How do we report specific missing EOBs from BCDA/DPC/CCLF for investigation/RCA?

[jacob.b...@gmail.com]

Hi BCDA team -

We are 99.99% certain we have identified six (6) ExplanationOfBenefits for a specific patient that we *should* be seeing from BFD server (both via BCDA and DPC) but are not returning (nor is it in all -time CCLFs).

The EOBs are for 6 separate dates of service with our affiliated primary care provider (PCP) from January, April, May, June, July and November 2025 with our primary care provider, all of which we have confirmed had claims submitted to and paid by the Southern California MAC (Noridian) shortly after each DOS. We have also confirmed that the patient was and is:

• primary insurance = Original Medicare
• ACO-aligned (BCDA/CCLF) and PCP-managed (DPC)
• not a data-opt-out patient nor administratively suppressed patient at any time
• and also had no SUD indicators/values (ICD codes etc) on any of the dates of service

We have other EOBs in the dataset for this patient via BFD and CCLF for dates of service prior and since, and for adjudication dates prior and since. We are truly stumped as to how these specific EOBs are not in any of the payloads, and believe it is time to escalate for a 'higher up' NCH/ICR/CCW review.

For context, the way this was identified was that we have the DOS records, claim submission and EOB payment records in our PCP's electronic medical record and billing system (which is also how we know there is no SUD-associated info that would result in an expected blind spot on these).

Please let us know how to proceed,

Jake

[Beneficiary Claims Data API (BCDA) Community]

Hi Jake,

We have reached out directly via email. Please let us know if you have not received an email from bc...@cms.hhs.gov.

The BCDA Team