EDGE, which stands for External Data Gathering Environment, is a common acronym within the risk adjustment space. Often referred to as the EDGE Server or simply EDGE, it’s the endpoint for ACA Marketplace data submissions. While the need for complete, accurate and timely submission of data is foundational across Medicare Advantage, Medicaid and ACA, there are a number of ACA Marketplace-specific nuances to consider.

Instead of submitting data directly to CMS, issuers that participate in the ACA maintain EDGE Servers housed either locally (on premise) or through cloud-based TPA hosting. This arrangement is classified as a distributed data collection model and serves three purposes:

  • It helps mitigate privacy and data security risks associated with protected health information
  • It standardizes business processes, timing and rules for issuers
  • Instead of being housed by CMS, proprietary issuer data stays within the issuer’s environment

What data gets loaded to EDGE and what is it used for?

If you’re most familiar with the types of transactional data submitted for Medicare Advantage risk adjustment calculation through the encounter data system, the types of data loaded and housed on the EDGE Server may come as a surprise. Qualified health plans submit and maintain five distinct data types on the EDGE Server:

  • Plan data
  • Enrollment data
  • Pharmacy claims
  • Medical claims
  • Supplemental data

EDGE data is used for calculating risk scores and is the basis for the risk transfer payment mechanism and the Risk Adjustment Data Validation audit. EDGE data is also used for determining annual high-cost risk pool amounts. 

What data is sent to CMS?

Although detail-level Rx claims, medical claims, enrollment, and supplemental diagnosis data are stored on each EDGE Server, only summary reports, summary data, and metrics pertaining to file processing are sent to CMS.

Understanding the downstream impacts of EDGE Server data submissions is key to develop and refine robust oversight and monitoring capabilities. ATTAC Consulting Group has the expertise to ensure that completeness and accuracy of data submissions are always at the forefront of your organization’s risk adjustment program. With a pulse on the latest industry trends and the knowledge of where to look, ATTAC is uniquely positioned to support your organization’s risk adjustment program as it enters the EDGE Server final submission season.