Advice from our experts on how to optimize your EDGE data submissions and accurately represent your commercial risk.
When managing enrollment and claims data, accuracy and security is non-negotiable. With the establishment of the Affordable Care Act (ACA), regulations were put into place to improve access to health insurance, lower healthcare costs to consumers, and established the exchanges to stabilize the markets and premiums. The Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), via the newly-established Center for Consumer Information and Insurance Oversight (CCIIO) implemented the commercial risk adjustment program for providers/issuers of health insurance.
Building on our expertise as day-one experts in prescription drug claims and enrollment data submissions for clients participating in the Retiree Drug Subsidy program, and unparalleled success in Early Retiree Reinsurance program medical claims and drug claim reporting. When the program was depleted of its $5B in funding, (our team facilitating receipt of $1.3B of those dollars into our client’s accounts), we rapidly evolved our expertise in compiling and aggregating claims and enrollment data in compliance with CMS specifications, by spinning up, hosting, and creating external data gathering environment (EDGE) data submissions for the CMS-required servers.
Since day one of EDGE, we’ve been a trusted and proven partner and provider of TPA services, working to ensure success in presenting plan risk and supporting accurate risk adjustment transfers. With this, our team has summarized five key practices to help you optimize your EDGE data submissions and accurately represent your commercial risk:
While risk adjusted claims transfer risk adjusting diagnosis and National Drug Codes (NDCs), the accuracy of your plan data lays the foundation for EDGE server reporting. Submitting accurate data in a rating region is critical, as even small errors can have significant financial impacts.
Another top priority; analyzing your EDGE server rejection summary and detail reports and resolving rejections. This ensures you are representing a full picture view of your risk and are credited for a complete and accurate accounting of your population’s HCCs and risk scores to HHS’s commercial risk adjustment program, optimizing your risk adjustment transfers.
This is paramount. As part of submitting accurate and complete enrollment data, it’s critical to set the EPAI indicator accurately for enrollees. Failure to set this correctly means not getting credit for claims that are otherwise risk adjustment eligible. Our team utilizes the expertise they have developed over the years, and routinely utilizes the EDGE server test zone to scrutinize the results and validate our client’s data is accurate and accepted. Make it a practice to test, correct if needed, and then post data to the production zone.
A deep and current knowledge base in EDGE server operations and program change management is key. Understanding continuity of program changes and getting in front of them via the annual Notice of Benefit and Payment Parameters is critical to rapidly implement updates to program requirements. Keeping current with the EDGE server Interface Control Document, Business Rules, Operations and Maintenance Manual and monthly updates to Global Reference Files takes an investment of time and resources that pays dividends by informing a more efficient process. This practice has developed our team’s ability to rapidly provision and maintain EDGE servers, as well as implement and deploy required schema updates in a strategic manner.
Build and maintain long-term relationships
In parallel to a strong operational foundation and program knowledge, relationships are key to success. If you are considering engaging a third party to be your EDGE TPA, ensure they have a good partnership with you, CMS, and CCIIO.
At Merative, we take our role as an EDGE server TPA partner seriously and are dedicated to nurturing long-standing relationships built on trust and reliability. We understand the critical importance of the EDGE server program in supporting accurate risk adjustment transfers and maintain a continuous and long-standing relationship with CMS. If you’d like to learn more about our EDGE server solutions, please download the solution brief or talk to one of our experts.
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