Appendix G - Discrepancy Report

APTC/CSR/UF Discrepancy Report
Report Description:
This draft report represents a conceptual layout that issuers could use to report payment discrepancies at the detail level. This format permits reporting of the advance payments of the premium tax credit (APTC),
advance payments for cost-sharing reductions (CSR) and FFM user fees that the QHP issuer believes it should have received/been assessed versus what was actually received/assessed as indicated on the 820.
CMS could use this report as a basis for comparison in order to determine where the payment discrepancy exists and to resolve any payment errors. When discrepancies exist and after receipt of the monthly
payment and 820, this report would be generated by the QHP Issuer and sent to CMS for analysis and remediation.
Element
Header Elements
Report date/time
Report type
Name of Organization
Tax Identification Number
Payment month (month/year)
Electronic Funds Transfer Trace number

Description

Level 2 Elements
Subscriber first name
Subscriber last name
Exchange assigned subscriber identifier
Exchange assigned QHP ID
Exchange assigned policy identifier
Issuer assigned policy identifier
Issuer assigned subscriber identifier
From/to date of payment
APTC amount expected for enrollment group
APTC amount received for enrollment group
Advance CSR amount expected for enrollment group

Qualified Health Plan level elements for APTC/CSR discrepancy report (this level should loop for each subscriber/from/to date of payment
combination)
First name of subscriber*
Last name of subscriber*
Unique member identifier assigned to the subscriber by the Exchange*
Unique qualified health plan identifier; the standard component or QHP ID
Unique policy identifier assigned by the Exchange*
Unique policy identifier assigned by the QHP issuer*
Unique member identifier assigned to the subscriber by the QHP issuer*
Date range in MM/DD/YYYY for payment within a payment month.
APTC amount the issuer believes it should have received on behalf of that enrollment group for the payment month.
APTC amount the issuer actually received on behalf of that enrollment group for the payment month and as depicted on the 820.
Advance CSR payment amount the issuer believes it should have received on behalf of that enrollment group for the payment month.

Advance CSR amount received for enrollment group

Advance CSR payment amount the issuer actually received on behalf of that enrollment group for the payment month and as depicted on the 820.

Header elements for APTC/CSR discrepancy report
Date/time of report execution
Classification of report based on report purpose; e.g., Monthly Payment Discrepancy Report
Payee Name, e.g., legal business name of insurance company
Payee TIN
Payment processing month/year, e.g., start and end dates
For payments, this is a unique payer assigned reference number on the 820. For non-payments, this is a unique remittance advice identification
number on the 820. The segment on the 820 is the TRN - Reassociation Trace Number (TRN02).

FFM User Fee amount expected for enrollment group

Federally Facilitated User Fee amount the issuer believes it should have been assessed on behalf of that enrollment group for the payment month.
FFM User Fee amount assessed for enrollment group
Federally Facilitated User Fee amount the issuer was assessed on behalf of that enrollment group for the payment month.
*These fields should be populated with the values on the received 820 unless the enrollment group does not appear on the 820, in which case the values should be those present in the issuer's system.
draft May 16, 2013
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