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Text of CMS Guidance for Issuers of Qualified Health Plans: Re-Adjudication of Claims Subject to Cost-Sharing Reductions (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 18, 2014
"CMS expects issuers to re-adjudicate claims in a manner resulting in cost-sharing reduction calculations approximating the amounts that would result if the claims were re-adjudicated in the order in which the claims arose ... [To] ensure accuracy and consistency, an issuer that uses a third-party PBM for pharmaceutical claims may elect to re-adjudicate claims by first setting all accumulators to zero, and then reprocessing the medical claims in temporal order followed by the pharmaceutical claims in temporal order.... [This] guidance also applies with respect to any other third-party administrator of a subset of an issuer's benefits, such as a third-party administrator of substance use disorder benefits."

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