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ACA Risk Adjustment Claims Submission Announcement

UPMC Health Plan·Provider Announcement
Effective date
Not stated
We identified it
Aug 7, 2026
Days to comply
—

Summary

All network providers must submit outstanding CY 2025 claims for ACA members (Platinum, Gold, Silver, Bronze plans) by April 1, 2026 to ensure inclusion in HHS EDGE server submission by April 30, 2026. Claims adjudicated after the April 1 deadline will be excluded from risk adjustment data and cannot be resubmitted for that reporting cycle.

Action Required

Action needed
By April 1, 2026: Billing team must ensure all outstanding CY 2025 ACA member claims are submitted and adjudicated through Provider OnLine at upmchealthplan.com/providers/medical. Identify any pending or delayed claims for ACA Platinum, Gold, Silver, and Bronze plan members and prioritize submission before the deadline. Claims adjudicated after April 1, 2026 will not be included in EDGE risk adjustment data submission. Coordinate with providers and front desk staff to verify all 2025 encounters for ACA members have corresponding claim submissions. Contact Provider Services or your physician account executive for submission issues or questions.

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