Respond to the final distributed data report

OMB Control Number 0938-1155 Expiration Date: 04/30/2025

Appendix A

Data Elements for Risk Adjustment and Reinsurance

Data Category	Data Elements	Submitting Entity
Geographic Data	Plan ID Metal Level Actuarial Value Benefit Year Rating Area Individual or small-group or merged market	State / Issuer
Market Level Data	State average actuarial risk (HHS-sourced) State Rating Curve	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 valid OMB control number for this information collection is 0938-1155.

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 6,403 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.

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

Data Category	Data Elements	Submitting Entity
Pharmacy Claims	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	Issuer

Data Category	Data Elements	Submitting Entity
Medical Claims	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	Issuer
Medical Claims (continued)	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	Issuer

Data Category	Data Elements	Submitting Entity
Medical Claims (continued)	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	Issuer
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