ERRP data inaccuracies and reopenings guidance

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-15
Baltimore, Maryland 21244-1850

Center for Consumer Information and Insurance Oversight

Explanation of the Processes for Reporting Early Retiree and Claims Data
Inaccuracies, and for Reopening – DRAFT
INSERT DATE
Section 1102 of the Affordable Care Act (42 U.S.C. §18002) established the Early Retiree Reinsurance
Program (ERRP). In order to effectively administer this program, plan sponsors, among other
requirements, must disclose any data inaccuracies upon which a reimbursement determination has
been made, including inaccurate claims data and negotiated price concessions received after a
reimbursement request has been made. 45 CFR 149.600. The regulations require that the sponsor
disclose this information in a manner and at a time specified by the Secretary in guidance.
This guidance sets forth the manner and timing for making such disclosures and also discusses the
reopening process. The Secretary of Health and Human Services may reopen and revise any ERRP
reimbursement determination on its own motion, or upon the request of a plan sponsor (45 CFR
149.610).
Reporting Data Inaccuracies – 45 CFR 149.600
The Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human
Services (HHS) administers the ERRP. CMS recognizes that a plan sponsor may discover that it
previously submitted inaccurate data as part of a reimbursement request. Alternatively, data may
require adjustment or modification after a plan sponsor submits a reimbursement request. When a
data inaccuracy is discovered, a plan sponsor must submit corrected data.
Definition of “Data Inaccuracy”
For purposes of ERRP, the term “data inaccuracy” is any instance of inaccurate data included in an
Early Retiree List, Summary Cost Data, or a Claim List, such as:

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An Early Retiree List record for an individual who is an active employee during the reported
plan coverage dates;
An Early Retiree List record containing an inaccurate Member ID, Member Group ID, plan
coverage dates, etc.;

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Costs reported with respect to an individual who did not satisfy the definition of “early retiree”
on the day the costs were incurred;
Over-reported or under-reported Costs Paid by Plan, Costs Paid by Early Retiree, Threshold
Reduction, or Limit Reduction amounts in Summary Cost Data;
Over-reported or under-reported amounts in the Item Plan Paid Amount or Cost Paid by Early
Retiree field for a claim included within the Claim List;
Inaccurate Procedure Code or Principal Diagnosis Code for a claim included in a Claim List; or
Over-reported or under-reported Cost Adjustment Amount included in a Claim List.

This list provides examples of data inaccuracies and is not an exhaustive list.
In contrast, instances that are not considered data inaccuracies include instances when a plan sponsor
does not report any costs at all:
1. For a given early retiree whose costs could have been eligible for credit towards the cost
threshold or cost limit, or for reimbursement, or
2. For a given claim, and those costs could have counted toward the cost threshold or cost limit,
or have been reimbursed.
In these two situations, the requirement that a plan sponsor disclose previously submitted data
inaccuracies does not apply. A plan sponsor may report this data, but it is not required to do so.
Manner and Timing of Reporting
When a plan sponsor discovers that previously submitted cost or claims data requires modification or
the plan sponsor discovers a data inaccuracy, it must correct the inaccurate data in CMS’ ERRP secure
system pursuant to 45 C.F.R. 149.600. Corrections to data must be made no later than the end of the
next calendar quarter after the plan sponsor knows, or should know, of the data inaccuracy. A plan
sponsor should update CMS with accurate data by submitting a reimbursement request during that
next calendar quarter, even if it has no additional claims to submit or does not otherwise intend to
request further reimbursement.
In order for the CMS system to process the updated, corrected data, the plan sponsor must follow the
regular reimbursement request process. In other words, it must update or correct any inaccurate data
and submit an accurate Early Retiree List, Summary Cost Data, and Claim List. To the extent that any of
the data inaccuracies were related to previously reported Costs Paid by Early Retiree, the sponsor must
also submit, as part of the reimbursement request, accurate prima facie evidence that the individual
actually paid such amounts. For more information about submitting such prima facie evidence, see the
Early Retiree Reinsurance Program Prima Facie Evidence Cover Sheet, and accompanying instructions,
on www.errp.gov.

The reimbursement request in which the plan sponsor is correcting a data inaccuracy will count as the
one reimbursement request permitted for that calendar quarter for that plan year. If a plan sponsor
intends to submit additional incurred and paid claims (unrelated to any data inaccuracies) for
reimbursement for that plan year, they should be included with the data inaccuracy adjustments, in
one reimbursement request. Otherwise, the plan sponsor must wait until the next calendar quarter to
submit the other or newly incurred and paid claims for reimbursement.
As background, a plan sponsor may request reimbursement once every calendar quarter per plan, per
plan year, but not within 30 days of its last reimbursement request for that plan and plan year. A plan
sponsor may update its Early Retiree List, Summary Cost Data, or submit a Claim List at any time.
However, CMS does not consider Summary Cost Data or a Claim List to be reported until the plan
sponsor submits this material along with a reimbursement request. Also, in order to submit a
reimbursement request, the plan sponsor must have submitted a current Early Retiree List to CMS.
CMS responds to the submission of the plan sponsor’s Early Retiree List with an Early Retiree List
Response File that indicates which individuals have approved ERRP eligibility periods. Once the plan
sponsor has reviewed and processed CMS’ Early Retiree List Response File, it may assemble a
reimbursement request based on its claims data, and then request reimbursement.
The ERRP statute and regulations require that a plan sponsor only submit costs for health benefits that
have been incurred with respect to early retirees and their spouses, surviving spouses, and dependents
during a given plan year, and which have been paid, 42 U.S.C. §18002(c); 45 CFR 149.325. Claims must
also take into account any negotiated price concessions that have already been subtracted from the
amount the employment-based plan or insurer paid for the cost of health benefits and the amount of
post-point of sale price concessions received. 45 C.F.R. § 149.110. Thus, the process of reporting data
inaccuracies may result in an overpayment. In such cases, plan sponsors will be required to promptly
repay the difference between reimbursement amounts that were based on costs other than those
contemplated by the statute and regulation, and reimbursement amounts that are based on actual
costs for health benefits, including price concessions, in cases where the costs that had been
submitted for reimbursement resulted in an overpayment. CMS reserves the right to adjust, by the
amount the plan sponsor owes, any future reimbursement to be paid to the plan sponsor for the
applicable plan for the current plan year or a different plan year, or for a different plan sponsored by
the plan sponsor, if necessary to meet these requirements.
Please note that a plan sponsor cannot update data associated with a pending reimbursement request,
or make a subsequent reimbursement request if a current request is pending for the same plan and
plan year. This is because once a reimbursement request is submitted, the system does not allow for it
to be updated, or allow the plan sponsor to submit a new reimbursement request for the same plan
and plan year until the pending reimbursement request is processed. A pending reimbursement
request in some instances may be canceled to allow for the reporting of the necessary updates.
Contact CMS’ ERRP Center at [email protected] or by calling toll free 877-574-ERRP (877-574-3777) (TTY
for hearing impaired: 877-575-ERRP (877-575-3777)), if assistance is needed.

Reopening Process - 45 CFR 149.610
There may be instances when CMS reopens and revises a reimbursement determination on its own
volition or upon the request of a plan sponsor. For example, CMS may determine through an audit that
certain claims should not have been submitted and included as part of a reimbursement request, and
may elect to reopen and revise the associated reimbursement determination. While 45 CFR 149.610
allows plan sponsors to request a reopening, as this program has developed it appears that most issues
for which a plan sponsor might request a reopening would be resolved through the process established
for reporting data inaccuracies under 45 C.F.R. 149.600 as discussed in this guidance. Plan sponsors
should reserve reopening requests to instances when a data inaccuracy (and therefore a
reimbursement discrepancy) cannot be resolved under the process discussed relating to 45 CFR
149.600.
A reimbursement determination may be reopened and revised only within the time periods specified
in 45 C.F.R. 149.610, unless fraud or similar fault is found. Whether on its own volition or upon request
of a plan sponsor, CMS may reopen and revise a reimbursement determination for any reason within
12 months following the date of the notice of a reimbursement determination. After 12 months, but
within 4 years from that date, CMS may reopen and revise a reimbursement determination upon
establishment of good cause. “Good cause” is defined in the regulation at 45 C.F.R. 149.2 as:
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New and material evidence exists that was not readily available at the time the reimbursement
determination was made;
A clerical error in the computation of reimbursement was made by CMS; or
The evidence that was considered in making the reimbursement determination clearly shows
on its face that an error was made.

CMS may reopen and revise a reimbursement determination at any time in instances of fraud or
similar fault of an ERRP plan sponsor or any subcontractor of the plan sponsor. Except in instances of
fraud or similar fault, the regulation does not allow for a reopening and revision beyond the four-year
period. In the limited instances when a plan sponsor requests a reopening under 45 CFR 149.610, CMS
prefers that reopening requests be submitted electronically. When submitting a request to reopen,
please comply with the following procedures:
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Submit an electronic copy of the reopening request and all applicable documentation to CMS
at [email protected]. Please include the phrase “Reopening Request” in the subject line of the
email. For ERRP purposes, plan sponsors should not send protected health information or
other identifiable information via email, as it is not considered a secure transfer.
If mailing a reopening request and supporting documentation to CMS via U.S. Postal Service,
please mail the package to:
ERRP Center Payment Operations
P.O. Box 6866
Towson MD 21204

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All requests must be submitted in compliance with all applicable privacy and security laws.

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In the request for reopening, please thoroughly describe the issue and submit sufficient
documentation supporting the request for reopening. Include a thorough analysis of the
estimated financial impact for each reason stated within the request, including the specific
amount of reimbursement that is believed at issue.
If the request to reopen and all supporting documentation are submitted via email, the request
is not considered received until the plan sponsor receives a confirmation email from CMS .
The specific date that a request to reopen is considered to have been submitted by a plan
sponsor for purposes of the deadlines specified in 45 CFR 149.610, is addressed in the following
bullets. The confirmation email from CMS should be received within five business days of filing
the request. If not, please contact CMS’ ERRP Center at [email protected] or by calling toll free
877-574-ERRP (877-574-3777) (TTY for hearing impaired: 877-575-ERRP (877-575-3777)).
If a request to reopen is submitted via email, the request is considered submitted on the date
listed in the “Sent” line of the email request, not the date that the plan sponsor receives the
confirmation email from CMS.
If the request and supporting documentation are submitted via U.S. Postal Service, the
submitter should have proof of delivery such as a return receipt, and is expected to provide the
proof of delivery upon request by CMS. Because a request for reopening, which includes all
supporting documentation, should be requested by a plan sponsor within one year of the
applicable reimbursement determination, if requesting the reopening for any reason, or within
four years, if the basis of the request is for good cause, a reopening request that is mailed will
be considered submitted on the postmark date of the request, provided that the plan sponsor
has proof of delivery.
Upon receipt of a request to reopen, CMS will analyze the request and supporting
documentation and make a decision whether or not to reopen and revise the reimbursement
determination. The regulation does not establish a time period for this review; however, CMS
will attempt to make a timely decision on the reopening request.
Once a decision is made by CMS, an email communicating the CMS decision will be sent to the
plan sponsor’s Authorized Representative and Account Manager.
If CMS elects to reopen, a plan sponsor can expect to receive further guidance from CMS. The
reopening and revision process may require substantial CMS preparation and resources, and
cannot be expected to be performed immediately after the plan sponsor receives the decision
to reopen. A decision by the Secretary not to revise a reimbursement determination is final and
binding (unless fraud or similar fault is found) and cannot be appealed.