CMS-10401 Appendix A 3Rs PRA

OMB Control Number 0938-1155
Expiration Date: XX/2025

Appendix A
Data Elements for Risk Adjustment and Reinsurance
Data Category

Data Elements

Geographic Data

•
•
•
•
•
•

Market Level Data

•
•

Plan ID
Metal Level
Actuarial Value
Benefit Year
Rating Area
Individual or small-group or merged market
State average actuarial risk (HHS-sourced)
State Rating Curve

Submitting Entity

State / Issuer

State

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Data Elements

Submitting Entity

Enrollee Level Data

Includes header, issuer, and enrollee data
elements:
• File ID
• File Execution Zone
• Run Date/Time
• Report Type
• Total Number of Enrollee Records
• Total Number of Enrollment Period Records
• Record ID
• Issuer ID
• Unique Enrollee ID
• Enrollee DOB
• Enrollee Gender
• Subscriber Indicator
• Enrollment Period Activity Indicator
• Subscriber ID
• Plan ID
• Enrollment Start Date
• Enrollment End Date
• Premium Amount
• Rating Area
• Zip Code
• Race
• Ethnicity
• Subsidy Indicator
• Qualified Small Employer Health
Reimbursement Arrangement Indicator
• Individual Coverage Health Reimbursement
Indicator

Issuers

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Pharmacy Claims

Data Elements
Includes header, issuer, plan and claim data
elements:
• File ID
• Execution Zone
• Run Date/Time
• Report Type
• Total Claims
• Total Plan Paid Amount
• Issuer ID
• Record ID
• Plan ID
• Unique Enrollee ID
• Claim ID
• Claim In-Network or Out-of-Network
Indicator
• Claim Processed Date/Time
• Fill Date
• Paid Date
• Prescription/Service Reference Number
• Product/Service ID Qualifier
• Product/Service ID
• Dispensing Provider Service ID Qualifier
• Dispensing Provider Service ID
• Fill Number
• Days Supply
• Dispensing Status
• Void/Replace Indicator
• Total Allowed Cost
• Derived Amount Indicator
• Plan Paid Amount
• Interface Control Release Number

Submitting Entity

Issuer

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Medical Claims

Data Elements
Includes header, issuer, plan and claim
header and claim line data elements:
• File ID
• Execution Zone
• Run Date/Time
• Report Type
• Total Claims
• Total Claim Lines
• Total Plan Paid Amount
• Record ID
• Issuer ID
• Plan ID
• Unique Enrollee ID
• Interface Control Release Number

Submitting Entity

Issuer

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Medical Claims (continued)

Data Elements
Claim Header Level Data Elements:
• Form Type
• Claim ID
• Original Claim ID
• Claim In-Network and Out-of-Network
Indicator
• Claim Processed Date/Time
• Bill Type
• Date Paid
• Void/Replace Indicator
• Discharge Status Code
• Statement Covers From
• Statement Covers Through
• Billing Provider ID Qualifier
• Billing Provider ID
• Total Amount Allowed
• Total Amount Paid
• Derived Amount Indicator
• Diagnosis Code Qualifier
• Diagnosis Code

Submitting Entity

Issuer

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Medical Claims (continued)

Data Elements
Claim Line Level Data Elements
• Diagnosis Code Record ID
• Claim Line Sequence Number
• In-Network and Out-of-Network Indicator
• Date of Service - From
• Date of Service - To
• Revenue Code
• Service Code Qualifier
• Service Code
• Service Code Modifier
• Place of Service
• Rendering Provider ID Qualifier
• Rendering Provider ID
• Amount Allowed
• Amount Paid
• Derived Amount Indicator

Submitting Entity

Issuer

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.

OMB Control Number 0938-1155
Expiration Date: XX/2025

Data Category

Data Elements

Submitting Entity

Supplemental Diagnoses

Includes header, issuer, plan and claim
header and claim line data elements:
• File ID
• Execution Zone
• Total Count of Detail Records
• Run Date/Time
• Report Type
• Record ID
• Issuer ID
• Plan ID
• Unique Enrollee ID
• Supplemental Diagnosis Detail Record ID
• Original Claim ID
• Detail Record Processed Date/Time
• Add/Delete/Void Indicator
• Original Supplemental Diagnosis Detail ID
• Date of Service From - From
• Date of Service - Through
• Supplemental Diagnosis Code Qualifier
• Supplemental Diagnosis Code
• Supplemental Diagnosis Code Source
Interface Control Release Number

Issuer

Paperwork Reduction Act Statement: According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are
required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control
number (0938-1155). The Department notes that a federal agency cannot conduct or sponsor a collection of information unless it is approved
by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
As described in 45 CFR §§ 153.400(b), 153.420(a), 153.610, and 153.710(a), risk adjustment covered plans and reinsurance eligible
plans are required to maintain risk adjustment and reinsurance data in order for HHS to operate reinsurance and risk adjustment (including the
high-cost risk pool) on behalf of a State. The public reporting burden for this collection of information for risk adjustment and reinsurance is
estimated to be an average of 6,391 hours per response, including time for reviewing general information about requesting assistance,
gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained.