EDPS Made Right: How to Prevent CMS Rejections During AEP

As the Annual Enrollment Period (AEP) begins, Medicare Advantage (MA) plans step into one of the most critical phases of their business cycle. It is the time when members enroll, revenue forecasts are locked in, and compliance demands hit peak intensity. At the heart of this complex process lies one technical but decisive challenge: submitting accurate data to CMS through the Encounter Data Processing System (EDPS).

For healthcare organizations, EDPS submissions are not just about ticking a compliance box. They are directly tied to risk adjustment scores, payment accuracy, and audit outcomes. Each rejected encounter compounds into added costs. From delayed reimbursements to repeat submissions, it underscores why plans with strong first-pass accuracy see more reliable revenue and lower compliance risk.

This naturally raises the question - How can plans ensure their EDPS healthcare submissions are flawless during AEP? In this blog post, we dive deep into practical strategies, supported by industry data, while showing how healthcare plans can strengthen their EDPS healthcare submissions and how Mirra provides the technology to make it seamless.

Why Does EDPS Accuracy Matter More Than Ever in Healthcare? 

The role of EDPS in healthcare has grown significantly over the last decade. When CMS introduced EDPS, it signaled a shift towards using encounter-level data instead of summarized RAPS data for risk adjustment. Since then, each year CMS has steadily increased its reliance on EDPS.

Why this matters:

• According to Kaiser Family Foundation, Medicare Advantage covers more than 32 million Americans in 2024, and payments exceeding $500 billion are tied to risk adjustment accuracy.¹
• CMS has explicitly stated its intent to phase out the RAPS system over time, making EDPS the core submission pathway. While the transition isn’t fully complete, plans that struggle with EDPS accuracy risk both financial penalties and future viability.

In other words, EDPS healthcare accuracy today is directly tied to payment stability tomorrow.

What Are the Common Pitfalls That Lead to CMS EDPS Rejections?

Despite clear CMS guidance, many Medicare Advantage organizations still struggle with a high rejection rate. Common pitfalls include:

1. Incomplete encounter records – Missing demographic or provider information is one of the top rejection triggers.

2. Incorrect ICD-10-CM coding – Even slight mismatches between the diagnosis entered and CMS-approved codes result in rejections.

3. Lack of timeliness in submissions – AEP creates a massive spike in data; delayed submissions often hit CMS deadlines too late.

4. Duplicate encounters – Without strong pre-submission reconciliation, duplicates lead to automatic failures.

5. Ignoring error feedback loops – CMS provides daily acknowledgement reports, but many plans fail to act quickly, leading to repeated mistakes.

The impact extends beyond finances. Persistent EDPS issues can trigger higher RADV audit exposure and weaken plan CMS trust, both of which directly shape future reimbursement stability. 

To cut billing error and reduce CMS grievances read our blog post on Premium Billing System: Protect Star Ratings in AEP 2025

How Can Healthcare Plans Improve EDPS Submission Strategies During AEP?

Improvement requires a mix of early preparation, cross-functional involvement, and automated controls. Instead of reactive fixes, leading plans are adopting proactive workflows. Core strategies include:

Start early

• Clean up provider directories and member eligibility data well before AEP.
• This prevents error carryover during peak file submissions.

Standardize data intake:

• Normalize formats across providers and facilities.
• Consistency upfront avoids mismatches when data hits EDPS workflows.

Lean on pre-validation tools: 

• Automate checks against CMS’s 837P/I standards.
• Rejections are eliminated before submission.

Align teams:

• Bring enrollment, claims, IT, and compliance into one workflow.
• Data silos are one of the biggest risk multipliers during AEP.

Use CMS feedback loops effectively:

• Treat daily rejections as immediate action items, not backlog.
• Dashboards and alerts reduce repeated mistakes.

Industry benchmarks suggest that plans adopting data pre-validation workflows can reduce rejections by 40%.²

Why Is Real-Time Monitoring Essential for EDPS Healthcare Data?

The traditional approach to EDPS processing has been reactive: submit, wait, and fix. But this approach is failing in today’s AEP-driven high-volume environment.

With real-time monitoring, organizations can:

• Catch missing mandatory fields before the file leaves the door.
• Auto-flag duplicates or invalid codes instantly.
• Track submission rates daily, ensuring CMS windows are not missed.
• Escalate systemic issues directly to compliance/IT in real time.

Real-time monitoring is particularly valuable during AEP, when filing volumes surge by 60–70% compared to off-cycle months. Without continuous oversight, small errors quickly escalate under AEP’s high volumes, making penalty risks disproportionate to the original data gap.

How Do Data Quality and Compliance Impact EDPS Submissions?

• Poor data in = poor EDPS outcomes. Compliance is inseparable from data quality.
• Data entry gaps lead to files missing required fields such as provider NPI or member HICN.
• Non-standardized data from provider systems creates inconsistencies, leading to coding mismatches.
• Manual workflows invite human error and increase compliance risk.

What Role Does Technology Play in Streamlining EDPS Healthcare Workflows?

Technology has evolved from being optional to essential in EDPS healthcare. Where manual processes fail, technology brings speed, accuracy, and transparency.

Key impact areas include:

Automation:

• Reduces manual file creation errors.
• Automatically validates structures before submission.

AI-driven analytics:

• Detects rejection trends in real time.
• Anticipates risk adjustment hiccups before they hit scorecards.

Integrated workflows:

• Creates a single source of truth across eligibility, claims, and compliance.
• Simplifies audits and reduces duplicate submissions.

Compliance monitoring:

• Keeps plans aligned with CMS 837P/I requirements.
• Supports continuous audit readiness.

How Can Mirra Help Medicare Advantage Plans Reduce EDPS Rejections? 

This is where Mirra’s Medicare Advantage in-a-Box platform creates measurable value for plans. Unlike generic systems, Mirra’s technology was purpose-built for EDPS healthcare submissions.

Key Mirra capabilities include:

• Eligibility, enrollment & member management: Ensures accurate demographic/member data, reducing rejections at source.
• Built-in compliance checks: Aligns with CMS’s 837P/I requirements out of the box.
• Automated validations & corrections: Eliminates manual fixes by providing clean files.
• Real-time monitoring dashboards: Give operations teams proactive visibility into error trends.
• Scalability for AEP: Handles submission surges without system downtimes. 

With Mirra Health Care, plans can cut rejection rates, improve cash flow predictability, and build CMS trust. All critical advantages during the hard deadlines of AEP. 

You can also read Digital AEP: TPA’s Path to Compliance & Efficiency in 2025

What Are the Next Steps for Healthcare Plans to Future-Proof Their EDPS Submissions?

As CMS places more weight on EDPS year after year, Medicare Advantage organizations must pivot from short-term fixes to long-term resilience. Key steps include:

1. Conduct a process audit: Identify weak points in current submissions.

2. Invest in continuous monitoring: Move beyond post-submission fixes into real-time prevention.

3. Strengthen compliance culture: Train teams regularly and enforce CMS alignment year-round.

4. Strategically adopt solutions: Leverage platforms like Mirra to achieve integrated and technology-backed EDPS healthcare workflows.

Future-proofing is not about fear of audits; it’s about building operational confidence and member trust.

Conclusion

The AEP season doesn’t need to be defined by rejected files, late-night rework, or compliance anxieties. With the right strategy, Medicare Advantage plans can turn EDPS healthcare submissions into a source of stability, predictability, and trust with CMS.

Accuracy, monitoring, and automation are the foundations of long-term financial resilience. AEP is happening now! The organizations that strengthen their EDPS workflows before deadlines will be the ones protecting revenue, reducing audit exposure, and building member confidence.

Let Mirra Healthcare be your trusted partner. Our Eligibility, Enrollment, and Member Management solutions help plans:

• Cut rejections at source with built-in compliance checks
• Automate validations and corrections in real time
• Scale seamlessly to handle AEP surges without disruptions

With AEP underway, now is the moment to streamline your EDPS strategy.

References: 

1. Kaiser Family Foundation 

2. OS inc. Measuring the Cost of Denials and the Impact of Prevention