Medicare Advantage Prescription Drug Plans Communication User Guide Appendices May 31 ...

414 Pages·2017·4.4 MB·English

May 31, 2017
Version 11.1
Plan Communications User Guide Appendices, Version 11.1

THIS PAGE INTENTIONALLY BLANK

May 31, 2017 ii
Plan Communications User Guide Appendices, Version 11.1

Change Log
May 31, 2017 Updates
Section Changes
Global Changes Updated the version to 11.1
Updated the publication date to May 31, 2017
Updated Table, Section, and Appendix references
Appendix A No Change
Appendix B No Change
Appendix C No Change
Appendix D No Change
Appendix E No Change
Appendix F Removed section F.4 - Failed Transaction Data File - OBSOLETE.
Removed line 'ee' from Field #24 in the Daily Transaction Reply Report (DTRR) Detailed
Record Layout.
Added updates to Field 46 (Risk Adjustment Factor Type Code) and Field 86 (Part D Risk
Adjustment Factor Type) of the Monthly Membership Detail Data File.
Updated the Header and Detail records for the MAO-004 layout.
Added "Special Reports" heading under Appendices F; added new F.33 "HICN to MBI
Crosswalk File Layout.”
Appendix G No Change
Appendix H No Change
Appendix I Updated Transaction Reply Codes (TRCs) 077 (Medicaid Status Set), 078 (Medicaid Status
Terminated), and 366 (Community Medicaid Status).
Added new TRCs 350 (MBI is Available for Beneficiary), 371 (LEP Exceeds SSA Harm
Limit), and 372 (SSA Harm LEP Refund).
Removed Section I.3, “Obsolete Transaction Reply Codes (TRCs).”
Appendix J No Change
Appendix K No Change
Appendix L No Change
Appendix M No Change
May 31, 2017 ii Change Log
Plan Communications User Guide Appendices, Version 11.1

THIS PAGE INTENTIONALLY BLANK

May 31, 2017 iii
Plan Communications User Guide Appendices, Version 11.1
Table of Contents

A: Glossary and List of Abbreviations and Acronyms ............................................... A-1
A.1 List of Abbreviations and Acronyms ........................................................................ A-4
B: CMS Payment Information ....................................................................................... B-1
B.1 Payment Information Form ........................................................................................ B-1
C: Monthly Schedule ...................................................................................................... C-1
D: Enrollment Data Transmission Schedule ................................................................ D-1
E: ESRD Network Contact Information Table ............................................................ E-1
F: Record Layouts........................................................................................................... F-1
Daily Record Layouts ....................................................................................................... F-3
F.1 Batch Completion Status Summary (BCSS) Data File............................................... F-3
F.1.1 Sample BCSS Report ................................................................................ F-3
F.1.2 BCSS ‘Failed Transaction’ Layout ........................................................... F-4
F.1.3 BCSS Error Condition ............................................................................... F-4
F.1.4 BCSS for Special Transaction Files .......................................................... F-7
F.2 Coordination of Benefits (COB); Validated Other Health Insurance (OHI) Data File
(Part D Only) ...................................................................................................... F-9
F.2.1 General Organization of Records .............................................................. F-9
F.2.2 Detail Records: Indicates the Beginning of a Series of Beneficiary
Subordinate Detail Records ............................................................. F-10
F.2.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences) F-
11
F.2.4 Supplemental Records: Subordinate to DTL (Unlimited Occurrences) .. F-17
F.3 MARx Batch Input Transaction Data File ................................................................ F-21
F.3.1 Header Record ......................................................................................... F-22
F.3.2 Disenrollment Transaction (TC 51/54) Detailed Record Layout ............ F-22
F.3.3 Enrollment Transaction (TC 61) Detailed Record Layout ...................... F-24
F.3.4 Miscellaneous Change Transactions – Detailed Record Layouts ........... F-27
F.3.4.1 4Rx Change (TC 72) Detailed Record Layout ..................................... F-27
F.3.4.2 NUNCMO Change (TC 73) Detailed Record Layout .......................... F-28
F.3.4.3 EGHP Change (TC 74) Detailed Record Layout ................................. F-29
F.3.4.4 Premium Payment Option (PPO) Change (TC 75) Detailed Record
Layout .............................................................................................. F-29
F.3.4.5 Residence Address Change (TC 76) Detailed Record Layout ............. F-30
F.3.4.6 Segment ID Change (TC 77) Detailed Record Layout ........................ F-32
F.3.4.7 Part C Premium Change (TC 78) Detailed Record Layout .................. F-32
F.3.4.8 Part D Opt-Out Change (TC 79) Detailed Record Layout ................... F-33
May 31, 2017 iv Table of Contents
Plan Communications User Guide Appendices, Version 11.1
F.3.5 Cancellation Transactions – Detailed Record Layouts ........................... F-34
F.3.5.1 Cancel Enrollment (TC 80) Detailed Record Layout ........................... F-34
F.3.5.2 Cancel Disenrollment Transaction (TC 81) Detailed Record Layout .. F-34
F.3.5.3 MMP Enrollment Cancellation (TC 82) Detail Record Layout ........... F-35
F.3.5.4 MMP Opt-Out Update (TC 83) Layout ................................................ F-35
F.3.5.5 POS Drug Edit (TC 90) Layout ............................................................ F-37
F.3.5.6 IC Model Participation (TC 91) Transaction Layout ........................... F-38
F.3.6 Correction Record ................................................................................... F-39
F.3.7 Notes for All Plan-Submitted Transaction Types ................................... F-40
F.4 Daily Transaction Reply Report (DTRR) Data File ................................................. F-44
F.4.1 DTRR Data File Detailed Record Layout ............................................... F-44
F.4.2 Verbatim Plan Submitted Transaction on DTRR .................................... F-57
F.5 Batch Eligibility Query (BEQ) Request File ............................................................ F-59
F.5.1 Header Record ......................................................................................... F-59
F.5.2 Detail Record (Transaction) .................................................................... F-60
F.5.3 Trailer Record ......................................................................................... F-62
F.5.4 Sample BEQ Request File Pass and Fail Acknowledgments .................. F-63
F.6 BEQ Response File ................................................................................................... F-65
F.6.1 Header Record ......................................................................................... F-65
F.6.2 Detail Record (Transaction) .................................................................... F-66
F.6.3 Trailer Record ......................................................................................... F-73
Weekly Record Layouts .................................................................................................. F-74
F.7 LIS/Part D Premium Data File ................................................................................. F-74
Monthly Record Layouts ................................................................................................ F-76
F.8 820 Format Payment Advice Data File .................................................................... F-76
F.8.1 Header Record ......................................................................................... F-77
F.8.2 Detail Record ........................................................................................... F-78
F.8.3 Trailer Record ......................................................................................... F-79
F.9 BIPA 606 Payment Reduction Data File .................................................................. F-80
F.10 Monthly Membership Detail Data File ................................................................... F-81
F.11 Monthly Membership Summary Data File ............................................................. F-94
F.12 Monthly Premium Withholding Report (MPWR) Data File .................................. F-96
F.12.1 Header Record ....................................................................................... F-96
F.12.2 Detail Record ......................................................................................... F-97
F.12.3 Trailer Record ....................................................................................... F-98
F.13 Part B Claims Data File .......................................................................................... F-99
F.13.1 Record Type 1 ....................................................................................... F-99
F.13.2 Record Type 2 ..................................................................................... F-100
F.14 Part C Risk Adjustment Model Output Data File ................................................. F-101
F.14.1 Header Record ..................................................................................... F-101
F.14.2 Detail Record Type B .......................................................................... F-102
May 31, 2017 v Table of Contents
Plan Communications User Guide Appendices, Version 11.1
F.14.3 Detail Record Type C .......................................................................... F-113
F.14.4 Detail Record Type D ......................................................................... F-123
F.14.5 Trailer Record ..................................................................................... F-133
F.15 Risk Adjustment System (RAS) Prescription Drug Hierarchical Condition Category
(RxHCC) Model Output Data File - aka Part D RA Model Output Data File F-134
F.15.1 Header Record ..................................................................................... F-134
F.15.2 Detail/Beneficiary Record ................................................................... F-135
F.15.3 Trailer Record ..................................................................................... F-145
F.16 Risk Adjustment System (RAS) Prescription Drug Hierarchical Condition Category
(RxHCC) Model Output Data File Type 2 ..................................................... F-146
F.16.1 Header Record ..................................................................................... F-146
F.16.2 Detail Record ....................................................................................... F-147
F.16.3 Trailer Record ..................................................................................... F-157
F.17 Medicare Advantage Organization (MAO) 004 Report – Encounter Data Diagnosis
Eligible for Risk Adjustment .......................................................................... F-158
F.17.1 Header Record ..................................................................................... F-158
F.17.2 Detail Record ....................................................................................... F-159
F.17.3 Trailer Record ..................................................................................... F-164
F.18 Monthly Full Enrollment Data File ...................................................................... F-165
F.19 LEP Data File ....................................................................................................... F-168
F.19.1 Header Record ..................................................................................... F-168
F.19.2 Detail Record ....................................................................................... F-169
F.19.3 Trailer Record ..................................................................................... F-171
F.20 LIS History Data File (LISHIST) ......................................................................... F-172
F.20.2 Header Record ..................................................................................... F-172
F.20.3 Detail Record (Transaction) ................................................................ F-173
F.20.4 Trailer Record ..................................................................................... F-175
F.21 NoRx File.............................................................................................................. F-176
F.21.1 Header Record ..................................................................................... F-176
F.21.3 Detail Record ....................................................................................... F-177
F.21.4 Trailer Record ..................................................................................... F-179
F.22 MA Full Dual Auto Assignment Notification File ............................................... F-180
F.22.1 Header Record ..................................................................................... F-180
F.22.2 Detail Record (Transaction) ................................................................ F-181
F.22.3 Trailer Record ...................................................................................... F-182
F.23 Auto Assignment Address Notification File......................................................... F-183
F.23.1 Header Record ..................................................................................... F-183
F.23.2 Detail Record ....................................................................................... F-184
F.23.3 Trailer Record ..................................................................................... F-186
F.24 Plan Payment Report (PPR)/Interim Plan Payment Report (IPPR) Data File ...... F-187
F.24.1 Header Record ..................................................................................... F-187
F.24.2 Capitated Payment – Current Activity ................................................ F-188
May 31, 2017 vi Table of Contents
Plan Communications User Guide Appendices, Version 11.1
F.24.3 Premium Settlement ............................................................................ F-189
F.24.4 Fees ...................................................................................................... F-189
F.24.5 Special Adjustments ............................................................................ F-190
F.24.6 Previous Cycle Balance Summary ...................................................... F-192
F.24.7 Payment Summary .............................................................................. F-194
F.25 Agent Broker Compensation Report Data File ..................................................... F-196
F.26 Monthly Medicare Secondary Payer (MSP) Information Data File ..................... F-199
F.26.1 Header Record ..................................................................................... F-199
F.26.2 Primary Record ................................................................................... F-200
F.26.3 Detail Record ....................................................................................... F-202
F.26.4 Trailer Record ..................................................................................... F-208
F.27 Failed Payment Reply Report (FPRR) Data File .................................................. F-209
F.28 MSA Deposit-Recovery Data File Layout ........................................................... F-211
F.28.1 Header Record ..................................................................................... F-212
F.28.2 Detail Record ....................................................................................... F-212
F.28.3 Trailer Record ..................................................................................... F-214
Yearly Record Layouts ................................................................................................. F-218
F.29 Medicare Advantage Medicaid Status Data File .................................................. F-215
F.29.1 Header Record ..................................................................................... F-215
F.29.2 Beneficiary Identification Record ....................................................... F-215
F.29.3 Beneficiary Detail Record ................................................................... F-216
F.30 Loss of Subsidy Data File ..................................................................................... F-218
F.30.1 LIS Data File Detail Record ................................................................ F-218
F.31 Long-Term Institutionalized (LTI) Resident Report Data File ............................ F-220
F.32 No Premium Due Data File Layout ...................................................................... F-222
Special Record Layouts ................................................................................................ F-225
F.33 HICN to MBI Crosswalk File Layout .................................................................. F-225
G: Screen Hierarchy ....................................................................................................... G-1
H: Validation Messages .................................................................................................. H-1
I: Codes ............................................................................................................................. I-1
I.1 Transaction Codes ........................................................................................................ I-1
I.2 Transaction Reply Codes (TRCs) ................................................................................. I-2
I.2.1 Example Calculations for TRCs 371 and 372 ........................................... I-91
I. 3 Transaction Reply Code (TRC) Groupings .................................................... I-93
I.4 Payment Reply Codes (PRCs) .................................................................................. I-104
I.5 MMR Adjustment Reason Codes ............................................................................. I-105
I.6 State Codes ............................................................................................................... I-107
I.7 Entitlement Status and Enrollment Reason Codes ................................................... I-109
I.8 Disenrollment Reason Codes.................................................................................... I-112
I.9 BEQ Response File Error Condition Table .............................................................. I-116
May 31, 2017 vii Table of Contents
Plan Communications User Guide Appendices, Version 11.1
I.9.1 Request File Error Conditions ................................................................. I-116
I.9.2 Request Transaction Detail Record Error Conditions ............................. I-117
I.10 IC Model Beneficiary Participation End Date Reason Codes ................................ I-118
J: Report Files .................................................................................................................. J-1
J.1 BIPA 606 Payment Reduction Report.......................................................................... J-2
J.2 HMO Bill Itemization Report....................................................................................... J-4
J.3 Monthly Membership Detail Report – Drug Report (Part D) ...................................... J-5
J.4 Monthly Membership Detail Report – Non-Drug Report (Part C) .............................. J-7
J.5 Monthly Membership Summary Report (MMSR) ....................................................... J-9
J.6 Monthly Summary of Bills Report ............................................................................. J-11
J.7 Part C Risk Adjustment Model Output Report .......................................................... J-12
J.8 RAS RxHCC Model Output Report - aka - Part D RA Model Output Report .......... J-13
J.9 Payment Records Report ............................................................................................ J-14
J.10 Plan Payment Report (APPS Payment Letter) ......................................................... J-15
J.11 Interim Plan Payment Report (IPPR) ....................................................................... J-18
J.12 No Premium Due Report Format ............................................................................. J-19
K: All Transmissions Overview ..................................................................................... K-1
L: MA Plan Connectivity Checklist .............................................................................. L-1
M: Valid Election Types for Plan-Submitted Transactions ....................................... M-1

May 31, 2017 viii Table of Contents
Plan Communications User Guide Appendices, Version 11.1
A: Glossary and List of Abbreviations and Acronyms
Table A-1: Glossary
Term Definition
The successful application of a requested action that was processed by
Accepted Transaction
MARx.
A number obtained from the Resource Access Control Facility (RACF) or
Account Number
system administrator.
The date that the beneficiary applies to enroll in a Plan. Enrollments
Application Date submitted by CMS or its contractors, such as the Medicare Beneficiary
Contact Center, do not need application dates.
An automated systems approach to processing in which data items to process
Batch Transaction
must be grouped and processed in bulk.
Beneficiary
The portion of the Medicare health insurance claim number that identifies a
Identification Code
specific beneficiary.
(BIC)
Established by CMS upon request of an HMO or CMP, when the HMO or
Benefit Stabilization CMP must provide its Medicare enrollees with additional benefits, to prevent
Fund (BSF) excessive fluctuation in the provision of those benefits in subsequent contract
periods.
A rectangular icon on a screen which, when clicked, engages an action. The
Button button is labeled with word(s) that describe the action, such as Find or
Update.
A cancellation may result from an action by the beneficiary, CMS, or another
Cancellation
Plan before the effective date of the election. A cancelled enrollment restores
Transaction
the beneficiary to his/her prior enrollment state.
A field that is part of a group of options, for which the user may select any
number of options. Each option is represented with a small box, where ‘x’
Checkbox means “on” and an empty box means “off.” When a checkbox is clicked, an
‘x’ appears in the box. When the checkbox is clicked again, the ‘x’ is
removed.
Connect:Direct The proprietary software that transfers files between systems.
A record submitted by a Plan or CMS office to correct or update existing
Correction
Beneficiary data.
A type of contract under which a Plan is reimbursed by CMS for its
Cost Plan
reasonable costs.
Represents the calendar month and year at the time of transaction submission.
Current Calendar For batch, the current month is derived from the batch file transmission date;
Month (CCM) for User Interface transactions, the current month is derived from the system
data at the time of transaction submission.
The calendar month in which processing occurs to generate payments. The
Current Processing
Current Processing Month is distinguished from the CPM, the month in which
Month
Plans receive payment from CMS.
Current Payment The month for which Plans receive payment from CMS, not the current
Month (CPM) calendar month.
Prescription drug coverage, generally from an employer or union, that is
Creditable Coverage
equivalent to, or better than, Medicare standard prescription drug coverage.
Data entry field A field that requires the user to enter information.
Date of Service (DOS) Date of service
The amount a Beneficiary must pay for medical services or prescription drugs
Deductible
before a Plan starts paying benefits.
May 31, 2017 A-1 Glossary and List of Abbreviations
and Acronyms