presentations, FAQshttps://www.REGTAP.info43
Locating CSR Data SubmissionD o c u m e n t s i n R E G TA PStakeholders can access additional documents athttps://www.REGTAP.info in the REGTAP Library.Under ProgramArea, select“Payment-CSRReconciliation”44
I n q u i r y Tr a c k i n g a n d M a n a g e m e n tSystem (ITMS)Stakeholders can submit inquiries tohttps://www.REGTAP.info through ITMS.Select “Submit anInquiry” or to viewsubmitted inquiriesselect ‘My Inquiries’from My Dashboard.Note: Enter only one (1) question per submission.45
FAQ Database on REGTAPThe FAQ Database allows users tosearch FAQs by FAQ ID,Keyword/Phrase, Program Area,Primary and Secondary Categories,Benefit Year, Retired and CurrentFAQs, and Publish Date.FAQs Database is available atwww.REGTAP.info46
Closing Remarks
Cost- sharing Reduction (CSR) Data Submission Discrepancy Process Overview for Benefit Year 2019 and BY 2018 Restatements. June 25, 2020. Health Insurance Exchange Program. Training Series. Agenda SessionGuidelines Cost-sharing Reduction (CSR
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