Plan Communications User Guide Appendices v5.1

449 Pages·2010·3.08 MB·English

Medicare Advantage
and Prescription Drug
Plans
April 21, 2010
Plan Communications
User Guide
Appendices
Version 5.1
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CENTERS FOR MEDICARE AND MEDICAID SERVICES

Center for Drug and Health Plan Choice

Medicare Advantage and Prescription Drug
Plan Communications User Guide
Appendices

Version 5.1

(April 21, 2010)
This page intentionally left blank.
Plan Communications User Guide Appendices, Version 5.1
Change Log
April 21, 2010 Updates

Section Changes
Global Changes Changed the version number from 5.0 to 5.1
Changed the publication date to April 21, 2010
Changed Centers for Beneficiary Choice to Center for Drug and Health Plan Choice
Updated hyperlinks throughout the Guide with the newly defined www.cms.gov
designation
Appendix A No change
Appendix B Updated the CMS Central Office Health Insurance Specialists - Division of Payment
Operations (DPO) by Region page B-2
Appendix C Added note “Effective with the April 2010 Plan Data Due date (March 12, 2010), the
cutoff time for Plan submissions to CMS has been extended from 6pm ET to 8pm ET”
page C-1
Replaced Year 2010 MARx Plan Monthly Schedule with revised layout page C-3
Appendix D Added note “Effective with the April 2010 Plan Data Due date (March 12, 2010), the
cutoff time for Plan submissions to CMS has been extended from 6pm ET to 8pm ET”
page D-1
Appendix E Added new layout E.30 Monthly MSP Information Data File and E.31 Other Health
Coverage Information Data File to Table E-1 Record Layouts page E-1
Replaced file layout E.6 Coordination of Benefits (COB) Data File with updates from
the April release page E-23
Replaced description of field #9 – Election Type and #17 – Prior Commercial
Override on Table E.7.5 – Notes for all Transactions on file layout E.7 MARx Batch
Input Transaction Data File page E-33
Replaced file layout E.9 Monthly Membership Detail Data File with updates from the
April release page E-49
Replaced file layout E.10 Monthly Membership Summary Data File with updates from
the April release page E-59
Updated description on field #38 – Election Type on E.15 Transaction Reply Report
(Weekly/Monthly) to include election type ‘F’ page E-95
Replaced file layout E.23 Batch Eligibility Query (BEQ) Response Data File with
updates from the April release page E-137
Added new layout E.30 Monthly MSP Information Data File as part of the updates
from the April release page E-185
Added new layout E.31 Other Health Coverage Information Data File as part of the
updates from the April release page E-187
Appendix F No change
Appendix G No change
Appendix H Modified TRCs 194 and 213 on Table H-2 Transaction Reply Codes page H-3
Added TRCs 225, 242 and 245 through 253 and 717 to Table H-2 Transactions
Reply Codes page H-3
Appendix I Replaced report I.6 Monthly Membership Detail Report – Non Drug Report (Part C)
with update from the April release page I-25
Replaced report I.7 Monthly Membership Summary Report with updates from the
April release page I-27
April 21, 2010 iii Change Log
Plan Communications User Guide Appendices, Version 5.1
Section Changes
Appendix J Added new report #64 – Monthly MSP Information Data File to monthly report listing
Table J-1 – All Transmissions Overview page J-22
Added new report #65 – Other Health Coverage Information Data File to monthly
report listing Table J-1 – All Transmissions Overview page J-22
Renumbered remaining reports following insertion of new Monthly MSP Information
Data File beginning with report #66 Table J-1 – All Transmissions Overview page
J-22
Appendix K No change
Appendix L Added Election Type ‘F’ to Table L-1 - Election Type for All Plans page L-1
April 21, 2010 iv Change Log
Plan Communications User Guide Appendices, Version 5.1
Table of Contents
A: Glossary and List of Abbreviations and Acronyms ........................................... A-1
Glossary ....................................................................................................................... A-1
List of Abbreviations and Acronyms ............................................................................. A-5
B: CMS Central Office Contact Information ............................................................. B-1
C: Monthly Schedule ................................................................................................. C-1
D: Enrollment Data Transmission Schedule ........................................................... D-1
E: Record Layouts ..................................................................................................... E-1
E.1 820 Format Payment Advice Data File .................................................................. E-3
E.2 September Preliminary PDP Notification File for Plans Losing Beneficiaries to
Reassignment ................................................................................................. E-9
E.3 Batch Completion Status Summary Data File...................................................... E-11
E.4 BIPA 606 Payment Reduction Data File .............................................................. E-19
E.5 Bonus Payment Data File .................................................................................... E-21
E.6 Coordination of Benefits (COB) (Validated Other Insurer Information) Data File . E-23
E.7 MARX Batch Input Transaction Data File ............................................................ E-33
E.8 Failed Transaction Data File - OBSOLETE ......................................................... E-47
E.9 Monthly Membership Detail Data File .................................................................. E-49
E.10 Monthly Membership Summary Data File .......................................................... E-59
E.11 Monthly Premium Withholding Report Data File (MPWR) ................................. E-63
E.12 Part B Claims Data File ..................................................................................... E-67
E.13 Part C Risk Adjustment Model Output Data File ................................................ E-69
E.14 RAS RxHCC Model Output Data File - aka Part D Risk Adjustment Model Output
Data File ........................................................................................................ E-81
E.15 Transaction Reply Activity Data File (Weekly/Monthly) ..................................... E-95
E.16 Monthly Full Enrollment Data File .................................................................... E-107
E.17 Low-Income Subsidy/Late Enrollment Penalty Data File ................................. E-111
E.18 Loss of Subsidy Data File ................................................................................ E-117
E.19 LIS / Part D Premium Data File ....................................................................... E-119
E.20 LIS History Data File (LISHIST) ....................................................................... E-121
E.21 NoRx File ......................................................................................................... E-125
E.22 Batch Eligibility Query (BEQ) Request File ...................................................... E-131
E.23 Batch Eligibility Query (BEQ) Response File ................................................... E-137
E.24 MA Full Dual Auto Assignment Notification File ............................................... E-155
E.25 Auto Assignment (PDP) Address Notification File ........................................... E-159
E.26 Plan Payment Report (PPR) / Interim Plan Payment Report (IPPR) Data File E-165
E.27 Low Income Subsidy (LIS) Weekly Activity History Data File ........................... E-175
E.28 Long Term Institutionalized Resident Report Data File ................................... E-181
April 21, 2010 v Table of Contents
Plan Communications User Guide Appendices, Version 5.1
E.29 Agent Broker Compensation Report Data File................................................. E-183
E.30 Monthly MSP Information Data File ................................................................. E-185
E.31 Other Health Coverage Information Data File.................................................. E-187
F: Screen Hierarchy ................................................................................................... F-1
F.1 Main Menu ............................................................................................................. F-3
F.2 Welcome Submenu ................................................................................................ F-4
F.3 Beneficiaries Submenu .......................................................................................... F-5
F.4 Transactions Submenu .......................................................................................... F-6
F.5 Payments Submenu ............................................................................................... F-7
F.6 Reports Submenu .................................................................................................. F-8
G: Validation Messages ............................................................................................. G-1
H: Codes ..................................................................................................................... H-1
H.1 Transaction Codes ................................................................................................ H-1
H.2 Transaction Reply Codes ...................................................................................... H-3
H.3 MMR Adjustment Reason Codes ........................................................................ H-93
H.4 State Codes ......................................................................................................... H-95
H.5 Entitlement Status and Enrollment Reason Codes .............................................. H-97
H.6 Disenrollment Reason Codes ............................................................................ H-101
H.7 Batch Eligibility Query (BEQ) Response File Error Condition Table .................. H-103
H.8 Obsolete Transaction Reply Codes ................................................................... H-105
I: Report Files .............................................................................................................. I-1
I.1 BIPA 606 Payment Reduction Report ...................................................................... I-3
I.2 Bonus Payment Report ............................................................................................ I-9
I.3 Demographic Report .............................................................................................. I-17
I.4 HMO Bill Itemization Report ................................................................................... I-21
I.5 Monthly Membership Detail Report – Drug Report (Part D) ................................... I-23
I.6 Monthly Membership Detail Report – Non Drug Report (Part C) ........................... I-25
I.7 Monthly Membership Summary Report .................................................................. I-27
I.8 Monthly Summary of Bills Report ........................................................................... I-31
I.9 Part C Risk Adjustment Model Output Report ........................................................ I-33
I.10 RAS RxHCC Model Output Report - aka - Part D Risk Adjustment Model Output
Report ............................................................................................................ I-35
I.11 Payment Records Report ..................................................................................... I-37
I.12 Plan Payment Report (APPS Payment Letter) ..................................................... I-39
I.13 Interim Plan Payment Report (IPPR) ................................................................... I-45
I.14 Transaction Reply Activity Report (TRR) (Weekly & Monthly) ............................. I-47
I.15 Enrollment Transmission Message File (STATUS) .............................................. I-61
I.16 Sample BEQ Request File Pass and Fail Acknowledgments .............................. I-67
April 21, 2010 vi Table of Contents
Plan Communications User Guide Appendices, Version 5.1
J: All Transmissions Overview ................................................................................. J-1
K: MA Plan Connectivity Checklist ........................................................................... K-1
L: Valid Election Types for Plan Submitted Transactions ...................................... L-1
April 21, 2010 vii Table of Contents
Plan Communications User Guide Appendices, Version 5.1
A: Glossary and List of Abbreviations and Acronyms
Glossary
Term Definition
Abend In mainframe computing, an abnormal job termination (abnormal end).
Account Number A number obtained from your Resource Access Control Facility (RACF)
or system administrator.
Adjustment Reason Code given to explain adjustments on Plan Membership Reports
Codes
Batch Processing An automated systems approach to processing in which data items to be
processed must be grouped.
Beneficiary That portion of the Medicare health insurance claim number that identifies
Identification Code a specific beneficiary.
(BIC)
Benefit Stabilization Established by CMS upon request of an HMO or CMP when it is required
Fund to provide its Medicare enrollees with additional benefits, in order to
prevent excessive fluctuation in the provision of those benefits in
subsequent contract periods.
Button A rectangular icon on a screen. When the button is clicked, an action is
taken. The button is labeled with word(s) that describe the action, such as
Find or Update.
Checkbox A field on a screen that is part of a group of options, any number of which
may be selected. Each checkbox is represented with a small box, where
‘x’ 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.
Concatenation The process of combining files, especially those being uploaded or
downloaded with one transmission.
Connect:Direct Proprietary software that transfers files between systems.
Correction A record submitted by a Plan or CMS office to correct or update existing
data concerning a beneficiary.
Cost Plan A type of contract under which a Plan is reimbursed by CMS for its
reasonable costs.
Current Payment The month for which Plans receive payment from CMS, not the current
Month (CPM) calendar month. The current Processing Month (PM) is the current
calendar month in which processing occurs to generate payments.
Creditable Coverage Prescription Drug coverage, generally from an employer or union, that
has been determined to be at least as good as the Medicare standard
prescription drug coverage.
Data entry field A field on a screen that requires the user to type in information.
Deductible The amount a beneficiary pays for medical services or prescription drugs
before a plan starts paying benefits.
Disenrollment A record submitted by a Plan, SSA DO, MCSC, or CMS when a
beneficiary discontinues membership in the Plan.
Dropdown list A field on a screen that contains a list of values from which you can
choose. Click on the down arrow on the right of the field to see the list of
values, and then click on a value to select it.
April 21, 2010 A-1 Glossary and List of Abbreviations and Acronyms