Medicare Advantage and Prescription Drug Plans December 28 ...

Medicare Advantage 

and Prescription Drug 

Plans 

December 28, 2012 

Plan Communications 

User Guide 

Appendices 

Version 6.3

Plan Communications User Guide Appendices, Version 6.3 

Section 

Changes 

Change Log 

December 28, 2012 Updates 

Global Changes Updated the version from 6.2 to 6.3 

Updated the publication date to December 28, 2012 

Updated Table, Section, and Appendix references 

Changed references to the Financial Alignment Demonstration from "FA/FA Demo" to 

"Medicare and Medicaid Plan" (MMP) 

Updated “Center for Beneficiary Choices (CBC)” to “Center for Medicare (CM)” 

Appendix A 

Appendix B 

Appendix C 

Appendix D 

Appendix E 

Appendix F 

Appendix G 

Appendix H 

No Change 

Updated CMS Central Office - Division of Payment Operations (DPO) Representatives table 

Added Year 2013 MARx Plan Monthly Schedule 

No Change 

No Change 

Updated Table F.6.3, Transaction Type 61 Layout, Enrollment Transaction 

No Change 

No Change 

Appendix I Updated Transaction Reply Codes (TRCs) definitions for 116 and 144 

Added TRCs 316, 317 and 718 

Appendix J 

Appendix K 

Appendix L 

Appendix M 

No Change 

No Change 

No Change 

No Change 

December 28, 2012 iii Change Log


THIS PAGE INTENTIONALLY BLANK 


iv


Table of Contents 

A: Glossary and List of Abbreviations and Acronyms ......................................................... A-1 

A.1 List of Abbreviations and Acronyms .................................................................................. A-4 

B: CMS Central Office Contact Information ..........................................................................B-1 

B.1 CMS Central Office ..............................................................................................................B-2 

B.2 Payment Information Form ...................................................................................................B-2 

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 

DTRR Data File Detailed Record Layout ..................................................................... F-1 

F.1 820 Format Payment Advice Data File ................................................................................. F-3 

F.1.1 Header Record ...................................................................................................... F-4 

F.1.2 Detail Record ........................................................................................................ F-5 

F.1.3 Trailer Record ...................................................................................................... F-6 

F.2 Batch Completion Status Summary Data File ....................................................................... F-7 

F.2.1 Failed Record ....................................................................................................... F-7 

F.2.2 BCSS ‘Failed Transaction’ Layout ...................................................................... F-8 

F.3 BIPA 606 Payment Reduction Data File .............................................................................. F-9 

F.4 Bonus Payment Data File ................................................................................................... F-10 

F.5 Coordination of Benefits (COB); Validated Other Health Insurance Data File .................. F-11 

F.5.1 General Organization of Records ....................................................................... F-11 

F.5.2 Detail Records: Indicates the Beginning of a Series of Beneficiary 

Subordinate Detail Records ........................................................................ F-11 

F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences) ....... F-12 

F.5.4 Supplemental Records: Subordinate to DTL (Unlimited Occurrences) ............. F-15 

F.6 MARX Batch Input Transaction Data File .......................................................................... F-18 

F.6.1 Header Record .................................................................................................... F-18 

F.6.2 Disenrollment Transaction (TC 51/54) Detailed Record Layout ....................... F-19 

F.6.3 Enrollment Transaction (TC 61) Detailed Record Layout ................................. F-20 

F.6.4 Miscellaneous Change Transactions – Detailed Record Layouts ...................... F-22 

F.6.5 Cancellation Transactions – Detailed Record Layouts ...................................... F-28 

F.6.6 Correction Record .............................................................................................. F-30 

F.6.7 Notes for All Plan-Submitted Transaction Types .............................................. F-31 

F.7 Failed Transaction Data File - OBSOLETE ........................................................................ F-35 

F.8 Monthly Membership Detail Data File ................................................................................ F-36 

December 28, 2012 v Table of Contents


F.9 Monthly Membership Summary Data File .......................................................................... F-44 

F.10 Monthly Premium Withholding Report Data File (MPWR) ............................................. F-47 

F.10.1 Header Record .................................................................................................. F-47 

F.10.2 Detail Record .................................................................................................... F-48 

F.10.3 Trailer Record .................................................................................................. F-49 

F.11 Part B Claims Data File ..................................................................................................... F-50 

F.11.1 Record Type 1 .................................................................................................. F-50 

F.11.2 Record Type 2 .................................................................................................. F-51 

F.12 Part C Risk Adjustment Model Output Data File .............................................................. F-52 


F.12.2 Detail Record Type A ...................................................................................... F-52 

F.12.3 Detail Record Type B ....................................................................................... F-60 


F.13 Risk Adjustment System (RAS) Prescription Drug Hierarchical Condition Category 

(RxHCC) Model Output Data File - aka Part D RA Model Output Data File ............ F-71 


F.13.2 Detail/Beneficiary Record ................................................................................ F-71 


F.14 Daily Transaction Reply Report (DTRR) Data File .......................................................... F-81 

F.14.1 DTRR Data File Detailed Record Layout ........................................................ F-81 

F.14.2 Verbatim Plan Submitted Transaction on Daily Transaction Reply Report 

(DTRR) ....................................................................................................... F-89 

F.15 Monthly Full Enrollment Data File ................................................................................... F-90 

F.16 LIS/LEP Data File ............................................................................................................. F-92 


F.16.2 Detail Record .................................................................................................... F-92 

F.17 Loss of Subsidy Data File .................................................................................................. F-95 

F.17.1 Loss of Subsidy Data File Detail Record ......................................................... F-95 

F.18 LIS/Part D Premium Data File .......................................................................................... F-97 

F.19 LIS History Data File (LISHIST) ...................................................................................... F-98 


F.19.2 Detail Record (Transaction) ............................................................................. F-99 

F.19.3 Trailer Record ................................................................................................ F-101 

F.20 NoRx File......................................................................................................................... F-102 

F.20.1 Header Record ................................................................................................ F-102 

F.20.2 Detail Record .................................................................................................. F-103 


F.21 Batch Eligibility Query (BEQ) Request File ................................................................... F-106 


F.21.2 Detail Record (Transaction) ........................................................................... F-107 


December 28, 2012 vi Table of Contents


F.22 BEQ Response File .......................................................................................................... F-109 




F.23 MA Full Dual Auto Assignment Notification File .......................................................... F-122 



F.23.3 Trailer Record ................................................................................................. F-123 

F.24 Auto Assignment (PDP) Address Notification File......................................................... F-125 


F.24.2 Detail Record .................................................................................................. F-126 

F.24.3 Trailer Record ................................................................................................ F-128 

F.25 Plan Payment Report (PPR)/Interim Plan Payment Report (IPPR) Data File .......... F-129 

F.25.1 Header Record .......................................................................................... F-129 

F.25.2 Capitated Payment – Current Activity ...................................................... F-130 

F.25.3 Premium Settlement .................................................................................. F-131 

F.25.4 Fees ........................................................................................................... F-131 

F.25.5 Special Adjustments ................................................................................. F-132 

F.25.6 Previous Cycle Balance Summary ............................................................ F-133 

F.25.7 Payment Summary ........................................................................................ F-134 

F.25.8 Payment Balance Carried Forward ............................................................... F-136 

F.26 Long-Term Institutionalized (LTI) Resident Report Data File ................................. F-138 

F.27 Agent Broker Compensation Report Data File ......................................................... F-140 

F.28 Monthly Medicare Second Payer (MSP) Information Data File ............................... F-142 

F.28.1 Header Record ....................................................................................... F-142 

F.28.2 Detail Record ........................................................................................ F-142 

F.28.3 Trailer Record ........................................................................................ F-143 

F.29 Other Health Coverage Information Data File ......................................................... F-144 

F.29.1 Header Record ....................................................................................... F-144 

F.29.2 Detail Record ........................................................................................ F-144 

F.29.3 Trailer Record ........................................................................................ F-149 

F.30 No Premium Due Data File Layout .......................................................................... F-150 

F.31 Failed Payment Reply Report (FPRR) Data File ............................................................. F-152 

F.32 Missing Payment Exception Report (MPER) Data File ............................................ F-153 

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 ................................................................................................ I-2 

December 28, 2012 vii Table of Contents


I.3 Obsolete Transaction Reply Codes .............................................................................. I-84 

I.4 Transaction Reply Code (TRC) Groupings .................................................................. I-91 

I.5 Payment Reply Codes ................................................................................................. I-100 

I.6 MMR Adjustment Reason Codes ............................................................................... I-101 

I.7 State Codes ................................................................................................................. I-103 

I.8 Entitlement Status and Enrollment Reason Codes ..................................................... I-105 

I.9 Disenrollment Reason Codes ..................................................................................... I-108 

I.10 BEQ Response File Error Condition Table ................................................................ I-111 

I.10.1 Request File Error Conditions .......................................................................... I-111 

I.10.2 Request Transaction Detail Record Error Conditions ...................................... I-112 

J: Report Files ............................................................................................................................ J-1 

J.1 BIPA 606 Payment Reduction Report..................................................................................... J-2 

J.2 Bonus Payment Report ............................................................................................................ J-6 

J.3 HMO Bill Itemization Report................................................................................................ J-11 

J.4 Monthly Membership Detail Report – Drug Report (Part D) ............................................... J-12 

J.5 Monthly Membership Detail Report – Non-Drug Report (Part C) ....................................... J-13 

J.6 Monthly Membership Summary Report (MMSR) ................................................................ J-15 

J.7 Monthly Summary of Bills Report ........................................................................................ J-19 

J.8 Part C Risk Adjustment Model Output Report ..................................................................... J-21 

J.9 RAS RxHCC Model Output Report - aka - Part D RA Model Output Report ..................... J-22 

J.10 Payment Records Report ........................................................................................................23 

J.11 Plan Payment Report (APPS Payment Letter) .......................................................................24 

J.12 Interim Plan Payment Report (IPPR) .................................................................................. J-29 

J.13 No Premium Due Report Format ........................................................................................ J-30 

J.14 Sample BEQ Request File Pass and Fail Acknowledgments .............................................. J-36 

K: All Transmissions Overview ............................................................................................... K-1 

L: MA Plan Connectivity Checklist .........................................................................................L-1 

M: Valid Election Types for Plan-Submitted Transactions ................................................. M-1 

December 28, 2012 viii Table of Contents


A: Glossary and List of Abbreviations and Acronyms 

Table A-1: Glossary 

Term 

Accepted Transaction 

Account Number 

Application Date 

Batch Transaction 

Beneficiary 

Identification Code 

(BIC) 

Benefit Stabilization 

Fund (BSF) 

Button 

Cancellation 

Transaction 

Checkbox 

Connect:Direct 

Correction 

Cost Plan 

Current Calendar 

Month (CCM) 

Current Processing 

Month 

Current Payment Month 

(CPM) 

Creditable Coverage 

Data entry field 

Deductible 

Disenrollment 

Dropdown list 

Definition 

The successful application of a requested action that was processed by MARx. 

A number obtained from the Resource Access Control Facility (RACF) or 

system administrator. 

The date that the beneficiary applies to enroll in a Plan. Enrollments 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 be 

processed must be grouped and processed in bulk. 

The portion of the Medicare health insurance claim number that identifies a 

specific beneficiary. 

Established by CMS upon request of an HMO or CMP, when the HMO or CMP 

must provide its Medicare enrollees with additional benefits, to prevent 

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 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 

Plan before the effective date of the election. A cancelled enrollment restores 

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’ 

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. 

The proprietary software that transfers files between systems. 

A record submitted by a Plan or CMS office to correct or update existing 

Beneficiary data. 

A type of contract under which a Plan is reimbursed by CMS for its reasonable 

costs. 

Represents the calendar month and year at the time of transaction submission. 

For batch, the current month is derived from the batch file transmission date; 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 Month is distinguished from the CPM, the month in which 

Plans receive payment from CMS. 

The month for which Plans receive payment from CMS, not the current calendar 

month. 

Prescription drug coverage, generally from an employer or union, that is 

equivalent to, or better than, Medicare standard prescription drug coverage. 

A field that requires the user to enter information. 

The amount a Beneficiary must pay for medical services or prescription drugs 

before a Plan starts paying benefits. 

A record submitted by a Plan, Social Security Administration District Office 

(SSA DO), Medicare Customer Service Center (MCSC), or CMS when a 

beneficiary discontinues membership in the Plan. 

A field that contains a list of values from which the user chooses. Clicking on 

the down arrow on the right of the field enables the user to view the list of 

values, and then click on a value to select it. 

December 28, 2012 A-1 Glossary and List of Abbreviations 

and Acronyms


Term 

Dual Eligible 

Election Period 

Enrollment 

Enrollment Process 

Exception 

Failed Payment Reply 

Codes 

Failed Transaction 

Formulary 

Gentran 

Hospice 

Logoff 

Logon 

Lookup field 

Medicaid 

Managed Care 

Organization (MCO) 

Menu 

Network Data Mover 

(NDM) 

MicroStrategy 

Nursing Home 

Certifiable (NHC) 

Off-cycle 

Definition 

Individuals entitled to both Medicare and Medicaid benefits 

Time periods during which a Beneficiary may elect to join, change, or leave 

Medicare Part C and/or Part D Plans. These periods are fully defined in CMS 

Enrollment and Disenrollment guidance for Part C and D Plans available on the 

Web at: http://www.cms.gov/home/medicare.asp under “Eligibility and 

Enrollment.” 

A record submitted when a Beneficiary joins an MCO or a drug plan. 

A process in which a Plan submits a request to enroll in a Plan, change 

enrollment, or disenroll. 

A transaction that is unprocessed due to errors or internal inconsistencies. 

Codes used for the Failed Payment Reply Report that identify incomplete 

payment calculations for a beneficiary. 

A transaction that did not complete due to problems with the format of the 

transaction or internal system problems. 

The medications covered by an MA organization or prescription drug plan. 

The Gentran servers provide Electronic Data Interchange (EDI) capabilities 

between CMS and CMS business partners. These servers provide MARx with 

transaction files from the Plans, and provide the Plans with MARx reports. 

A health facility for the terminally ill. 

The method of exiting an online system. 

The method for gaining entry to an online system. 

A field that provides a list of possible values. When the user clicks on the 

“binocular” button next to the field, a window pops up with a list of values for 

that field. Clicking on one of those values closes the pop-up window and the 

field is filled with the value chosen. 

A jointly funded, Federal-State health insurance program for certain low-income 

and needy people. It covers approximately 36 million individuals including 

children, the aged, blind, and/or disabled, and people eligible to receive 

Federally assisted income maintenance payments. 

A type of contract under which CMS pays for each member, based on 

demographic characteristics and health status; also referred to as Risk. In a Risk 

contract, the MCO accepts the risk if the payment does not cover the cost of 

services, but keeps the difference if the payment is greater than the cost of 

services. Risk is managed through a membership where the high costs for very 

sick members are balanced by the lower cost for a larger number of relatively 

healthy members. 

A horizontal list of items at the top of a screen. Clicking on a menu item 

displays a screen and may display a submenu of items corresponding to the 

selected menu item. 

Software used for transmitting and receiving data; replaced by Connect:Direct. 

A tool used for generating and viewing standard and ad hoc reports. 

A code that reflects the relative frailty of an individual. NHC Beneficiaries are 

those whose condition would ordinarily require nursing home care. The code is 

only acceptable for certain social health maintenance organization (SHMO)- 

type Plans. 

A retroactive transaction awaiting CMS approval because its effective date is 

too old for automatic acceptance. 




Term 

Online 

Premium 

Premium Payment 

Option (PPO) 

Program for All 

Inclusive Care for the 

Elderly (PACE) Plans 

Radio button 

Required field 

Risk 

Special Needs Plan 

(SNP) 

Submenu 

TIBCO MFT Internet 

Server 

Transaction Code (TC) 

Transaction Reply Code 

(TRC) 

User ID 

User Interface 

Definition 

An automated systems approach that processes data in an interactive manner, 

normally through computer input. 

The monthly payment a Beneficiary makes to Medicare, an insurance company, 

or a healthcare Plan. 

The method selected by the beneficiary to pay the premium owed to the Plan. 

PPO choices are: (1) withhold from SSA (S) or RRB (R) benefit check or (2) 

Direct self-pay (D) to the Plan. 

PACE is a unique capitated managed care benefit for the frail elderly provided 

by a not-for-profit or public entity that features a comprehensive medical and 

social service delivery system. It uses a multidisciplinary team approach in an 

adult day health center supplemented by in-home and referral service in 

accordance with participants' needs. 

A field that is part of a group of options, of which the user may only select one 

option. A radio button is represented with a small circle; a filled circle indicates 

the button is selected, and an empty circle means it is not selected. Clicking a 

radio button selects that option and deselects the existing selection. 

A field that the user must complete before a button is clicked to engage an 

action. If the button is clicked and the field is not filled in, an error message 

displays and the action does not occur. 

There are two types of required fields: 

• Always required, which are marked with an asterisk (*) 

• Conditionally required, where the user must fill in at least one or only one of 

the conditionally required fields. These are marked with a plus sign (+). 

A contract under which Beneficiaries are “locked in” to network providers and a 

payment is received from CMS for each member, based on demographic 

characteristics and health status. In a Risk contract, the MCO accepts the risk if 

the payment does not cover the cost of services, but keeps the difference if the 

payment is greater than the cost of services. Risk is managed through a 

membership where the high costs for very sick members are balanced by the 

lower costs for a larger number of relatively healthy members. 

A certain type of MA Plan that serves a limited population of individuals in 

CMS special-needs categories, as defined in CMS Part C Enrollment and 

Eligibility Guidance. This Plan is fully defined on the Web at: 

http://www.cms.gov/home/medicare.asp under “Health Plans.” 

A horizontal list of items below the screen’s menu. Clicking on a submenu item 

displays a screen. 

The TIBCO MFT Internet Servers provide Electronic Data Interchange (EDI) 

capabilities between CMS and CMS business partners. These servers provide 

MARx and MBD with transaction files from the Plans, and provide the Plans 

with MARx and MBD reports. 

Identifies batch transactions submitted by the Plans or CMS. 

The code that explains the action taken by the system in response to new 

information from CMS systems or in response to input from MCOs, CMS, or 

other users. 

Valid user identification code for accessing the CMS Data Center and the 

Medicare Data Communications Network. 

The screens, forms, and menus that display to a user logged on to an automated 

system. 




A.1 List of Abbreviations and Acronyms 

AAPCC Adjusted Average Per Capita Cost 

ADAP AIDS Drug Assistance Program 

AE-FE Automated Enrollment-Facilitated Enrollment 

AEP 

Annual Enrollment Period 

APPS Automated Plan Payment System 

BBA Balanced Budget Act of 1997 

BCSS Batch Completion Status Summary 

BEQ 

Beneficiary Eligibility Query 

BIC 

Beneficiary Identification Code 

BIN 

Beneficiary Identification Number 

BIPA Benefits Improvement & Protection Act of 2000 

BSF 

Benefit Stabilization Fund 

CAN 

Claim Account Number 

CCIP/FFS Chronic Care Improvement Program/Fee-for-Service 

CCM Current Calendar Month 

C:D 

Connect:Direct 

CHF 

Congestive Heart Failure 

CM 

Center for Medicare 

CMP 

Competitive Medical Plan 

CMS 

Centers for Medicare & Medicaid Services 

CO 

Central Office 

COB 

Close of Business 

COB 

Coordination of Benefits 

COBA Coordination of Benefits Agreement 

COBC Coordination of Benefits Contractor 

COM Current Operation Month 

CPM 

Current Payment Month 

CR 

Change Request 

CSR 

Customer Service Representative 

CWF 

Common Working File database (CMS’ beneficiary database) 

DCG 

Diagnostic Cost Group 

DDPS Drug Data Processing System 

DO 

District Office 

DOB 

Date of Birth 

DOD 

Date of Death 




DPO 

DSA 

DTL 

DTRR 

ECRS 

EDB 

EFT 

EGHP 

EIN 

EOY 

EPOC 

ESRD 

FAQ 

FEFD 

FERAS 

FFS 

FTR 

GHP 

GUIDE 

HCC 

HCFA 

HCPP 

HIC 

HICN 

HIPAA 

HMO 

HPMS 

HTML 

HTTPS 

IACS 

ICD 

ICD-9-CM 

ICEP 

ID 

IEP 

IPPR 

IRMAA 

Division of Payment Operations 

Data Sharing Agreement 

Detail 

Daily Transaction Reply Report 

Electronic Correspondence Referral System 

Enrollment Database 

Enterprise File Transfer 

Employer Group Health Plan 

Employee Identification Number 

End of Year 

External Point of Contact 

End Stage Renal Disease 

Frequently Asked Question 

Full Enrollment File Data 

Front End Risk Adjustment System 

Fee-For-Service 

Failed Transaction Report 

Group Health Plan 

Plan Communications User Guide 

Hierarchical Condition Category 

Health Care Financing Administration (renamed to CMS) 

Health Care Premium Plan 

Health Insurance Claim 

Health Insurance Claim Number 

Health Insurance Portability and Accountability Act 

Health Maintenance Organization 

Health Plan Management System 

Hypertext Markup Language 

Hypertext Transfer Protocol Secure 

Individuals Authorized Access to CMS Computer Services 

Interface Control Document 

International Classification of Diseases, 9 th Edition 

Initial Coverage Election Period 

Identification 

Initial Enrollment Period 

Interim Plan Payment Report 

Income-Related Monthly Adjustment Amount 




IRS 

IT 

LEP 

LICS 

LIPS 

LIS 

LISHIST 

LISPRM 

LTC 

LTI 

MA 

MA BSF 

MADP 

MAPD 

MARx 

MARx UI 

MBD 

MCO 

MDS 

MCSC 

MMA 

MMCM 

MMDR 

MMP 

MMR 

MMSR 

MPWE 

MPWR 

MSA 

MSHO 

MSP 

NCPDP 

NDM 

NMEC 

NHC 

NUNCMO 

OEPI 

Internal Revenue Service 

Information Technology 

Late Enrollment Penalty 

Low-Income Cost Sharing 

Low-Income Premium Subsidy 

Low-Income Subsidy 

LIS History Data File 

LIS Premium Data File 

Long-Term Care 

Long-Term Institutional 

Medicare Advantage 

Medicare Advantage Benefit Stabilization Fund 

Medicare Advantage Disenrollment Period 

Medicare Advantage and Part D 

Medicare Advantage and Prescription Drug System 

Medicare Advantage and Prescription Drug System User Interface 

Medicare Beneficiary Database 

Managed Care Organization 

Minimum Data Set 

Medicare Customer Service Center (1-800-MEDICARE) 

Medicare Modernization Act 

Medicare Managed Care Manual 

Monthly Membership Detail Report 

Medicare and Medicaid Plan 

Monthly Membership Report 

Monthly Membership Summary Report 

Monthly Premium Withhold Extract 

Monthly Premium Withholding Report Data File 

Medical Savings Account 

Minnesota Senior Health Options 

Medicare Secondary Payer 

National Council of Prescriptions Drug Programs 

Network Data Mover 

National Medicare Education Campaign 

Nursing Home Certifiable 

Number of Uncovered Months 

Open Enrollment Period for Institutionalized Individuals 




OHI 

OMB 

OPM 

PACE 

PAP 

PBM 

PBO 

PBP 

PCN 

PDE 

PDP 

PFFS 

PIP 

POS 

PPO 

PPR 

PRM 

PWS 

QMB 

RA 

RACF 

RAS 

RDS 

REMIS 

RO 

RRB 

RRE 

RxHCC 

SCC 

SEP 

SFTP 

SHMO 

SIMS 

SLMB 

SNP 

SPAP 

SSA 

Other Health Insurance 

Office of Management and Budget 

Office of Personnel Management 

Program of All-Inclusive Care for the Elderly 

Patient Assistance Program 

Pharmacy Benefit Manager 

Payment Bill Option 

Plan Benefit Package 

Processor Control Number 

Prescription Drug Event 

Prescription Drug Plan 

Private Fee-for-Service 

Principal Inpatient Diagnostic Cost Group 

Point-of-Sale 

Premium Payment Option 

Plan Payment Report 

Primary Record 

Premium Withhold System 

Qualified Medicare Beneficiary Program 

Risk Adjustment/Risk Adjusted 

Resource Access Control Facility 

Risk Adjustment System 

Retiree Drug Subsidy 

Renal Management Information System 

CMS Regional Office 

Railroad Retirement Board 

Responsible Reporting Entity 

Prescription Drug Hierarchical Condition Category 

State and County Code 

Special Election Period 

Secure Shell File Transfer Protocol 

Social Health Maintenance Organization 

Standard Information Management System 

Specified Low-Income Medicare Beneficiary Program 

Special Needs Plan 

State Pharmaceutical Assistance Program 

Social Security Administration 




SSA DO 

SSN 

SUP 

TC 

TIN 

TRC 

TrOOP 

TRR 

UI 

WC 

WCSA 

WPP 

Social Security Administration District Office 

Social Security Number 

Supplemental Record 

Transaction Code 

Tax Identification Number 

Transaction Reply Code 

True Out-of-Pocket 

Transaction Reply Report 

User Interface 

Workers Compensation 

Workers Compensation Set-Aside 

Wisconsin Partnership Program 




B: CMS Central Office Contact Information 

This appendix contains consolidated contact information for Plans to reference when they need 

assistance with questions or issues on information contained in the Plan Communications User 

Guide (the Guide) or on other issues or topics as summarized in the tables below. 

Note: For questions or issues on payment or premium information contained in this guide or on 

any of the topics listed below, Plans should contact their Center for Medicare and Medicaid 

Services (CMS) Central Office (CO) Health Insurance Specialist in the Division of Payment 

Operations (DPO) for their particular region. See DPO contact list by region on page B-2 below. 

Table B-1: DPO Central Office Contact Information 

Full Dual Eligibility; Business Questions Only 

Dual eligibility in general 

Rules for auto assignment 

Rules for passive enrollment 

Info on Special Needs Plan (SNP) - NOT 

the files 

Late Enrollment Penalty (LEP); Business Only 

CMS Plan Reporting Requirements; Not file 

format 

Reports 

 

Report Contents, Timing, and Payment; 

Medicare Advantage and Prescription 

Drug System (MARx) 

Full Dual Eligibility; (Business Only) 

Plan Payments 

Calculation of payment 

Delivery of payment 

Payment errors 

Premium calculations 

Automated Plan Payment System (APPS) 

operation and APPS reports 

Actual payments going to the Plans 

Payment rules 

Payment operations 

Interim payments 

Monthly Membership Report (MMR) 

Center for Medicare (CM) Plan Payment Letters 

All APPS Payment Reports; (Business Only) 

Plan Communications User Guide 

December 28, 2012 B-1 CMS Central Office Contact Information


B.1 CMS Central Office 

Table B-2: Division of Payment Operations (DPO) Representatives 

Region Contact Telephone Number E-mail Address 

1. Boston and 

Kansas City 

2. New York, 

Demos/PACE 

Terry Williams (410) 786-0705 Terry.Williams@cms.hhs.gov 

William Bucksten (410) 786-7477 William.Bucksten@cms.hhs.gov 

3. Philadelphia James Krall (410) 786-6999 James.Krall@cms.hhs.gov 

4. Atlanta Louise Matthews (410) 786-6903 Louise.Matthews@cms.hhs.gov 

5. Chicago Mary Stojak (410) 786-6939 Mary.Stojak@cms.hhs.gov 

6. Dallas Michelle Page (410) 786-6937 Michelle.Page@cms.hhs.gov 

7. San Francisco Kim Miegel (410) 786-3311 Kim.Miegel@cms.hhs.gov 

and Denver 

8. Seattle Shawanda Perkins 410-786-7412 Shawanda.Perkins@cms.hhs.gov 

9. DPO Director John Scott (410) 786-3636 John.Scott@cms.hhs.gov 

B.2 Payment Information Form 

Government vendor organizations with Medicare contracts receive payment from the 

Department of Treasury through an Electronic Funds Transfer (EFT) program. On the expected 

payment date, government vendor receive payments as direct deposits into corporate accounts at 

financial institutions. Additionally, CMS must have the Employee Identification Number 

(EIN)/Tax Identification Number (TIN) and associated name as registered with the Internal 

Revenue Service (IRS). 



NAME OF ORGANIZATION: 

DBA, if any: 

ORGANIZATION INFORMATION 

ADDRESS: 

CITY: STATE: ZIP CODE: 

CONTACT PERSON NAME: 

TELEPHONE NUMBER: 

CONTRACT NO’s.: H ; H ; H ; H 

(If known) 

EIN/TIN NAME of business for tax purposes (as registered with the IRS: a W-9 may be 

required) 

EMPLOYER/TAX IDENTIFICATION NUMBER (EIN or TIN): 

Mailing address for 1099 tax form: 

STR1: 

STR2: 

CITY: 

STATE: ZIP: - 

FINANCIAL INSTITUTION 

NAME OF BANK: 

ADDRESS: 

CITY: STATE: ZIP CODE: - 

ACH/EFT COORDINATOR NAME: 

TELEPHONE NUMBER: 

_____ 

NINE DIGIT ROUTING TRANSIT (ABA) NUMBER: 

DEPOSITOR ACCOUNT TITLE: 

DEPOSITOR ACCOUNT NUMBER: 

CIRCLE ACCOUNT TYPE: CHECKING SAVINGS (Please attach a copy of a voided 

check) 

SIGNATURE & TITLE OF ORGANIZATION’S AUTHORIZED REPRESENTATIVE: 

Signature 

Title 

DATE: ____________________ 

_____________________________________________ 

Print Name 

______________________ 

Phone Number 

3/12/03 



Special Note: 

For assistance with Beneficiary-specific issues with enrollments, disenrollments, cancellations, 

and changes, Plans should contact their designated CMS regional caseworker. 

Plans should e-mail their inquiry or research request for enrollment issues to the home Regional 

Office (RO) associated with their Beneficiary’s address at PartDComplaints_RO#@cms.hhs.gov 

Note: Replace the # sign in the above e-mail address with the specific RO number from the list 

above. For example: if the Beneficiary resides in Baltimore, send the inquiry to the Philadelphia 

RO using the following e-mail address: 

Example: PartDComplaints_RO3@cms.hhs.gov 

Please Note: Plans should report premium or other Plan Payment issues directly to their DPO 

contact listed on Page B-2 and not to the ROs/caseworkers. Also, if MARx reflects that the 

Beneficiary is in SSA Deduct and the Plan is not getting paid, then the Plan should contact its 

DPO representative. 

For non-payment-related software, database questions, errors or issues related to any of the 

topics listed below, Plans may contact the Medicare Advantage and Prescription Drug (MAPD) 

Help Desk at 1-800-927-8069 or via e-mail at MAPDHelp@cms.hhs.gov. 

Table B-3: MAPD Help Desk Contact Information 

 

 

 

 

 

File transfer software; Connect:Direct, Secure FTP, Gentran HTTPS, and TIBCO MFT Internet 

Server 

Ongoing Connectivity, File Transmission Support and Troubleshooting 

Supporting access to CMS systems; Individuals Authorized Access to CMS Computer Services 

(IACS) and Common User Interface (UI) 

Coordination with other help desks for proper routing of issues 

Questions related to file layouts; MAPD Help and OIS system letters, user guides, Frequently 

Asked Questions (FAQs), etc. 



Plan Manager; Medicare Advantage (MA) Plans only – Contact regional Plan Manager for 

questions or issues related to the topics listed below: 

Table B-4: Plan Manager Contact Information 

 

Special Needs Plan questions, unless 

drug related 

 

Regional Premium Payment Option (PPO) Plan 

Questions, unless drug related 

 

MA Medical Savings Account (MSA) 

- Part C Plan manager issue, unless drug 

related 

 

Part C Managed Care Appeals Policy 

 

MA only Plan Finder Tool 

Account Manager (Part D Plans Only) – Contact Account Manager for questions or issues 

related to the topics listed below: 

Table B-5: Account Manager Contact Information 

Online Enrollment Center General Part D Information 

General Part D Medicare Information General Part D MMA Information 

General Part D Policy Questions Part D Managed Care Appeals Policy 

Part D vs. Part B Drug Coverage Health Insurance Portability and Accountability 

Act (HIPAA) Privacy 

Creditable Coverage Marketing Requirements 

Financial Solvency – Application COB Survey 

Plan Finder & Formulary 





vi

C: Monthly Schedule 


The following pages contain the 2011 Plan Medicare Advantage and Prescription Drug System 

(MARx) Monthly Schedule, which provides dates for the following: 

 

 

 

 

 

 

Plan Data Due 

Down Days 

Availability of Monthly Reports 

Due Date for Certification of Enrollment, Payment, and Premium Reports 

Payments Due to Plans 

Holidays 

Note: The Daily Transaction Reply Report (DTRR), is not indicated on this schedule because it is 

a daily report. 

This calendar is also available as a single document in the Medicare Advantage and Prescription 

Drug (MAPD) Help Desk Web site downloads section: http://www.cms.gov/mapdhelpdesk/. Both 

color and text 508 compliant versions of this schedule are available at the above link. 

C.1 MARx Plan Payment Processing Schedule Description - Calendar Year 2013 

It is vital that everyone involved in the Medicare enrollment and payment operations of the 

contract is aware of target dates schedule attached to this description. The schedule includes: 

(1) PLAN DATA DUE - This is the last day for Plans to transmit records to the CMS Data 

Center for processing in the month. Plans must complete the transmission by the close of 

business (8 p.m. ET) on the date noted. 

(2) PAYMENT DUE PLANS - This is the date that CMS deposits the CMS monthly payment 

to the Plans; all deposits are made to arrive on the first calendar day of the month unless 

the first day falls on a weekend or a Federal holiday. In this case, the deposit arrives on the 

last workday prior to the first of the month. 

Note: The January deposit is the first business day of the month. 

(3) MONTHLY REPORTS AVAIL - This is the date all the CMS monthly reports are 

available for downloading from the mailbox or received in the system. 

Note: These reports are not mailed; the Plan must download them to receive them! 

(3) ANNUAL ELECTION PERIOD BEGINS AND ENDS - The Annual Election Period (AEP) 

is October 15 through December 7 every year. Elections made during the AEP are 

effective January 1 of the following year. 

(4) CERTIFICATION DUE - This is the date by which Plans must certify the accuracy of the 

enrollment information of the MARx Report. Plans must send the Certification to the 

Retroactive Processing Contractor. 

(5) APPROVED RETROS TO CMS - Any records processed as batch retroactive files must 

arrive at CMS by noon on the date shown, along with the appropriate paperwork approved 

by CMS. 

December 28, 2012 C-1 Monthly Schedule






D: Enrollment Data Transmission Schedule 

The following is a recommendation for the best time to transmit data: 

 

 

Monday through Friday - 24 hours. 

Data IS received for monthly processing. 

Saturday, Sunday, and system down days. 

Data IS RECEIVED AND HELD for monthly processing. 

Refer to the Plan Monthly Schedule. (Appendix C) 

 

Enrollment Data Cutoff Day - Data is due by 8 p.m. ET. 

The Plan Monthly Schedule in Appendix C lists cutoff dates for each month. 

Note: Retros are due by noon two days prior to the Plan Data Due/Submission 

cutoff day. 

December 28, 2012 D-1 Enrollment Transmission Schedule



December 28, 2012 D-2 Enrollment Transmission Schedule


E: ESRD Network Contact Information Table 

Network Region States Name & Address Contact Information 

1 1 Connecticut 

Maine 

Massachusetts 

New Hampshire 

Rhode Island 

Vermont 

ESRD Network of New England 

Jaya Bhargava, Data Manager 

30 Hazel Terrace. 

Woodbridge, Connecticut 06525 

Phone: (203) 387-9332 

Fax: (203) 389-9902 

2 2 New York IPRO/CKD Network for New York 

Bernadette Cobb, Data Manager 

1979 Marcus Avenue 

Lake Success, New York 11042-1002 

3 2 New Jersey 

Puerto Rico 

Virgin Islands 

4 3 Delaware 

Pennsylvania 

5 3 D of Columbia 

Maryland 

Virginia 

West Virginia 

6 4 Georgia 

North Carolina 

South Carolina 

Trans-Atlantic Renal Council 

Chris Milkosky, Data Manager 

Cranbury Gate Office Park 

109 S. Main St., Suite 21 

Cranbury, New Jersey 08512-9595 

ESRD Network 4 Inc. 

Rhonda Lockett, Data Manager 

40 24 th Street, Suite 410 

Pittsburgh, Pennsylvania 15222 

Mid-Atlantic Renal Coalition 

Jason Robins, Data Manager 

1527 Huguenot Road 

Midlothian, Virginia 23113 

Southeastern Kidney Council, Inc. 

Margo Clay, Data Manager 

1000 St. Albans Drive, Suite 270 

Raleigh, North Carolina 27609 

7 4 Florida ESRD Network of Florida, Inc. 

LeChrystal Williams, Data Manager 

5201 W Kennedy Boulevard, Suite 900 

Tampa, Florida 33606 

8 4 Alabama 

Mississippi 

Tennessee 

9 5 Kentucky 

Indiana 

Ohio 

ESRD Network Eight, Inc. 

Robert Bain, Data Manager 

1755 Lelia Drive, Suite 400 

Jackson, Mississippi 39210 

The Renal Network, Inc. 

Christy Harper, Data Manager 

911 East 86th Street, Suite 202 

Indianapolis, Indiana 46240 

10 5 Illinois The Renal Network, Inc. 

Christy Harper, Data Manager 

911 E 86th Street, Suite 202 

Indianapolis, Indiana 46240 

11 5 Michigan 

Minnesota 

North Dakota 

South Dakota 

Wisconsin 

12 7 Iowa 

Kansas 

Missouri 

Nebraska 

Renal Network of the Upper Midwest 

Tom Kysilko, Data Manager 

1360 Energy Park Drive, Suite 200 

St. Paul, Minnesota 55108 

ESRD Network 12 

Jeff Arnell, Data Manager 

7306 NW Tiffany Springs Parkway 

Suite 230 

Kansas City, Missouri 64153 

Phone: (516) 209-5619 

Fax: (516) 326-8929 

Phone: (609) 490-0310 

Fax: (609) 490-0835 

Phone: (412) 325-2250 

Fax: (412) 325-1811 

Phone: (804) 794-3757 

Fax: (804) 794-3793 

Phone: (919) 855-0882 

Fax: (919) 855-0753 

Phone: (813) 383-1530 

Fax: (813) 354-1514 

Phone: (601) 936-9260 

Fax: (601) 932-4446 

Phone: (317) 257-8265 

Fax: (317) 257-8291 

Phone: (317) 257-8265 

Fax: (317) 257-8291 

Phone: (651) 644-9877 

Fax: (651) 644-9853 

Phone: (816) 880-9990 

Fax: (816) 880-9088 

December 28, 2012 E-1 ESRD Network Contact Information 

Table


Network Region States Name & Address Contact Information 

13 6 Arkansas 

Louisiana 

Oklahoma 

ESRD Network 13 

Cindy Smith, Data Manager 

4200 Perimeter Center Drive, Suite 102 

Phone: (405) 942-6000 

Fax: (405) 942-6884 

Oklahoma City, Oklahoma 73112 

14 6 Texas ESRD Network of Texas, Inc. 

Nathan Muzos, Data Manager 

4040 McEwen, Suite 350 

Dallas, Texas 75244 

15 10 Arizona 

Colorado 

Nevada 

New Mexico 

Utah 

Wyoming 

16 10 Alaska 

Idaho 

Montana 

Oregon 

Washington 

17 10 Amer Samoa 

Hawaii 

N. California 

Pacific Islands 

Intermountain ESRD Network, Inc. 

Matt Howard, Data Manager 

165 S. Union Blvd 

Suite 466 

Lakewood, Colorado 80228 

Northwest Renal Network 

Donna Swenson, Data Manager 

4702 42nd Avenue, SW 

Seattle, Washington 98116 

Western Pacific Renal Network 

Susan Tanner, Data Manager 

505 San Marin Drive, Bldg A, Suite 300 

Novata, California 94945 

18 10 S. California Southern California Renal Disease 

Council 

Svetlana Lyulkin, Data Manager 

6255 Sunset Boulevard, Suite 2211 

Los Angeles, California 90028 

Phone: (972) 503-3215 

Fax: (972) 503-3219 

Phone: (303) 831-8818 

Fax: (303) 860-8392 

Phone: (206) 923-0714 

Fax: (206) 923-0716 

Phone: (415) 897-2400 

Fax: (415) 897-2422 

Phone: (323) 962-2020 

Fax: (323) 962-2891 

December 28, 2012 E-2 ESRD Network Contact Information 

Table


F: Record Layouts 

This appendix provides record layouts for data files exchanged with Plans. Field lengths, formats, and descriptions 

are included along with expected values where applicable. Table F-1 below lists the names of all the layouts and on 

which page of Appendix F to find them. Appendix K identifies the naming conventions of for all files exchanged 

between CMS and the Plans. 

Table F-1: Record Layouts Lookup Table 

Section Name Page 

F.1 820 Format Payment Advice Data File F-3 

F.2 Batch Completion Status Summary Data File F-7 

F.3 BIPA 606 Payment Reduction Data File F-8 

F.4 Bonus Payment Data File F-9 

F.5 Coordination of Benefits (COB) Validated Other Insurer Information Data File F-10 

F.6 MARx Batch Input Transaction Data File F-17 

F.6.1 Header Record F-17 

F.6.2 Disenrollment Transaction (TC 51/54) F-18 

F.6.3 Enrollment Transaction (TC 61) F-19 

F.6.4.1 RX Change (TC 72) F-22 

F.6.4.2 NUNCMO Change (TC 73) F-23 

F.6.4.3 EGHP Change (TC 74) F-24 

F.6.4.4 Premium Payment Option (POP) Change (TC 75) F-24 

F.6.4.5 Residence Address Change (TC 76) F-25 

F.6.4.6 Segment ID Change (TC 77) F-26 

F.6.4.7 Part C Premium Change (TC 78) F-26 

F.6.4.8 Part D Opt-Out Change (TC 79) F-27 

F.6.5.1 Cancel Enrollment (TC 80) F-28 

F.6.5.2 Cancel Disenrollment (TC 81) F-28 

F.6.5.3 MMP Enrollment Cancellation (TC 82) Detail Record Layout F-29 

F.6.5.4 MMP Opt-Out Update (TC 83) Layout F-29 

F.6.6 Correction Record F-30 

F.6.7 Notes for All Plan-Submitted Transaction Types F-31 

F.7 Failed Transaction Data File - OBSOLETE F-35 

F.8 Monthly Membership Detail Data File F-36 

F.9 Monthly Membership Summary Data File F-44 

F.10 Monthly Premium Withholding Report Data File (MPWR) F-47 

F.11 Part B Claims Data File F-50 

F.12 Part C Risk Adjustment Model Output Data File F-52 

F.13 

RAS RxHCC Model Output Data File aka Part D Risk Adjustment Model Output 

Data File 

F-59 

F.14 Daily Transaction Reply Report (DTRR) Data File F-81 

F.14.1 DTRR Data File Detailed Record Layout F-81 

F.14.2 Verbatim Plan Submitted Transaction on Transaction Reply Report F-89 

F.15 Monthly Full Enrollment Data File F-89 

December 28, 2012 F-1 Record Layouts



F.16 Low Income Subsidy (LIS)/Late Enrollment Penalty (LEP) Data File F-92 

F.17 Loss of Subsidy Data File F-95 

F.18 LIS/Part D Premium Data File F-97 

F.19 LIS History Data File (LISHIST) F-98 

F.20 NoRx File F-102 

F.21 Batch Eligibility Query (BEQ) Request File F-106 

F.22 Batch Eligibility Query (BEQ) Response File F-109 

F.23 MA Full Dual Auto Assignment Notification File F-122 

F.24 Auto Assignment PDP Address Notification File F-125 

F.25 Plan Payment Report (PPR) / Interim Plan Payment Report (IPRR) Data File F-129 

F.26 Long-Term Institutionalized Resident Report Data File F-138 

F.27 Agent Broker Compensation Report Data File F-140 

F.28 Monthly Medicare Secondary Payer (MSP) Information Data File F-142 

F.29 Other Health Coverage Information Data File F-144 

F.30 No Premium Due Data File Layout F-150 

F.31 Failed Payment Reply Report Data File F-152 

F.32 Missing Payment Exception Report F-153 

December 28, 2012 F-2 Record Layouts


F.1 820 Format Payment Advice Data File 

The 820 Format Payment Advice data file is a Health Insurance Portability & Accountability Act 

(HIPAA)-compliant version of the Plan Payment Report, which is also known as the Automated 

Plan Payment System (APPS) Payment Letter. The data file itemizes the final monthly payment to 

the Plan. It is produced by APPS when final payments are calculated, and is available to Plans as 

part of the month-end processing. This file is not available through Medicare Advantage and 

Prescription Drug System (MARx). 

The following records are included in this file: 

Header Record (numbers 1-6 below) 

Detail Record (numbers 7-10 below) 

Summary Record (number 11 below) 

The segments are listed in a required order: 

1. ST, 820 Header 

2. BPR, Financial Information 

3. TRN, Re-association Key 

4. DTM, Coverage Period 

5. N1, Premium Receiver’s Name 

6. N1, Premium Payer’s Name 

7. RMR, Organization Summary Remittance Detail 

8. IT1, Summary Line Item 

9. SLN, Member Count 

10. ADX, Organization Summary Remittance Level Adjustment 

11. SE, 820 Trailer 

The physical layout of a segment is: 

Segment Identifier, an alphanumeric code, followed by 

Each selected field (data element) preceded by a data element separator (“*”) 

And terminated by a segment terminator (“~”). 

Fields are mostly variable in length and do not contain leading/trailing spaces. If fields are empty, 

they are skipped by inserting contiguous data element separators (“*”) unless they are at the end of 

the segment. Fields that are not selected are represented in the same way as fields that are selected, 

but as this particular iteration of the transaction set contain no data, they are skipped. 

For example, in fictitious segment XXX, fields 2, 3, and 5 (the last field) are skipped: 

BALANCING REQUIREMENTS 1 

XXX*field 1 content***field 4 content~ 

1 See pp.16 in National EDI Transaction Set Implementation Guide for 820, ASCX12N, 820 (004010X061), dated 

May 2000 

December 28, 2012 F-3 820 Format Payment 

Advice Data File


Following two balancing rules are given: 

1. BPR02 = total of all RMR04 

2. RMR04 = RMR05 + ADX01 

To comply with balancing rules, BPR02 and RMR04 are set equal to Net Payment (paid amount), 

RMR05 is set equal to Gross/Calculated Payment (billed amount), and ADX01 is set equal to 

Adjustment amount. 

On Cost/Health Care Premium Plan (HCPP) contracts, Plans should enter the actual dollars billed, 

rather than the “risk equivalent” dollar amounts, into RMR05. 

F.1.1 Header Record 

Item 

Segment 

Data 

Element 

Description Length Type Contents 

820 Header Segment ID 2 AN “ST” 

ST01 Transaction Set ID Code 3/3 ID “820” 

ST02 

Transaction Set Control 

Number 

4/9 AN Begin with “00001” 

Increment each Run 

Beginning Segment For 

3 AN “BPR” 

Payment Order/Remittance 

Advice 

BPR BPR01 Transaction Handling Code 1/2 ID “I”(Remittance Information 

Only) 

BPR BPR02 Total Premium Payment 

Amount 

1/18 R Payment Letter – Net 

Payment 

See discussion on Balancing. 

BPR BPR03 Credit/Debit Flag Code 1/1 ID “C” (Credit) 

BPR BPR04 Payment Method Code 3/3 ID “BOP” (Financial Institution 

Option) 

BPR BPR16 Check Issue or EFT Effective 

Date 

8/8 DT Use Payment Letter – 

Payment Date in 

CCYYMMDD format 

Re-Association Key 3 AN “TRN” 

TRN TRN01 Trace Type Code 1/2 ID “3” (Financial Re-association 

Trace Number) 

TRN TRN02 Check or EFT Trace Number 1/30 AN “USTREASURY” 

Coverage Period 3 AN “DTM” 

DTM DTM01 Date/Time Qualifier 3/3 ID “582” (Report Period) 

DTM DTM05 Date/Time Period Format 

Qualifier 

2/3 ID “RD8”(Range of dates 

expressed in format 

CCYYMMDD – 

CCYYMMDD) 

DTM DTM06 Date/Time Period 1/35 AN Range of Dates for Payment 

Month. See DTM05. 


Advice Data File


Item 

Segment 

Data 

Element 


Premium Receiver’s Name 2 AN “N1” 

1000A N101 Entity Identifier Code 2/3 ID “PE” (Payee) 

1000A N102 Name 1/60 AN Contract Name 

1000A N103 Identification Code Qualifier 1/2 ID “EQ” Insurance Company 

Assigned ID Number 

1000A N104 Identification Code 2/80 AN Contract Number 

Premium Payer’s Name 2 AN “N1” 

1000B N101 Entity Identifier Code 2/3 ID “PR” (Payer) 

1000B N102 Name 1/60 AN “CMS” 

1000B N103 Identification Code Qualifier 1/2 ID “EQ” Insurance Company 

Assigned ID Number 

1000B N104 Identification Code 2/80 AN “CMS” 

F.1.2 Detail Record 

Item 

Segment 

Data 

Element 


Organization Summary 3 AN “RMR” 

Remittance Detail 

2300A RMR01 Reference Identification 2/3 ID “CT” 

Qualifier 

2300A RMR02 Contract Number 1/30 AN Payment Letter – Contract # 

2300A RMR04 Detail Premium Payment 

Amount 

1/18 R Payment Letter – Net Payment 


2300A RMR05 Billed Premium Amount 1/18 R Payment Letter – Capitated Payment. 


Summary Line Item 3 AN “IT1” 

2310A IT101 Line Item Control 1/20 AN “1” (Assigned for uniqueness) 

Number 

Member Count 3 AN “SLN” 

2315A SLN01 Line Item Control 

Number 

1/20 AN “1” (Assigned for uniqueness) 

2315A SLN03 Information Only 

1/1 ID “O” (For Information only) 

Indicator 

2315A SLN04 Head Count 1/15 R Payment Letter – Total Members 

2315A 

SLN05- 

1 

Unit or Basis for 

Measurement Code 

2/2 ID “IE” - used to identify that the value 

of SLN04 represents the number of 

contract holders with individual 

coverage 

Organization Summary 3 AN “ADX” 

Remittance Level 

Adjustment 

2320A ADX01 Adjustment Amount 1/18 R Payment Letter – Total Adjustments is 

the difference between Capitated 

Payment and Net Payment. See 

discussion on Balancing. 


Advice Data File


Item 

Segment 

Data 

Element 


2320A ADX02 Adjustment Reason Code 2/2 ID “H1” - Information forthcoming – 

detailed information related to the 

adjustment is provided through a 

separate mechanism 

F.1.3 Trailer Record 

Item Segment 

Data 

Element 


Summary 820 Trailer AN “SE” 

SE01 Number of Included 

Segments 

1/10 N0 “11” 

SE02 

Transaction Set Control 

Number 

4/9 AN Use control number, 

same as in 820 Header. 


Advice Data File


F.2 Batch Completion Status Summary (BCSS) Data File 

As of the April 2011 release, the Batch Completion Status Summary (BCSS) file is a hybrid file 

that communicates the status of file transmissions, as well as reporting and reports on submitted 

transaction records that failed due to formatting issues. Previously, this file also returned the 

processing results of accepted and rejected transactions, but as of the April 2011 release, those 

are reported only on the Daily Transaction Reply Report (DTRR) Data file. Note: The 

Enrollment Transmission Message File (STATUS) discontinued as of the April 2011 Release. 

This data file is sent to the submitter after a batch of submitted transactions is processed. It 

provides a count of all transactions within the batch and details the number of rejected and 

accepted transactions. It also provides an image of each failed transaction. 

F.2.1 Failed Record 

Below, the example of a BCSS report displays the format of the file transmission status. Plans 

get a sense of how the file status incorporates the new Transaction Codes (TCs) 76 through 83 

and that the counts for accepted, rejected and failed transactions are displayed. 

Beginning of Message Text 

H1 TRANSACTIONS RECEIVED ON 2012-03-27 AT 16.59.49 

H2 TRANSACTIONS PROCESSED ON 2012-03-27 AT 17.03.50 

H3 ENROLLMENT PROCESSING COMPLETED 

H4 HEADER CODE= AAAAAAHEADER 

H5 HEADER DATE= 032012 

H6 REQUEST ID = 

H7 BATCH ID = 0123456789 

H8 USER ID = X7YZ 

C1 TRAN CNTS1 = 00000019 T01 0000000 T51 0000000 T61 0000000 T72 0000001 

C2 TRAN CNTS2 = T73 0000002 T74 0000000 T75 0000000 T76 0000000 

C3 TRAN CNTS3 = T77 0000000 T78 0000000 T79 0000002 T80 0000002 

C4 TRAN CNTS4 = T81 0000003 T82 0000004 T83 0000005 TXX 0000000 

P1 TOTAL TRANSACTIONS PROCESSED= 00000043 

P2 TOTAL ACCEPTED TRANSACTIONS = 00000041 

P3 TOTAL REJECTED TRANSACTIONS = 00000002 

P4 TOTAL FAILED TRANSACTIONS = 00000000 

F………………failed transaction text image……………… 

End of Message Text 

All BCSS records begin with a two-character record type identifier. The first character 

designates the type of data reported in that section. 

December 28, 2012 F-7 BCSS Data File


F.2.2 BCSS ‘Failed Transaction’ Layout 

Item Field Size Position Description 

1 Record Type Identifier 2 1-2 Failed Record Type: “F ” (‘F’ and space) 

2 Filler 1 3 Spaces 

3 

Failed Input Transaction Record 

Text 

300 4-303 Failed transaction text 

4 Filler 5 304-308 Spaces 

5 Transaction Reply Codes (TRCs) 3 309-311 First TRC 

6 TRCs 3 312- 314 Second TRC; otherwise, spaces 

7 TRCs 3 315 - 317 Third TRC; otherwise, spaces 

8 TRCs 3 318-320 Fourth TRC; otherwise, spaces 

9 TRCs 3 321-323 Fifth TRC; otherwise, spaces 

Total Length = 323 

December 28, 2012 F-8 BCSS Data File


F.3 BIPA 606 Payment Reduction Data File 


1 Contract Number 5 1-5 Contract Number 

2 PBP Number 3 6-8 999 

3 Run Date 8 9-16 YYYYMMDD 

4 Payment Month 6 17-22 YYYYMM 

5 Adjustment Reason Code 2 23-24 99; SPACES = Payment 

6 Payment/Adjustment Start Month 6 25-30 YYYYMM 

7 Payment/Adjustment End Month 6 31-36 YYYYMM 

8 HIC 12 37-48 External Format 

9 Surname First 7 7 49-55 

10 First Initial 1 56 

11 Sex 1 57 M = Male; F = Female 

12 Date of Birth 8 58-65 YYYYMMDD 

13 BIPA606 Payment Reduction Rate 6 66-71 999.99; must be GE ZERO 

14 

Total Net Blended Payment/Adjustment 

Excluding BIPA606 Reduction Amount 

9 72-80 -99999.99 

15 BIPA606 Net Payment Reduction Amount 8 81-88 

-9999.99; Normally negative, may 

include positive adjustments 

Applies only to Part B amounts 

16 Net Part A Blended Amount 9 89-97 -99999.99; Same as MMR amount 

17 

18 

Net Part B Blended Amount plus BIPA606 

Net Payment Reduction 

Total Net Blended Payment/Adjustment 

Including BIPA606 Reduction Amount 

9 98-106 -99999.99 

9 107-115 -99999.99 



December 28, 2012 F-9 BIPA 606 Payment Reduction Data File


F.4 Bonus Payment Data File 


1 Contract Number 5 1-5 Plan contract number 

2 Run Date 8 6-13 

YYYYMMDD; date the report 

was created 

3 Payment Month 6 14-19 

YYYYMM; the month that 

payments are effective 

4 Adjustment Reason Code 2 20-21 

Reason for the adjustment; equal 

to spaces if a payment 

5 Payment/Adjustment Start Month 6 22-27 YYYYMM 

6 Payment/Adjustment End Month 6 28-33 YYYYMM 

7 State and County Code 5 34-38 

2-digit state code followed by 3- 

digit county code of residence 

8 HIC 12 39-50 Beneficiary’s claim number 

9 Surname 7 51-57 First 7 letters of the last name 

10 Initial 1 58 Initial of the first name 

11 Sex 1 59 Gender; M=male, F=female 


13 Bonus Percentage 5 68-72 

14 

Total Blended Payment/Adjustment w/o 

Bonus 

9 73-81 

Bonus payment percent; 5.000% 

or 3.000% 

Total Payment/Adjustment 

without bonus 

15 Bonus Part A Payment/Adjustment 8 82-89 Part A bonus payment/adjustment 

16 Bonus Part B Payment/Adjustment 8 90-97 Part B bonus payment/adjustment 

17 Total Bonus Payment/Adjustment 9 98-106 Total bonus payment/adjustment 

18 

Blended + Bonus Payment/Adjustment 

Part A 

9 107-115 

19 Blended + Bonus Payment/Adjustment 9 116-124 

20 

Total Blended + Bonus 

Payment/Adjustment 


9 125-133 

Part A payment/adjustment with 

bonus 

Part B payment/adjustment with 

bonus Part B 

Total payment/adjustment with 

bonus 

December 28, 2012 F-10 Bonus Payment Data File


F.5 Coordination of Benefits (COB); Validated Other Health Insurance Data 

File 

This file contains members’ primary and secondary coverage, validated through COB 

processing. MARx forwards this report whenever a Plan’s enrollees are affected, which may 

occur as often as daily. The enrollees included on the report are those newly enrolled who have 

known Other Health Insurance (OHI) and those Plan enrollees with changes to their OHI. 


 

 

 

Detail Record 



F.5.1 General Organization of Records 

Detail Record (DTL) Record 1 (Beneficiary A) 

Primary (PRM) records associated with ‘DTL’ Record 1 (Beneficiary A) 

Supplemental (SUP) records associated with ‘DTL’ Record 1 (Beneficiary A) 

‘DTL’ Record 2 (Beneficiary B) 

‘PRM’ records associated with ‘DTL’ Record 2 (Beneficiary B) 

‘SUP’ records associated with ‘DTL’ Record 2 (Beneficiary B) 

‘DTL’ Record 3 (Beneficiary C) 

‘PRM’ records associated with ‘DTL’ Record 3 (Beneficiary C) 

‘SUP’ records associated with ‘DTL’ Record 3 (Beneficiary C) 

‘DTL Record n 

‘PRM’ records associated with ‘DTL’ Record n 

‘SUP’ records associated with ‘DTL’ Record n 

F.5.2 Detail Records: Indicates the Beginning of a Series of Beneficiary Subordinate Detail 

Records 

Item Field Size Position Format Valid Values/Description 

1 Record Type 3 1-3 CHAR "DTL" 

2 HICN/RRB Number 12 4-15 CHAR Spaces if unknown 

3 SSN 9 16-24 ZD 000000000 if unknown 

4 Date of Birth (DOB) 8 25-32 CHAR YYYYMMDD 

5 Gender Code 1 33 CHAR 

0=unknown, 1 = male, 2 = 

female 

6 Contract Number 5 34-38 CHAR 

7 Plan Benefit Package 3 39-41 CHAR 

8 Action Type 1 42 CHAR 2 = Full replacement 

9 Filler 958 43-1000 CHAR Spaces 

Note: Record Length = 1000 

December 28, 2012 F-11 COB; Validated Other Health Insurance 

Data


F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences) 


1 Record Type 3 1-3 CHAR "PRM" 

2 HICN/RRB Number 12 4-15 CHAR Spaces if unknown 


4 Date of Birth (DOB) 8 25-32 CHAR YYYYMMDD 

5 Gender Code 1 33 CHAR 0=unknown, 1 = male, 2 = female 

6 RxID Number* 20 34-53 CHAR 

7 RxGroup Number* 15 54-68 CHAR 

8 RxBIN Number* 6 69-74 ZD 

9 RxPCN Number* 10 75-84 CHAR 

10 

Rx Plan Toll Free 

Number* 

18 85-102 CHAR 

11 Sequence Number* 3 103-105 CHAR 

12 

COB Source Code* 

Note: There may be 

instances where an 

unknown COB Source 

Code will be provided. 

Plans should contact 

COBC for clarification 

on any unknown Source 

Codes. 

5 106-110 CHAR 

11100 Non Payment/Payment Denial 

11101 IEQ 

11102 Data Match 

11103 HMO 

11104 Litigation Settlement BCBS 

11105 Employer Voluntary Reporting 

11106 Insurer Voluntary Reporting 

11107 First Claim Development 

11108 Trauma Code Development 

11109 Secondary Claims Investigation 

11110 Self Report 

11111 411.25 

11112 BCBS Voluntary Agreements 

11113 Office of Personnel 

Management (OPM) Data Match 

11114 Workers' Compensation Data 

Match 

11118 Pharmacy Benefit Manager 

(PBM) 

11120 COBA 

11125 Recovery Audit Contractor 

(RAC) 1 (April Release) 

11126 RAC 2 (April Release) 


P0000 PBM 

S0000 Assistance Program 

Note: Contractor numbers 11100 - 

11199 are reserved for COB 


Data



13 

MSP Reason 

(Entitlement Reason 

from COB) 

1 111 CHAR 

14 Coverage Code* 1 112 CHAR 

15 Insurer's Name* 32 113-144 CHAR 

16 Insurer's Address-1* 32 145-176 CHAR 

17 Insurer's Address-2* 32 177-208 CHAR 

18 Insurer's City* 15 209-223 CHAR 

19 Insurer's State* 2 224-225 CHAR 

20 Insurer's Zip Code* 9 226-234 CHAR 

21 Insurer TIN 10 235-244 CHAR 

22 

Individual Policy 

Number* 

17 245-261 CHAR 

23 Group Policy Number* 20 262-281 CHAR 

24 Effective Date* 8 282-289 ZD CCYYMMDD 

A=Working Aged 

B=ESRD 

C=Conditional Payment 

D=Automobile Insurance, No fault 

E=Workers Compensation 

F=Federal (public) 

G=Disabled 

H=Black Lung 

I=Veterans 

L=Liability 

A=Hospital and Medical 

U=Drug (network benefit) 

V=Drug with Major Medical (nonnetwork 

benefit) 

W=Comprehensive, Hospital, Medical, 

Drug (network) 

X=Hospital and Drug (network) 

Y=Medical and Drug (network) 

Z=Health Reimbursement Account 

(hospital, medical, and drug) 

25 Termination Date* 8 290-297 ZD CCYYMMDD 

26 Relationship Code* 2 298-299 CHAR 

01=Bene is Policy Holder 

02=Spouse 

03=Child 

04=Other 

27 Payer ID* 10 300-309 CHAR This is a future element. 

28 Person Code* 3 310-312 CHAR 

29 Payer Order* 3 313-315 ZD 

30 

Policy Holder's First 

Name 

9 316-324 CHAR 

31 

Policy Holder's Last 

Name 

16 325-340 CHAR 

32 Policy Holder's SSN 12 341-352 CHAR 

33 

Employee Information 

Code 

1 353 CHAR 

34 Employer's Name 32 354-385 CHAR 

P=Patient 

S=Spouse 

M=Mother 

F=Father 


Data



35 Employer's Address 1 32 386-417 CHAR 

36 Employer's Address 2 32 418-449 CHAR 

37 Employer's City 15 450-464 CHAR 

38 Employer's State 2 465-466 CHAR 

39 Employer's Zip Code 9 467-475 CHAR 

40 Filler 20 476-495 CHAR 

41 Employer TIN 10 496-505 CHAR 

42 Filler 20 506-525 CHAR 

43 Claim Diagnosis Code 1 10 526-535 CHAR 





48 Attorney's Name 32 576-607 CHAR 

49 Attorney's Address 1 32 608-639 CHAR 

50 Attorney's Address 2 32 640-671 CHAR 

51 Attorney's City 15 672-686 CHAR 

52 Attorney's State 2 687-688 CHAR 

53 Attorney's Zip 9 689-697 CHAR 

54 Lead Contractor 9 698-706 CHAR 

55 Class Action Type 2 707-708 CHAR 

56 Administrator Name 32 709-740 CHAR 

57 Administrator Address 1 32 741-772 CHAR 

58 Administrator Address 2 32 773-804 CHAR 

59 Administrator City 15 805-819 CHAR 

60 Administrator State 2 820-821 CHAR 

61 Administrator Zip 9 822-830 CHAR 

62 WCSA Amount 9 831-842 ZD Integer value 

63 WCSA Indicator 2 843-844 CHAR 

64 

WCMSA Settlement 

Date 

8 845-852 ZD CCYYMMDD 

65 

Administrator’s 

Telephone Number 

18 853-870 CHAR 

66 

Total Rx Settlement 

Includes decimal point: 

12 871-882 CHAR 

Amount 

9999999999.99 

67 

Rx $ included in the 

Y = Yes 

WCMSA Settlement 1 883 CHAR 

N = No 

Amount 

68 Filler 120 884-1000 CHAR 


*Indicates that these fields have same position in PRM and SUP record layouts. 


Data


F.5.4 Supplemental Records: Subordinate to DTL (Unlimited Occurrences) 


1 Record Type 3 1-3 CHAR "SUP" 

2 

HICN/RRB 

Number 

12 4-15 CHAR Spaces if unknown 


4 

Date of Birth 

(DOB) 

8 25-32 CHAR YYYYMMDD 

5 Gender Code 1 33 CHAR 0=unknown, 1 = male, 2 = female 

6 

7 

8 

9 

10 

11 

12 

RxID 

Number* 

RxGroup 

Number* 

RxBIN 

Number* 

RxPCN 

Number* 

Rx Plan Toll 

Free Number* 

Sequence 

Number* 

COB Source 

Code* 

20 34-53 ZD 

15 54-68 CHAR 

6 69-74 ZD 

10 75-84 CHAR 

18 85-102 CHAR 

3 103-105 CHAR 

5 106-110 CHAR 

11100 Non Payment/Payment Denial 

11101 IEQ 

11102 Data Match 

11103 HMO 

11104 Litigation Settlement BCBS 

11105 Employer Voluntary Reporting 

11106 Insurer Voluntary Reporting 

11107 First Claim Development 

11108 Trauma Code Development 

11109 Secondary Claims Investigation 

11110 Self Report 

11111 411.25 

11112 BCBS Voluntary Agreements 

11113 Office of Personnel Management (OPM) Data 

Match 

11114 Workers' Compensation Data Match 

11118 Pharmacy Benefit Manager (PBM) 

11120 COBA 

11125 Recovery Audit Contractor (RAC) 1 (April 

Release) 



P0000 PBM 

S0000 Assistance Program 

Note: Contractor numbers 11100 - 11199 are reserved 

for COB 


Data



13 

Supplemental 

Type Code 

1 111 CHAR 

L=Supplemental 

M=Medigap 

N=State Program (Non-Qualified SPAP) 

O=Other 

P=Patient Assistance Program 

Q=Qualified State Pharmaceutical Assistance Program 

(SPAP) 

R=Charity 

S=AIDS Drug Assistance Program 

T=Federal Health Program 

1=Medicaid 

2=Tricare 

3 = Major Medical 

14 

15 

16 

17 

Coverage 

Code* 

Insurer's 

Name* 

Insurer's 

Address-1* 

Insurer's 

Address-2* 

1 112 CHAR 

32 113-144 CHAR 

32 145-176 CHAR 

32 177-208 CHAR 

18 Insurer's City* 15 209-223 CHAR 

U=Drug (network benefit) 

V=Drug with Major Medical (non-network benefit) 

19 Insurer's State* 2 224-225 CHAR 

20 

Insurer's Zip 

Code* 

9 226-234 CHAR 


22 

23 

Individual 

Policy 

Number* 

Group Policy 

Number* 

17 245-261 CHAR 

20 262-281 CHAR 

24 

Effective 

Date* 

8 282-289 ZD CCYYMMDD 

25 

Termination 

Date* 

8 290-297 ZD CCYYMMDD 

26 

Relationship 

Code* 

2 298-299 CHAR 

01=Bene is Policy Holder 

02=Spouse 

03=Child 

04=Other 

27 Payer ID* 10 300-309 CHAR 


Data



28 Person Code* 3 310-312 CHAR 

29 Payer Order* 3 313-315 ZD 

30 Filler 685 316-1000 SPACES 

Total Length = 1,000 

*Indicates that these fields have same position in PRM and SUP record layouts 


Data


F.6 MARX Batch Input Transaction Data File 

A transaction file is submitted to CMS by a Plan, and consists of a header record followed by 

individual transaction records. The transaction code (TC) identifies the type of transaction record. 

This section details the contents and format that each record type may include in the transaction 

file. 

This file may include the following records: 

• Header Record 

• Disenrollment (51/54) Detail Record 

• Enrollment (61) Detail Record 

• Miscellaneous Change Detail Records: 

- Correction (01) Record 

- 4Rx Data Change (72) 

- Number of Uncovered Months (NUNCMO) Change (73) 

- Employer Group Health Plan (EGHP) Change (74) 

- Premium Payment Option (PPO) Change (75) 

- Residence Address Change (76) 

- Segment ID Change (77) 

- Part C Premium Change (78) 

- Part D Opt-Out (79) 

- MMP Opt-Out Update (TC83) 

• Cancellation of Enrollment (80) and Cancellation of Disenrollment (81) Detail Records 

- MMP Enrollment Cancelation (TC82) 



1 

Header 

Message 

12 1-12 "AAAAAAHEADER" 


3 

Batch File 

Type 

5 14-18 

“RETRO” = retroactive batch file submission; 

“POVER” = Plan rollover batch file submission; 

“SVIEW” = Special organization review batch file submission. 


5 

CMS Approval 

Request ID 

10 20-29 


7 

Current 

Calendar 

Month (CCM) 

6 34-39 



"Spaces" when “Batch File Type,” field #3, contains spaces; 

otherwise, the right justified CMS pre-approval request ID from the 

special batch request utility. 

Reference month for enrollment processing formatted MMYYYY. 

The CCM date determines whether to accept a file and evaluates the 

appropriate effective date for submitted transactions. 

December 28, 2012 F-18 MARX Batch Input 

Transaction Data File


F.6.2 Disenrollment Transaction (TC 51/54) Detailed Record Layout 


1 HICN 12 1-12 Required 

2 Surname 12 13-24 Required 

3 First Name 7 25-31 Required 

4 M. Initial 1 32 Optional 

5 Gender Code 1 33 Required 

6 Birth Date (YYYYMMDD) 8 34-41 Required 

7 Filler 1 42 Required 

8 PBP 3 43-45 Optional 

9 Election Type 1 46 

Required for all Plan types except HCPP, COST 

1 without drug, COST 2 without drug, CCIP/FFS 

demo, MDHO demo, MSHO demo, and PACE 

National Plans 

10 Contract # 5 47-51 Required 

11 Filler 8 52-59 N/A 

12 Transaction Codes (TCs)* 2 60-61 “51” or “54” 

13 DRC 2 62-63 

14 

Effective Date 

(YYYYMMDD) 

8 64-71 Required 

15 Segment ID 3 72-74 Optional 

16 Filler 24 75-98 N/A 

Required for Involuntary Disenrollments. 

Optional for Voluntary Disenrollments. 

17 Part D Opt-Out Flag 1 99 Optional for all Part D Plans; otherwise blank 

18 MMP Opt-Out Flag 1 100 Optional for all Plans 

19 Filler 109 101-209 N/A 

20 

Plan Transaction Tracking 

ID** 

15 210-224 Optional 

21 Filler 76 225-300 N/A 


*The “51” transaction is Plan submitted. The “54” is submitted by 1-800-Medicare without a header record. 

**Plan Transaction Tracking ID field is not used by 1-800-Medicare. 




F.6.3 Enrollment Transaction (TC 61) Detailed Record Layout 

Item Fields Size Position Description 







7 EGHP Flag 1 42 Blank field has a meaning. 

8 PBP # 3 43-45 Required 

9 Election Type 1 46 


11 Application Date 8 52-59 Required 

12 Transaction Code 2 60-61 Required 

13 Disenrollment Reason 2 62-63 N/A 

14 Effective Date (YYYYMMDD) 8 64-71 Required 

15 Segment ID 3 72-74 

16 Filler 5 75-79 N/A 

17 ESRD Override 1 80 

18 

19 

Premium Withhold Option/Parts C- 

D 

Part C Premium Amount 

(XXXXvXX) 

1 81 

6 82-87 

20 Filler 6 88-93 N/A 

Required: for all Plan types when Note 3 is true; 

otherwise not required for HCPP, COST 1 without 

drug, COST 2 without drug, CCIP/FFS demo, 

MDHO demo, MSHO demo, and PACE National 

Plans. 

Optional: if provided, must have three digits and a 

valid Segment for the Contract/PBP. 

Required: for MA Plans to successfully enroll 

ESRD exceptions. 

Required: for all Plan types except HCPP, COST 1 

without drug, COST 2 without drug, CCIP/FFS 

demo, MSA/MA and MSA/demo Plans. 

Required: for all Plan types except HCPP, COST 

1, COST 2, CCIP/FFS demo, MSA/MA and 

MSA/demo Plans. 

21 Creditable Coverage Flag 1 94 Required: for all Part D Plans; otherwise blank. 

22 Number of Uncovered Months 3 95-97 

23 

Employer Subsidy Enrollment 

Override Flag 

1 98 

24 Part D Opt-Out Flag 1 99 

25 Filler 35 100-134 N/A 

26 Secondary Drug Insurance Flag 1 135 

Required: for all Part D Plans; otherwise blank. 

Blank = zero, meaning no uncovered months. 

Required: if beneficiary has Employer Subsidy 

status for Part D; otherwise blank. 

Required: when changing PBPs; 'Y' when Opting 

Out of Part D; 'N' when Opting in for Part D; 

otherwise, blank. 

Required: for Part D Plans. Value is 'Y' or 'N' or 

blank. For auto/facilitated enrollments and 




Item Fields Size Position Description 

27 Secondary Rx ID 20 136-155 

28 Secondary Rx Group 15 156-170 

29 Enrollment Source 1 171 

30 Filler 38 172-209 N/A 

31 

Plan Assigned Transaction 

Tracking ID 

15 210-224 Optional 

32 Part D Rx BIN 6 225-230 

33 Part D Rx PCN 10 231-240 

34 Part D Rx Group 15 241-255 

35 Part D Rx ID 20 256-275 

36 Secondary Drug BIN 6 276-281 

37 Secondary Drug PCN 10 282-291 

38 Filler 9 292-300 N/A 


rollovers, value is blank. For non-Part D Plans, 

value is blank. 

Required: if secondary insurance; otherwise, 

blank. 


blank. 

Required: for Point of Service (POS) submitted 

enrollment transactions; otherwise, optional. 

Required: for all Part D Plans except PACE 

National and MMP; otherwise, blank. 

Change-to value for all Part D Plans, otherwise 

blank. 

Change-to value for all Part D Plans, otherwise 

blank. 

Required: for all Part D Plans except PACE 

National and MMP; otherwise, blank. 


blank. 


blank. 

*The “51” transaction is Plan submitted. The “54” is submitted by 1-800-Medicare without a 

header record. 

**Plan Transaction Tracking ID field is not used by 1-800-Medicare. 

Note: Election type rules do apply to HCPP, COST 1 without drug, COST 2 without drug, 

CCIP/FFS demos, MDHO demo, MSHO demo and PACE National enrollments in cases where 

such an enrollment would causes an automatic disenrollment from another plan requiring an 

election type. It is important that the election type for the Plan on the enrollment request is 

consistent with the election type required for automatic disenrollment. 

Note: MA organizations and cost plans that auto/facilitate enroll LIS Beneficiaries on behalf of 

CMS should use the appropriate newly-designated enrollment source code when submitting autoenrollments 

or facilitated enrollments: E = Plan-submitted auto-enrollment, F = Plan-submitted 

facilitated enrollment, G = Point-of-Sale (POS) submitted enrollment; for use by POS contractor 

only, H = CMS reassignment enrollment, I = Assigned to Plan-submitted enrollment with 

enrollment source other than any of the following: B, E, F, G, H and blank. 




F.6.4 Miscellaneous Change Transactions – Detailed Record Layouts 

F.6.4.1 RX Change (TC 72) Detailed Record Layout 


1 HICN 12 1 – 12 Required 

2 Surname 12 13 – 24 Required 

3 First Name 7 25 – 31 Required 



6 Birth Date (YYYYMMDD) 8 34 – 41 Required 

7 Filler 1 42 N/A 

8 PBP # 3 43 – 45 Required 


10 Contract # 5 47 – 51 Required 

11 Filler 8 52 – 59 N/A 

12 Transaction Code (TC) 2 60 – 61 Required 

13 Filler 2 62 – 63 N/A 

14 Effective Date (YYYYMMDD) 8 64 – 71 Required 

15 Filler 63 72-134 N/A 

16 

17 

18 

Secondary Drug Insurance Flag 

Secondary Rx ID 

Secondary Rx Group 

1 135 

20 136-155 

15 156-170 

19 Filler 54 171-209 N/A 

20 Transaction Tracking ID 15 210-224 Optional 

21 

22 

23 

Part D Rx BIN 

Part D Rx PCN 

Part D Rx Group 

6 225-230 

10 231-240 

15 241-255 

Blank or new value. Blank does not remove or replace 

existing data. 

Blank or new additional value. Blank does not remove or 

replace existing data. 



Required together with Part D Rx ID when changing 4Rx 

primary insurance information. Must include either the 

beneficiary’s current field value or the change-to value. 

Blank is appropriate when not changing a beneficiary’s 4Rx 

primary insurance information. 

Change-to value, either a new value or a blank. Blank 

removes the beneficiary’s existing value. 

Change-to value, either a new value or a blank. Blank 

removes the beneficiary’s existing value. 

24 Part D Rx ID 20 256-275 Required together with Part D Rx ID when changing 4Rx 

primary insurance information. Must include either the 

beneficiary’s current field value or the change-to value. 

Blank is appropriate when not changing a beneficiary’s 4Rx 

primary insurance information. 

25 

Secondary Drug BIN 

6 276-281 







26 

Secondary Drug PCN 

10 282-291 

27 Filler 9 292-300 N/A 


F.6.4.2 NUNCMO Change (TC 73) Detailed Record Layout 














11 Filler 8 52-59 N/A 

12 TC 2 60-61 Required 

13 Filler 2 62-63 N/A 


15 Filler 22 72-93 N/A 

16 Creditable Coverage Flag 1 94 Required 

17 NUNCMO 3 95-97 Blank or change-to value 

18 Filler 112 98-209 N/A 


20 Filler 76 225-300 N/A 





F.6.4.3 EGHP Change (TC 74) Detailed Record Layout 








7 EGHP Flag 1 42 Required change-to value 




11 Filler 8 52-59 N/A 


13 Filler 2 62-63 N/A 


15 Filler 138 72-209 N/A 


17 Filler 76 225-300 N/A 


F.6.4.4 Premium Payment Option (PPO) Change (TC 75) Detailed Record Layout 












11 Filler 8 52-59 N/A 

12 TC 2 60- 61 Required 

13 Filler 2 62- 63 N/A 


15 Filler 9 72-80 N/A 





16 PPO/ Parts C-D 1 81 Required change-to value 

17 Filler 128 82-209 N/A 


19 Filler 76 225- 300 N/A 


F.6.4.5 Residence Address Change (TC 76) Detailed Record Layout 







6 

Birth Date 

(YYYYMMDD) 

8 34-41 

7 Filler 5 42-46 N/A 

Required 


9 Filler 8 52-59 N/A 

10 TC 2 60-61 76 

11 Filler 2 62-63 N/A 

12 


(YYYYMMDD) 

8 64-71 

13 Filler 3 72-74 N/A 

14 

Residence Address Line 1 

65 75-139 

Required 

15 Residence Address Line 2 65 140-204 Optional 

16 Filler 4 205-208 N/A 

17 

Address Update/Delete 

Flag 

1 209-209 

Required when Address Update/Delete Flag indicates 

“Update” code 

Required 


19 

20 

21 

Residence City 

Residence State 

Residence Zip Code 


2 282-283 


22 Residence Zip Code+4 4 289-292 Optional 

23 End Date 8 293-300 Optional 











F.6.4.6 Segment ID Change (TC 77) Detailed Record Layout 












11 Filler 8 52-59 N/A 


13 Filler 2 62-63 N/A 


15 Segment ID 3 72-74 Required 

16 Filler 135 75-209 N/A 


18 Filler 76 225-300 N/A 


F.6.4.7 Part C Premium Change (TC 78) Detailed Record Layout 


1 HIC# 12 1-12 Required 




5 Sex 1 33 Required 






11 Filler 8 52-59 N/A 


13 Filler 2 62-63 N/A 


15 Filler 10 72-81 N/A 





16 Part C Premium Amount (XXXXvXX) 6 82-87 Required 

17 Filler 122 88-209 N/A 


19 Filler 76 225-300 N/A 


F.6.4.8 Part D Opt-Out Change (TC 79) Detailed Record Layout 












11 Filler 8 52-59 N/A 


13 Filler 2 62-63 N/A 


15 Filler 27 72-98 N/A 

16 Part D Opt-Out Flag 1 99 Required 

17 Filler 110 100-209 N/A 


19 Filler 76 225-300 N/A 





F.6.5 Cancellation Transactions – Detailed Record Layouts 

F.6.5.1 Cancel Enrollment (TC 80) Detailed Record Layout 


1 HIC# 12 1-12 Required 







8 PBP # 3 43-45 Required: if Plan has PBPs 

9 Filler 1 N/A 


11 Filler 8 52-59 N/A 

12 Transaction Code (TC) 2 60-61 Required 

13 Filler 2 62-63 N/A 


15 Filler 138 72-209 N/A 


17 Filler 76 225-300 N/A 


F.6.5.2 Cancel Disenrollment Transaction (TC 81) Detailed Record Layout 








7 Filler 5 42-46 N/A 


9 Filler 8 52-59 N/A 

10 Transaction Code 2 60-61 Required 

11 Filler 2 62-63 N/A 


13 Filler 138 72-209 N/A 


15 Filler 76 225– 300 N/A 


December 28, 2012 F-28 MARX Batch Input 



F.6.5.3 MMP Enrollment Cancellation (TC 82) Detail Record Layout 









8 PBP 3 43-45 Required for PBP contracts; otherwise, spaces 



11 Filler 8 52-59 N/A 

12 Transaction Code (TC) 2 60-61 Required 

13 DRC 2 62-63 Optional 

14 Effective Date (YYYYMMDD) 8 64-71 Required (must equal the enrollment date) 

15 Filler 28 72-99 N/A 

16 MMP Opt-Out Flag 1 100 Optional 

17 Filler 109 101-209 N/A 

18 Plan Transaction Tracking ID 15 210-224 Optional 

19 Filler 76 225-300 N/A 





F.6.5.4 MMP Opt-Out Update (TC 83) Layout 












11 Filler 8 52-59 N/A 


13 Filler 2 62-63 N/A 


15 Filler 28 72-99 N/A 

16 MMP Opt-Out Flag 1 100 Required 

17 Filler 109 101-209 N/A 

18 Plan Transaction Tracking ID 15 210-224 Optional 

19 Filler 76 225-300 N/A 


F.6.6 Correction Record 

Note: The effective date for ‘01’ transactions comes from the file header. 

Item Field Size Position Correction Description 

1 HICN 12 1-12 R 

Nine-byte SSN of primary Beneficiary Claim Account 

Number (CAN); two-byte Beneficiary Identification Code 

(BIC) one-byte filler (except RRB) 

-2 Surname 12 13-24 R Beneficiary’s last name 

3 First Name 7 25-31 R Beneficiary’s first name 

4 M. Initial 1 32 Beneficiary’s middle initial 

D = Institutional ON 

E = Medicaid ON 

5 Action Code 1 33 R 

F = Medicaid OFF 

G = Nursing Home Certifiable (NHC) ON 

6 Filler 13 34-41 N/A Spaces 

7 Contract # 5 47-51 R Contract Number 


Transaction 

9 

Code (TC) 

2 60-61 R ‘01’ = Correction 






F.6.7 Notes for All Plan-Submitted Transaction Types 

Item Field Description 

1 HICN Health Insurance Claim Number - CAN plus BIC 

2 Surname Beneficiary’s last name 

3 First Name Beneficiary’s first name 

4 M. Initial Beneficiary’s middle initial 

5 Gender Code 

1 = male 

2 = female 

0 = unknown 

6 

Birth Date 

The date of the beneficiary’s birth 

(YYYYMMDD) YYYYMMDD 

This flag indicates whether the Plan associated with this transaction is an Employer 

Group Health Plan (EGHP). 

For an Enrollment (TC 61) Transaction: 

Y = EGHP 

7 EGHP Flag 

blank for all others 

8 PBP # 

9 Election Type 

For an EGHP Change (TC 74) Transaction: 

Y = EGHP 

N = not EGHP 

blank = no change 

Three-character Plan Benefit Package (PBP) identifier, 001 – 999 (zero padded), for 

the plan associated with this transaction. 

PBP is required for all organizations except HCPP and CCIP/FFS demos. For these 

non-PBP organizations, populate with blanks. 

The election type associated with the enrollment or disenrollment associated with this 

transaction. 

A = AEP 

D = MADP 

E = IEP 

F = IEP2 

I = ICEP 

R = 5 Star Quality Rating SEP 

S = Other SEP 

T = OEPI 

U = Dual/LIS SEP 

V = Permanent Change in Residence SEP 

W = EGHP SEP 

X = Administrative SEP 

Y = CMS/Case Worker SEP. 

10 Contract # 

I, A, D, O, S, N, U, V, W, X, Y and T are valid for MA only enrollments. 

I, A, D, O, S, U, V, W, X, Y, T, E, F, N, and T are valid for MAPD enrollments. 

A, S, U, V, W, X, Y, E and F are valid for PDP enrollments. 

The contract number associated with the transaction. 

Hxxxx = local Plans 

Rxxxx = regional Plans 

Sxxxx = PDPs 

Fxxxx = fallback Plans 

Exxxx = employer sponsored MA/MAPD and PDP Plans. 





11 Application Date 

12 TC 

13 Disenrollment Reason 

14 


(YYYYMMDD) 

15 Segment ID 

The application date associated with this enrollment transaction. The application date 

is generally the date the enrollment request was initially received by the Plan, as 

further defined in the CMS plan enrollment manual guidance. 

YYYYMMDD 

This identifies the type of transaction submitted on this record. 

01 = Internal corrections or cleanups 

30 = Turn Bene-Level Demonstration Factor On (Demos Only) 

31 = Turn Bene-Level Demonstration Factor Off (Demos Only) 

41 = Part D Opt-Out Change (Submitted by CMS) 

42 = MMP Opt-Out Update 

51 = Disenrollment (MCO or CMS) 

54 = Disenrollment (Submitted by 1-800-MEDICARE) 

61 = Single Enrollment 

72 = 4Rx Record Update 

73 = NUNCMO Update 

74 = Employer Group Health Plan (EGHP) Update 

75 = Premium Payment Option (PPO) Update 

76 = Residence Address Update 

77 = Segment ID Update 

78 = Part C Premium Update 

79 = Part D Opt-Out Update 

80 = Cancellation of Enrollment 

81= Cancellation of Disenrollment 

82 = MMP Enrollment Cancellation 

83 = MMP Opt-Out Update 

The reason the beneficiary is disenrolled from the Plan. This is required for all Plan 

submitted Disenrollment transactions. Refer to the published Disenrollment Reason 

Code (DRC) list and the appropriate CMS plan enrollment manual instructions. 

The effective date for the action taken by the submitted transaction. 

YYYYMMDD 

The three character segment identifier, 001-999 (zero-padded), associated with this 

transaction. This is only required for segmented Plans. Only local MA/MAPD Plans 

(Hxxxx) may have segments. 

For non-segmented plans, this field is populated with blanks. 

16 Filler Blank 

17 ESRD Override 

This is populated to enroll an End Stage Renal Disease (ESRD) beneficiary into a 

non-PDP Plan. 

Any alpha-numeric value (1-9 and A-F) indicates an override. 

Zero (0) or blank indicates no override. 

18 PPO/ Parts C-D 

This indicates the premium payment option (PPO) requested by the beneficiary on 

this transaction. 

D = Direct self-pay 

S = Deduct from SSA benefits 

N = No Premium 

R = RRB benefits 

O = Deduct from OPM benefits (future) 

19 

Part C Premium 

Amount (XXXXvXX) 

The option applies to both Part C and D premiums. 

The amount of the Part C Premium is formatted as six digits with leading zeroes. A 

decimal point is assumed 2-digits from right; XXXXvXX. Zero is interpreted as an 

actual value. If Part C premium does not apply to the transaction, this field is treated 

as blank. 






21 

Creditable Coverage 

Flag 

22 NUNCMO 

23 

Employer Subsidy 

Enrollment Override 

Flag 

24 Part D Opt-Out Flag 

25 MMP Opt-Out Flag 

26 

Secondary Drug 

Insurance Flag 

This indicates whether the beneficiary has creditable drug coverage in the period prior 

to this enrollment in a Part D prescription plan. It is also used to reset the count of 

uncovered months to zero due to a new IEP or LIS change and to remove resets that 

were set in error. 

For enrollment (TC 61) transactions, valid values are Y, N, R and blank. 

For NUNCMO change (TC 73), valid values are Y, N, R, U and blank. 

Y = the beneficiary has creditable coverage. 

N = the beneficiary does not have creditable coverage. 

R = the accumulated NUNCMO is reset to zero as of the effective date on the 

transaction. 

U = the previous reset associated with the effective date on the transaction is 

removed and the total uncovered month accumulation reinstated. 

The number of months during which the beneficiary did not have creditable coverage 

in the period prior to this enrollment, as determined by the Plan according to the 

applicable CMS policy. 

A NUNCMO is greater than 0 only if the Creditable Coverage Flag is N. 

This field is populated with zero if the Creditable Coverage Flag is Y, R or U. 

This flag indicates that the Beneficiary is currently in a Plan receiving an employer 

subsidy, but still wants to enroll in a Part D Plan. 

Y = override the employer subsidy check and enroll the beneficiary 

Blank = No override 

This flag indicates that the beneficiary does not want AE in a Part D Plan. It applies to 

LIS beneficiaries who are subject to AE-FE into Part D. 

Y = add the flag to opt-out of Part D AE-FE. 

N = remove the flag to opt-out of Part D AE-FE. 

Blank = no change to opt-out status 

This flag indicates the beneficiary does not want passive enrollment into an MMP. 

Y = add the flag to opt-out of passive enrollment into MMPs. 

N = remove the flag to opt-out of passive enrollment into an MMP. 

Blank = no change to opt-out status 

This flag indicates whether that beneficiary has secondary drug insurance. 

Y = beneficiary has secondary drug insurance 

N = beneficiary does not have secondary drug insurance 

blank = status of beneficiary’s secondary drug insurance is unknown 

27 Secondary Rx ID 

28 Secondary Rx Group 

Secondary insurance Plan's Identifier for a Beneficiary. It can consist of any 

combination of alphanumeric characters. 

Secondary insurance Plan's Group ID for a Beneficiary. It can consist of any 

combination of alphanumeric characters. 





Indicates the source of the enrollment. 

A = AE by CMS 

B = Beneficiary election (Default when a blank enrollment source is submitted). 

C = FE by CMS 

D = System generated rollover 

E = Plan submitted AE 

F = Plan submitted FE 

29 Enrollment Source 

G = Point of Sale (POS) submitted enrollment 

H = Re-assignment submitted by CMS or Plan 

J = State-submitted passive enrollment 

K = CMS-submitted passive enrollment 

L = MMP beneficiary election 

M= Default for MMP enrollments submitted without an Enrollment Source 

Code (M is not submitted on an enrollment) 


31 Transaction Tracking ID Optional value created and used by the Plan to track the replies of the transaction. 

Part D insurance Plan's Beneficiary Identification Number (BIN) 

Numeric and right justified 

32 Part D Rx BIN 

Example: If BIN is five-position numeric (12345), the submitted BIN is a sixposition 

numeric with zero added in the first position (012345). 

Part D insurance Plan's Pharmacy Control Number (PCN) for the Beneficiary. 

33 Part D Rx PCN 

Alphanumeric (upper case and/or numeric) and left justified 

Default value = spaces 

Part D insurance Plan's group identifier for the Beneficiary. 

34 Part D Rx Group Alphanumeric (upper case and/or numeric) and left justified 


Part D insurance Plan's ID for the Beneficiary. 

35 Part D Rx ID 

Alphanumeric (upper case and/or numeric) and left justified 


Secondary insurance Plan's BIN number for the Beneficiary. 

36 Secondary Rx BIN 

Numeric and right justified 

Secondary insurance Plan's PCN identifier for a Beneficiary. 

37 Secondary Rx PCN Alphanumeric (upper case and/or numeric) and left justified 






F.7 Failed Transaction Data File - OBSOLETE 

Effective with the April 2011 Software Release, CMS no longer generates the Failed 

Transaction Data File. The reporting of failed records was incorporated into the BCSS Data 

file. 

The Failed Transaction data file details transactions that CMS cannot load into MARx for 

processing due to formatting errors with the file header, user authentication, transaction format or 

incorrect data types for transaction data elements. It is sent to the user who submitted the batch. 

December 28, 2012 F-35 Failed Transaction Data 

File - OBSOLETE


F.8 Monthly Membership Detail Data File 

This is a data file version of the Monthly Membership Detail Report (MMDR). The report lists 

every Part C and Part D Medicare member of the contract and provides details about the 

payments and adjustments made for each. This file contains the data for both Part C and Part D 

members and is generated monthly. 


1 

MCO Contract 

Number 

5 1-5 MCO Contract Number 

2 Run Date of the File 8 6-13 YYYYMMDD 

3 Payment Date 6 14-19 YYYYMM 

4 HIC Number 12 20-31 Member’s HIC # 

5 Surname 7 32-38 

6 First Initial 1 39-39 

7 Sex 1 40-40 M = Male, F = Female 


9 Age Group 4 49-52 BBEE; BB = Beginning Age; EE = Ending Age 

10 State & County Code 5 53-57 

11 Out of Area Indicator 1 58-58 Y = Out of contract-level service area 

12 Part A Entitlement 1 59-59 Y = Entitled to Part A 

13 Part B Entitlement 1 60-60 Y = Entitled to Part B 

14 Hospice 1 61-61 Y = Hospice 

15 ESRD 1 62-62 Y = ESRD 

16 Aged/Disabled MSP 1 63-63 

‘Y’ = aged/disabled factor applicable to beneficiary; 

‘N’ = aged/disabled factor not applicable to beneficiary 

17 Institutional 1 64-64 Y = Institutional (monthly) 

18 NHC 1 65-65 Y = Nursing Home Certifiable 

December 28, 2012 F-36 Monthly Membership 

Detail Data File



1. Prior to 2008, payments/payment adjustments report: 

Y = Medicaid status, 

Blank = not Medicaid. 

2. In 2008, payments and payment adjustments report: 

Y = Beneficiary is Medicaid and a default risk factor 

was used, 

N = Beneficiary is not Medicaid and a default risk 

factor was used, 

Blank = CMS is not using a default risk factor or the 

beneficiary is Part D only. 

3. Beginning in 2009: 

Payment adjustments with effective dates in 2008 and 

after, and all prospective payments report: 

19 

Y = Beneficiary is Medicaid and a default risk factor 

New Medicare 

was used, 

Beneficiary Medicaid 1 66-66 

Status Flag 

N = Beneficiary is not Medicaid and a default risk 

factor was used, 

Blank = CMS is not using a default risk factor or the 

beneficiary is Part D only. 

Payment adjustments with effective dates in 2007 and 

earlier report as follows: 

Y = A payment adjustment was made at a “Medicaid” 

rate to the demographic component of a blended 

payment. 

N = A payment adjustment was made to the 

demographic payment component of a blended 

payment, not at “Medicaid” rate. 

Blank = Either the adjusted payment had no 

demographic component, or only the risk portion of a 

blended payment was adjusted. 

20 LTI Flag 1 67-67 Y = Part C Long-Term Institutional 

21 Medicaid Indicator 1 68-68 

When: 

An RAS-supplied factor is used in the payment, and 

Part C Default Indicator in the Payment Profile is 

blank, and 

Medicaid Switch present in the RAS-supplied data that 

corresponds to the risk factor used in payment is not 

blank then value is Y = Medicaid Add-on Otherwise 

the value is blank. 

22 PIP-DCG 2 69-70 PIP-DCG Category - Only on pre-2004 adjustments 


Detail Data File



23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

Default Risk Factor 

Code 

Risk Adjuster Factor 

A 

Risk Adjuster Factor 

B 

Number of 

Paymt/Adjustmt 

Months Part A 

Number of 


Months Part B 

Adjustment Reason 

Code 

Paymt/Adjustment/M 

SA Start Date 

Paymt/Adjustment/M 

SA End Date 

Demographic 


Amount A 

Demographic 


Amount B 

Monthly 


Amount A 

1 71-71 

7 72-78 NN.DDDD 

7 79-85 NN.DDDD 

2 86-87 99 

2 88-89 99 

2 90-91 

Prior to 2004, ‘Y’ indicates a new enrollee risk adjustment 

(RA) factor was in use. 

In the period 2004 through 2008, ‘Y’ indicates that a 

default factor was generated by the system due to lack of a 

RA factor. 

For 2009 and after, for payments and payment adjustments 

and regardless of the effective date of the adjustment, the 

following applies: 

‘1’ = Default Enrollee- Aged/Disabled 

‘2’ = Default Enrollee- ESRD dialysis 

‘3’ = Default Enrollee- ESRD Transplant Kidney, Month 1 

‘4’ = Default Enrollee- ESRD Transplant Kidney, Months 2- 

3 

‘5’ = Default Enrollee- ESRD Post Graft, Months 4-9 

‘6’ = Default Enrollee- ESRD Post Graft, 10+Months 

‘7’ = Default Enrollee Chronic Care SNP 

Blank = The beneficiary is not a default enrollee. 

FORMAT: 99 

Always Spaces on Payment and MSA Deposit or Recovery 

Records 

8 92-99 FORMAT: YYYYMMDD 

8 100-107 FORMAT: YYYYMMDD 

9 108-116 

9 117-125 

9 126-134 

FORMAT: -99999.99 

Prior to 2008, Demographic Paymt/Adjustmt Amount A is 

displayed. 

In 2008 and beyond, Demographic Paymt/Adjustmt Amount 

A is displayed as 0.00. 

FORMAT: -99999.99 

Prior to 2008, Demographic Paymt/Adjustmt Amount B is 

displayed. 

In 2008 and beyond, Demographic Paymt/Adjustmt Amount 

B is displayed as 0.00. 

Part A portion for the beneficiary’s payment or payment 

adjustment dollars. For Medicare Savings Account (MSA) 

Plans, the amount does not include any lump sum deposit or 

recovery amounts. It is the Plan capitated payment only, 

which includes the MSA monthly deposit amount as a 

negative term. 

FORMAT: -99999.99 


Detail Data File



34 

35 

Monthly 


Amount B 

LIS Premium 

Subsidy 

9 135-143 

36 ESRD MSP Flag 1 152-152 

37 

38 

39 

MSA Part A 

Deposit/Recovery 

Amount 

MSA Part B 


Amount 

MSA 


Months 

40 Current Medicaid 

Status 

41 

42 

Risk Adjuster Age 

Group (RAAG) 

Previous Disable 

Ratio (PRDIB) 

Part B portion for the beneficiary’s payment or payment 

adjustment dollars. For MSA Plans, the amount does not 

include any lump sum deposit or recovery amounts. It is the 

Plan capitated payment only, which includes the MSA 

monthly deposit amount as a negative term. 

FORMAT: -99999.99 

8 144-151 FORMAT: -9999.99 

8 153-160 

8 161-168 

2 169-170 

1 171-171 

4 172-175 

7 176-182 

43 De Minimis 1 183-183 

As of January 2011: 

T = Transplant/Dialysis 

P = Post Graft 

Blank = ESRD MSP not applicable 

Prior to 2011: 

Format X. Values = ‘Y’ or ‘N’(default) 

Indicates if Medicare is the Secondary Payer 

MSA lump sum Part A dollars for deposit/recovery. Deposits 

are positive values and recoveries are negative. 

FORMAT: -9999.99 

MSA lump sum Part B dollars for deposit/recovery. Deposits 

are positive values and recoveries are negative. 

FORMAT: -9999.99 

Number of months associated with MSA deposit or recovery 

dollars 

Beginning mid-2008, this field reports the beneficiary current 

Medicaid status. (Prior to 11/07, Medicaid status was 

reported in field #19.) 

‘1’ = Beneficiary is determined as Medicaid as of CPM minus 

two (CPM –2) or minus one (CPM – 1), 

‘0’ = Beneficiary was not determined as Medicaid as of CPM 

minus two (CPM – 2) or minus one (CPM – 1), 

Blank = This is a retroactive transaction and Medicaid status 

is not reported. 

The four sources to determine Current Medicaid Status are: 

1. MMA State files or Dual Medicare Table 

2. Low Income Territory Table 

3. Medicaid Eligibility Table (Only valid records with a 

Medicaid source code of "003U" and "003C" are used.) 

4. Point of Sale Table 

BBEE 

BB = Beginning Age 

EE = Ending Age 

Beginning in 2011, if the risk adjuster factor is from RAS, the 

RAAG reported is the one used by RAS in calculating the risk 

factor 

NN.DDDD 

Percentage of Year (in months) for Previous Disable Add-On. 

Only on pre-2004 adjustments 

Prior to 2008, flag is spaces. 

Beginning 2008: 

‘N’ = “de minimis” does not apply, 

‘Y’ = “de minimis” applies. 


Detail Data File



44 

45 

Beneficiary Dual and 

Part D Enrollment 

Status Flag 

Plan Benefit Package 

Id 

1 184-184 

3 185-187 

46 Race Code 1 188-188 

47 

RA Factor Type 

Code 

2 189-190 

0’ – Non-Drug Plan without drug benefit, Beneficiary not 

dual enrolled 

’1’ – Drug Plan with drug benefit, Beneficiary not dual 

enrolled 

‘2’ – Non-Drug Plan without drug benefit, Beneficiary dual 

enrolled 

‘3’ – Drug Plan with drug benefit, Beneficiary dual enrolled. 

Plan Benefit Package Id 

FORMAT 999 

Format X 

Values: 

0 = Unknown 

1 = White 

2 = Black 

3 = Other 

4 = Asian 

5 = Hispanic 

6 = N. American Native 

Type of factors in use (see Fields 24-25): 

C = Community 

C1 = Community Post-Graft I (ESRD) 

C2 = Community Post-Graft II (ESRD) 

D = Dialysis (ESRD) 

E = New Enrollee 

ED = New Enrollee Dialysis (ESRD) 

E1 = New Enrollee Post-Graft I (ESRD) 

E2 = New Enrollee Post-Graft II (ESRD) 

G1 = Graft I (ESRD) 

G2 = Graft II (ESRD) 

I = Institutional 

I1 = Institutional Post-Graft I (ESRD) 

I2 = Institutional Post-Graft II (ESRD) 

SE=New Enrollee Chronic Care SNP 

48 Frailty Indicator 1 191-191 Y = MCO-level Frailty Factor Included 

49 

Original Reason for 

Entitlement Code 

(OREC) 

1 192-192 

50 Lag Indicator 1 193-193 

51 Segment ID 3 194-196 

52 Enrollment Source 1 197 

53 EGHP Flag 1 198 

54 

Part C Basic 

Premium – Part A 

Amount 

8 199-206 

0 = Beneficiary insured due to age 

1 = Beneficiary insured due to disability 

2 = Beneficiary insured due to ESRD 

3 = Beneficiary insured due to disability and current ESRD 

9 = None of the above 

Y = Encounter data used to calculate RA factor lags payment 

year by 6 months 

Identification number of the segment of the PBP. Blank if 

there are no segments. 

The source of the enrollment. Values are: 

A = Auto-enrolled by CMS, 

B = Beneficiary election, 

C = Facilitated enrollment by CMS, 

D = Systematic enrollment by CMS (rollover) 

Employer Group flag; 

Y = member of employer group, 

N = member is not in an employer group 

The premium amount for determining the MA payment 

attributable to Part A. It is subtracted from the MA Plan 

payment for Plans that bid above the benchmark. -9999.99 


Detail Data File



55 

Part C Basic 

Premium – Part B 

Amount 

8 207-214 

The premium amount for determining the MA payment 

attributable to Part B. It is subtracted from the MA Plan 

payment for Plans that bid above the benchmark. -9999.99 

56 

57 

58 

59 

60 

61 

62 

63 

64 

65 

66 

Rebate for Part A 

Cost Sharing 

Reduction 

Rebate for Part B 

Cost Sharing 

Reduction 

Rebate for Other Part 

A Mandatory 

Supplemental 

Benefits 

Rebate for Other Part 

B Mandatory 

Supplemental 

Benefits 


Premium Reduction – 

Part A Amount 


Premium Reduction – 

Part B Amount 

Rebate for Part D 

Supplemental 

Benefits – Part A 

Amount 


Supplemental 

Benefits – Part B 

Amount 

Total Part A MA 

Payment 

Total Part B MA 

Payment 

Total MA Payment 

Amount 

8 215-222 

8 223-230 

8 231-238 

8 239-246 

8 247-254 

8 255-262 

8 263–270 

8 271–278 

The amount of the rebate allocated to reducing the member’s 

Part A cost-sharing. This amount is added to the MA Plan 

payment for Plans that bid below the benchmark. -9999.99 

The amount of the rebate allocated to reducing the member’s 

Part B cost-sharing. This amount is added to the MA Plan 


The amount of the rebate allocated to providing Part A 

supplemental benefits. This amount is added to the MA Plan 


The amount of the rebate allocated to providing Part B 

supplemental benefits. This amount is added to the MA Plan 


The Part A amount of the rebate allocated to reducing the 

member’s Part B premium. This amount is retained by CMS 

for non ESRD members and it is subtracted from ESRD 

member’s payments. -9999.99 

The Part B amount of the rebate allocated to reducing the 

member’s Part B premium. This amount is retained by CMS 

for non ESRD members and it is subtracted from ESRD 

member’s payments. -9999.99 

Part A Amount of the rebate allocated to providing Part D 

supplemental benefits. -9999.99 

Part B Amount of the rebate allocated to providing Part D 

supplemental benefits. -9999.99 

10 279–288 The total Part A MA payment. -999999.99 

10 289–298 The total Part B MA payment. -999999.99 

11 299-309 

67 Part D RA Factor 7 310-316 

68 

69 

70 

Part D Low-Income 

Indicator 

Part D Low-Income 

Multiplier 

Part D Long-Term 

Institutional Indicator 

1 317 

7 318-324 

1 325 

The total MA A/B payment including MMA adjustments. 

This also includes the Rebate Amount for Part D 

Supplemental Benefits -9999999.99 

The member’s Part D risk adjustment factor. 

NN.DDDD 

From 2006 through 2010, an indicator to identify if the Part D 

Low-Income multiplier is included in the Part D payment. 

Values are 1 (subset 1), 2 (subset 2) or blank. Beginning 

2011, value ‘Y’ indicates the beneficiary is Low Income, 

value ‘N’ indicates the beneficiary is not Low Income for the 

payment/adjustment being made. 

The member’s Part D low-income multiplier. NN.DDDD 

For 2011 payment months and beyond, field is zero. 

From 2006 through 2010, an indicator to identify if the Part D 

Long-Term Institutional multiplier is included in the Part D 

payment. Values are A (aged), D (disabled) or blank. For 

2011 payment months and beyond, this field is blank. 


Detail Data File



Part D Long-Term 

The member’s Part D institutional multiplier. NN.DDDD 

71 Institutional 

7 326-332 

For 2011 payment months and beyond, field is zero. 

Multiplier 

72 

73 

74 


Basic Premium 

Reduction 

Part D Basic 

Premium Amount 

Part D Direct Subsidy 

Monthly Payment 

Amount 

8 333-340 

Amount of the rebate allocated to reducing the member’s 

basic Part D premium. -9999.99 

8 341-348 The Plan’s Part D premium amount. -9999.99 

10 349-358 

The total Part D Direct subsidy payment for the member. 

When POS contract (X is first character of contract number), 

then it is total POS Direct Subsidy for the member. - 

999999.99 

The amount of the reinsurance subsidy included in the 

payment. -999999.99 

The amount of the low-income subsidy cost-sharing amount 

included in the payment. -999999.99 

75 

Reinsurance Subsidy 

Amount 

10 359-368 

76 

Low-Income Subsidy 

Cost-Sharing Amount 

10 369-378 

77 Total Part D Payment 11 379-389 The total Part D payment for the member -9999999.99 

Number of 

78 Paymt/Adjustmt 2 390-391 99 

Months Part D 

79 

80 

81 

PACE Premium Add 

On 

PACE Cost Sharing 

Add-on 

Part C Frailty Score 

Factor 

10 392-401 Total Part D Pace Premium Add-on amount -999999.99 

10 402-411 Total Part D Pace Cost Sharing Add-on amount -999999.99 

7 412-418 

82 MSP Factor 7 419-425 

83 

84 

85 

MSP 

Reduction/Reduction 

Adjustment Amount 

– Part A 

MSP 

Reduction/Reduction 

Adjustment Amount 

– Part B 

Medicaid Dual Status 

Code 

10 426-435 

10 436-445 

2 446-447 

Beneficiary’s Part C frailty score factor, NN.DDDD; 

otherwise, spaces 

Beneficiary’s MSP secondary payor reduction factor, 

NN.DDDD; otherwise, spaces 

Net MSP reduction or reduction adjustment dollar amount– 

Part A, SSSSSS9.99 

Net MSP reduction or reduction adjustment dollar amount – 

Part B, SSSSSS9.99 

Entitlement status for the dual eligible beneficiary. 

The valid values when Field 40 = 1 are: 

01 = Eligible is entitled to Medicare- QMB only 

02 = Eligible is entitled to Medicare- QMB AND Medicaid 

coverage 

03 = Eligible is entitled to Medicare- SLMB only 

04 = Eligible is entitled to Medicare- SLMB AND Medicaid 

coverage 

05 = Eligible is entitled to Medicare- QDWI 

06 = Eligible is entitled to Medicare- Qualifying individuals 

08 = Eligible is entitled to Medicare- Other Dual Eligibles 

(Non QMB, SLMB,QDWI or QI) with Medicaid coverage 

09 = Eligible is entitled to Medicare – Other Dual Eligibles 

but without Medicaid coverage 

99=Unknown 

The valid value when Field 40 = 0 is: 

00 = No Medicaid Status 

The valid value when Field 40 is blank is: Blank 


Detail Data File



Part D Coverage Gap 

The amount of the Coverage Gap Discount Amount included 

86 

8 448-455 

Discount Amount 

in the payment. -9999.99 

Beginning with January 2011 payment, factors in use (see 

Field 67): 

D1 = Community Non-Low Income Continuing Enrollee, 

D2 = Community Low Income Continuing Enrollee, 

D3 = Institutional Continuing Enrollee, 

D4 = New Enrollee Community Non-Low Income Non- 

Part D RA Factor 

87 

2 456-457 ESRD, 

Type 

D5 = New Enrollee Community Non-Low Income ESRD, 

D6 = New Enrollee Community Low Income Non-ESRD, 

D7 = New Enrollee Community Low Income ESRD, 

D8 = New Enrollee Institutional Non-ESRD, 

D9 = New Enrollee Institutional ESRD, 

Blank when it does not apply. 

88 

89 

90 

91 

Default Part D Risk 

Factor Code 

Part A Risk Adjusted 

Monthly Rate 

Amount for Pymt/Adj 

Part B Risk Adjusted 

Monthly Rate 


Part D Direct Subsidy 

Monthly Rate 


1 458 

9 459-467 

9 468-476 

9 477-485 

92 Cleanup ID 10 486-495 


Beginning with January 2011 payment : 

1=Not ESRD, Not Low Income, Not Originally Disabled, 

2=Not ESRD, Not Low Income, Originally Disabled, 

3=Not ESRD, Low Income, Not Originally Disabled, 

4=Not ESRD, Low Income, Originally Disabled, 

5= ESRD, Not Low Income, Not Originally Disabled, 

6= ESRD, Low Income, Not Originally Disabled, 

7= ESRD, Not Low Income, Originally Disabled, 

8= ESRD, Low Income, Originally Disabled, 

Blank when it does not apply. 

Beginning August 2011: 

Payments = Rate amount in effect for payment period 

Adjustments = Rate amount in effect for adjustment period 

Format: -99999.99 




Format: -99999.99 




Format: -99999.99 

Cleanup Identifier, a reference linking to further 

documentation about a specific cleanup. 


Detail Data File


F.9 Monthly Membership Summary Data File 

This is a data file version of the Monthly Membership Summary Report (MMSR) for both Part C 

and Part D members, summarizing payments made to a Plan for the month, in several categories; 

and the adjustments, by all adjustment categories. 


1 MCO Contract Number 5 1-5 MCO Contract Number 

2 Run Date of the File 8 6-13 YYYYMMDD 

3 Payment Date 6 14-19 YYYYMM 

4 Adjustment Reason Code 2 20-21 Adjustment Reason Code 

5 Record Description 10 22-31 

Description of the record: 

TOTAL PAYM 

ESRD 

HOSPICE 

MCAID 

OTHER 

WA 

OUTOFAREA 

DIR SUBSDY 

LIS CSTSHR 

EST REINS 

PACE PRM 

PACE CSHR 

PTC PREM 

RBT AB CSR 

RBT AB MSB 

RBT D PRRE 

RBT D SUBE 

PTB PRM RE 

B PRM RE A 

B PRM RE D 

BSF MNTHLY 

AD MSP 

COV GAP 

TOTAL ADJ 

HOSPIC ON 

HOSPIC OFF 

ESRD ON 

ESRD OFF 

INST ON 

INST OF 

MCAID ON 

MCAID OFF 

WKAGE ON 

WKAGE OFF 

NHC ON 

NHC OFF 

DEATH 

RETRO ENRO 

RETRO DISEN 

CORR PARTA 

RETRO SCC C 

CORR DEATH 


Summary Data File



CORR BIRTH 

CORR SEX 

PTC RATE 

CORR PARTB 

DISENROLL P 

DEMO FACTO 

PTC RSK AD 

PTCRAF MID 

RETRO CHF 

HOSPICE RAT 

RTRO PTC P 

RTRO PTD L 

RTRO CST S 

RTRO EST R 

RTRO PTC R 

RTRO REBAT 

PTD RATE C 

PTD RAF 

SEG ID CHG 

PTDRAF MID 

RETRO MSP 

PLN SUB PREM 

ESRD MSP 

LIPS 

XRF MRG 

PYMT CORR 

CLNUP ADJ 

6 

Payment Adjustment 

Count 

7 32-38 Beneficiary Count 

7 Month count 7 39-45 

For payment record it is Beneficiary Count, but for 

adjustment record it is spaces. 

8 Part A Member count 7 46-52 

For payment records, Beneficiary count for Part A; for 

adjustment records, spaces. 

9 Part A Month count 7 53-59 

For payment record Beneficiary count for Part A , but 

for adjustment record it is the number of months 

adjusted for Part A. 

10 Part B Member count 7 60-66 

For payment record Beneficiary count for Part B; for 

11 Part B Month count 7 67-73 

12 

13 

Part A 


Amount 

Part B 


13 74-86 PART A Amount 

13 87-99 PART B Amount 

adjustment records, spaces. 

For payment record Beneficiary count for Part B but 


adjusted for Part B. 

Amount 

14 Total Amount 13 100-112 Total Payment/Adjustment Amount 

15 Part A Average 9 113-121 Average Part A Amount per Part A Member 

16 Part B Average 9 122-130 Average Part B Amount per Part B Member 

17 


Indicator 

1 131-131 ‘P’ for Payments and ‘A’ for Adjustments 

18 PBP Number 3 132-134 Plan Benefit Package Number 

19 Segment Number 3 135-137 Segment Number 


Summary Data File



20 Part D Member Count 7 138-144 

For payment records, beneficiary count for PART D; 

for adjustment records, spaces. 

21 Part D Month Count 7 145-151 

For payment record Beneficiary count for Part D but 


adjusted for Part D. 

22 Part D Amount 13 152-164 Part D Amount 

23 Part D Average 9 165-173 Average Part D Amount per Part D Member 

24 

LIS Band 25% member 

count 

7 174-180 Count of Beneficiaries in the 25% LIS band 

25 


count 


26 


count 


27 


count 




Summary Data File


F.10 Monthly Premium Withholding Report Data File (MPWR) 

This is a monthly reconciliation file of premiums withheld from Social Security Administration 

(SSA), Railroad Retirement Board (RRB), or Office of Personnel Management (OPM) checks. It 

includes Part C and Part D premiums and any Part D Late Enrollment Penalties (LEPs). This file 

is produced by the Premium Withhold System (PWS), which makes this report available to Plans 

as part of the month-end processing. 

The file includes the following records: 

 

 

 

Header Record 

Detail Record 

Trailer Record 



1 Record Type 2 1-2 

H = Header Record 

PIC XX 

MCO Contract Number 

2 MCO Contract Number 5 3-7 

PIC X(5) 

YYYYMMDD 

3 Payment Date 8 8-15 

PIC 9(8) 

First 6 digits contain payment month 

4 Report Date 8 16-23 

YYYYMMDD 

Date this report created 

PIC 9(8) 



December 28, 2012 F-47 MPWR Data File




1 Record Type 2 1-2 D = Detail Record PIC XX 

2 MCO Contract Number 5 3-7 MCO Contract Number PIC X(5) 

3 Plan Benefit Package Id 3 8-10 Plan Benefit Package ID PIC X(3) 

4 Plan Segment Id 3 11-13 PIC X(3) 

5 HIC Number 12 14-25 Member’s HIC # PIC X(12) 

6 Surname 7 26-32 PIC X(7) 

7 First Initial 1 33 PIC X 

8 Sex 1 34 M = Male, F = Female PIC X 

9 Date of Birth 8 35-42 YYYYMMDD PIC 9(8) 

PPO in effect for this Pay Month 

“SSA” = Withholding by SSA 

10 PPO 3 43-45 “RRB” = Withholding by RRB 

“OPM” = Withholding by OPM 

PIC X(3) 

11 Filler 1 46 Space 

12 Premium Period Start Date 8 47-54 

Starting Date of Period Premium Payment 

Covers 

YYYYMMDD PIC 9(8) 

13 Premium Period End Date 8 55-62 

Ending Date of Period Premium Payment 

Covers 

YYYYMMDD PIC 9(8) 

Number of Months in Premium 

14 

Period 

2 63-64 PIC 99 

Part C Premiums Collected for this 

Beneficiary, Plan, and premium period. A 

negative amount indicates a refund by 

15 Part C Premiums Collected 8 65-72 

withholding agency to Beneficiary of 

premiums paid in a prior premium period. 

PIC -9999.99 

Part D Premiums Collected (excluding LEP) 

for this Beneficiary, Plan, and premium 

period. A negative amount indicates a refund 

16 Part D Premiums Collected 8 73-80 

by withholding agency to Beneficiary of 

premiums paid in a prior premium period. 

PIC -9999.99 

17 

Part D Late Enrollment Penalties 

Collected 

8 81-88 



Part D Late Enrollment Penalties Collected 

for this Beneficiary, Plan, and premium 

period. A negative amount indicates a refund 

by withholding agency to Beneficiary of 

penalties paid in a prior premium period. PIC 

-9999.99 





1 Record Type 2 1-2 T1 = Trailer Record, withheld totals at 

segment level 

T2 = Trailer Record, withheld totals at 

PBP level 

T3 = Trailer record, withheld totals at 

contract level 

PIC XX 

2 MCO Contract Number 5 3-7 MCO contract number 

PIC X(5) 

3 Plan Benefit Package (PBP) ID 3 8-10 PBP ID, not populated on T3 records 

PIC X(3) 

4 Plan Segment Id 3 11-13 Not populated on T2 or T3 records 

PIC X(3) 

5 Total Part C Premiums Collected 14 14-27 Total withholding collections as specified 

by Trailer Record type, field (1) 

PIC -9(10).99 

6 Total Part D Premiums Collected 14 28-41 Total withholding collections as specified 


PIC -9(10).99 

7 Total Part D LEPs Collected 14 42-55 Total withholding collections as specified 


PIC -9(10).99 

8 Total Premiums Collected 14 56-69 Total Premiums Collected = 

+ Total Part C Premiums Collected 

+ Total Part D Premiums Collected 

+ Total Part D Penalties Collected 

PIC -9(10).99 





F.11 Part B Claims Data File 

F.11.1 Record Type 1 


1 Contract Number 5 1-5 MCO contract number 

2 Record Type 1 6 Record Type Number 6 – 

Physician/Supplier 

Record Type Number 7 – Durable 

Medical Equipment 

3 CAN-BIC 12 7-18 HIC Number 

4 Period From 8 19-26 Start Date – YYYYMMDD 

5 Period To 8 27-34 End Date – YYYYMMDD 

6 Date of Birth 8 35-42 Beneficiary's Date of Birth – 

YYYYMMDD 

7 Surname 6 43-48 First six positions of Beneficiary’s 

surname. 

8 First Name 1 49 First letter of Beneficiary’s first 

name. 

9 Middle Initial 1 50 First letter of Beneficiary’s middle 

name. 

10 Reimbursement Amount 11 51-61 Reimbursement amount for claim. 

11 Total Allowed Charges 11 62-72 Total allowed charges for claim. 

12 Report Date 6 73-78 Claims processed through date – 

YYYYMM. Assigned by the system 

as this file is produced. This is the 

cut-off date for including a claim in 

this file. 

13 Contractor identification number 5 79-83 Identification number of the 

contractor that processed claim. 

14 Provider identification number 10 84-93 Provider’s identification number. 

15 Internal Control Number 15 94-108 Internal control number assigned by 

the Medicare contractor to claim. 

16 Provider Payment Amount 11 109-119 Total amount paid to provider for this 

claim. 

17 Beneficiary Payment Amount 11 120-130 Total amount paid to Beneficiary for 

this claim. 



December 28, 2012 F-50 Part B Claims Data File

F.11.2 Record Type 2 



1 Contract Number 5 1-5 MCO contract number 

2 Record Type 1 6 Record Type Number 5 – Home Health Agency 

3 CAN-BIC 12 7-18 HIC Number 

4 Period From 8 19-26 Start Date – YYYYMMDD 

5 Period To 8 27-34 End Date – YYYYMMDD 

6 Date of Birth 8 35-42 Beneficiary's Date of Birth – YYYYMMDD 

7 Surname 6 43-48 First six positions of Beneficiary’s surname. 

8 First Name 1 49 First letter of Beneficiary’s first name. 

9 Middle Name 1 50 First letter of Beneficiary’s middle name. 

10 Reimbursement 11 51-61 Reimbursement amount for claim. 

Amount 

11 Total Charges 11 62-72 Total charges on the claim. 

12 Report Date 6 73-78 Claims processed through date – YYYYMM. Assigned by the 

system when processing claims. This is the cut-off date for 

including a claim in this file. 

13 Contractor 

identification 

number 

14 Provider 

identification 

number 

5 79-83 Identification number of the contractor that processed the 

claim. 

6 84-89 Provider’s identification number. 



December 28, 2012 F-51 Part B Claims Data File


F.12 Part C Risk Adjustment Model Output Data File 

This is the data file version of the Part C Risk Adjustment Model Output Report, which shows the 

Hierarchical Condition Codes (HCCs) used by the RAS to calculate Part C risk adjustment factors 

for each Beneficiary. RAS produces the report, and MARx forwards it to Plans as part of the 

month-end processing. 


 

 

 

Header Record 

Detail Record 



Item Field Size Position Comment Description 

1 Record Type Code 1 1 Set to "1" 

1 = Header 

A = Details for old V12 PTC MOR 

B = Details for new V21 PTC MOR 

3 = Trailer 

2 Contract Number 5 2-6 Unique identification for a Medicare 

Advantage Contract 

3 Run Date 8 7-14 Format as 

yyyymmdd 

The run date when this file was 

created 

4 Payment Year and 

Month 

6 15-20 Format as 

yyyymm 

This identifies the risk adjustment 

payment year and month for the 

model run. 

5 Filler 180 21-200 Spaces Filler 


F.12.2 Detail Record Type A 


1 Record Type 

Code 

2 Health Insurance 

Claim Account 

Number 

1 1 Set to "A" 1 = Header 

A = Details for old V12 PTC 

MOR 

B = Details for new V21 PTC 

MOR 

3 = Trailer 

12 2-13 Also known as HICAN The HICAN identifies the 

primary Medicare Beneficiary 

under the SSA or RRB programs. 

The HICAN, consisting of 

Beneficiary Claim Number 

(BENE_CAN_NUM) along with 

the Beneficiary Identification 

Code (BIC_CD), uniquely 

identifies a Medicare Beneficiary. 

For the RRB program, the claim 

December 28, 2012 F-52 Part C Risk Adjustment Model Output 

Data File



account number is a 12-byte 

account number. 

3 

Beneficiary Last 

Name 

12 14-25 First 12 bytes of the 

Bene Last Name 

Beneficiary Last Name 

4 

Beneficiary First 

Name 

7 26-32 First 7 bytes of the bene 

First Name 

Beneficiary First Name 

5 Beneficiary Initial 1 33 1-byte Initial Beneficiary Initial 

6 

Date of Birth 8 34-41 Formatted as yyyymmdd The date of birth of the Medicare 

Beneficiary 

7 

Sex 1 42 0=unknown, 1=male, Represents the sex of the 

2=female 

Medicare Beneficiary. Examples 

include Male and Female. 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

Social Security 

Number 

Age Group 

Female0_34 

Age Group 

Female35_44 

Age Group 

Female45_54 

Age Group 

Female55_59 

Age Group 

Female60_64 

Age Group 

Female65_69 

Age Group 

Female70_74 

Age Group 

Female75_79 

Age Group 

Female80_84 

9 43-51 Also known as 

SSN_NUM 

1 52 Set to “1” if applicable, 

otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

The beneficiary's current 

identification number that was 

assigned by the Social Security 

Administration 

The sex and age group for the 

beneficiary based on a given as of 

date: female between ages 0 and 

34, inclusive 




44, inclusive 




54, inclusive 




59, inclusive 




64, inclusive 




69, inclusive 




74, inclusive 




79, inclusive 



date: female between ages of 80 


Data File



and 84, inclusive 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 


29 

30 

Age Group 

Female85_89 

Age Group 

Female90_94 

Age Group 

Female95_GT 

Age Group 

Male0_34 

Age Group 

Male35_44 

Age Group 

Male45_54 

Age Group 

Male55_59 

Age Group 

Male60_64 

Age Group 

Male65_69 

Age Group 

Male70_74 

Age Group 

Male75_79 

Age Group 

Male80_84 

Age Group 

Male85_89 

1 61 Set to "1" if applicable, 

otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 











date: female, age 95 or greater 



date: male between ages of 0 and 

34, inclusive 



date: male between ages of 35 












date. Male between ages of 60 

and 64, inclusive. 






















Data File



31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

44 

45 

46 

47 

48 

49 

Age Group 

Male90_94 

Age Group 

Male95_GT 

Medicaid Female 

Disabled 

Medicaid Female 

Aged 

Medicaid Male 

Disabled 

Medicaid Male 

Aged 

Originally 

Disabled Female 

Originally 

Disabled Male 

Disease 

Coefficients 

HCC1 

Disease 

Coefficients 

HCC2 

Disease 

Coefficients 

HCC5 

Disease 

Coefficients 

HCC7 

Disease 

Coefficients 

HCC8 

Disease 

Coefficients 

HCC9 

Disease 

Coefficients 

HCC10 

Disease 

Coefficients 

HCC15 

Disease 

Coefficients 

HCC16 

Disease 

Coefficients 

HCC17 

Disease 

Coefficients 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 







date: male, age 95 or greater 

Beneficiary is a female disabled 

and also entitled to Medicaid. 

Beneficiary is a female aged (> 

64) and also entitled to Medicaid. 

Beneficiary is a male disabled and 

also entitled to Medicaid. 

Beneficiary is a male aged (> 64) 


Beneficiary is a female and 

original Medicare entitlement was 

due to disability. 

Beneficiary is a male and original 

Medicare entitlement was due to 

disability. 

HIV/AIDS 

Septicemia/Shock 

Opportunistic Infections 

Metastatic Cancer and Acute 

Leukemia 

Lung, Upper Digestive Tract, and 

Other Severe Cancers 

Lymphatic, Head and Neck, 

Brain, and Other Major Cancers 

Breast, Prostate, Colorectal and 

Other Cancers and Tumors 

Diabetes with Renal or Peripheral 

Circulatory Manifestation 

Diabetes with Neurologic or 

Other Specified Manifestation 

Diabetes with Acute 

Complications 

Diabetes with Ophthalmologic or 

Unspecified Manifestation 


Data File



HCC18 

50 

51 

52 

53 

54 

55 

56 

57 

58 

59 

60 

61 

62 

63 

64 

65 

66 

Disease 

Coefficients 

HCC19 

Disease 

Coefficients 

HCC21 

Disease 

Coefficients 

HCC25 

Disease 

Coefficients 

HCC26 

Disease 

Coefficients 

HCC27 

Disease 

Coefficients 

HCC31 

Disease 

Coefficients 

HCC32 

Disease 

Coefficients 

HCC33 

Disease 

Coefficients 

HCC37 

Disease 

Coefficients 

HCC38 

Disease 

Coefficients 

HCC44 

Disease 

Coefficients 

HCC45 

Disease 

Coefficients 

HCC51 

Disease 

Coefficients 

HCC52 

Disease 

Coefficients 

HCC54 

Disease 

Coefficients 

HCC55 

Disease 

Coefficients 

HCC67 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Diabetes without Complication 

Protein-Calorie Malnutrition 

End-Stage Liver Disease 

Cirrhosis of Liver 

Chronic Hepatitis 

Intestinal Obstruction/Perforation 

Pancreatic Disease 

Inflammatory Bowel Disease 

Bone/Joint/Muscle 

Infections/Necrosis 

Rheumatoid Arthritis and 

Inflammatory Connective Tissue 

Disease 

Severe Hematological Disorders 

Disorders of Immunity 

Drug/Alcohol Psychosis 

Drug/Alcohol Dependence 

Schizophrenia 

Major Depressive, Bipolar, and 

Paranoid Disorders 

Quadriplegia, Other Extensive 

Paralysis 


Data File



Disease 

67 Coefficients 


otherwise "0" 

Paraplegia 

HCC68 

Disease 



otherwise "0" 

Spinal Cord Disorders/Injuries 

HCC69 

Disease 



otherwise "0" 

Muscular Dystrophy 

HCC70 

Disease 



otherwise "0" 

Polyneuropathy 

HCC71 

Disease 



otherwise "0" 

Multiple Sclerosis 

HCC72 

Disease 

1 115 Set to "1" if applicable, Parkinson’s and Huntington’s 


otherwise "0" 

Diseases 

HCC73 

73 

74 

75 

76 

77 

78 

79 

80 

81 

82 

83 

84 

Disease 

Coefficients 

HCC74 

Disease 

Coefficients 

HCC75 

Disease 

Coefficients 

HCC77 

Disease 

Coefficients 

HCC78 

Disease 

Coefficients 

HCC79 

Disease 

Coefficients 

HCC80 

Disease 

Coefficients 

HCC81 

Disease 

Coefficients 

HCC82 

Disease 

Coefficients 

HCC83 

Disease 

Coefficients 

HCC92 

Disease 

Coefficients 

HCC95 

Disease 

Coefficients 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Seizure Disorders and 

Convulsions 

Coma, Brain 

Compression/Anoxic Damage 

Respirator 

Dependence/Tracheostomy Status 

Respiratory Arrest 

Cardio-Respiratory Failure and 

Shock 


Acute Myocardial Infarction 

Unstable Angina and Other Acute 

Ischemic Heart Disease 

Angina Pectoris/Old Myocardial 

Infarction 

Specified Heart Arrhythmias 

Cerebral Hemorrhage 

Ischemic or Unspecified Stroke 


Data File



HCC96 

85 

86 

87 

88 

89 

90 

91 

92 

93 

94 

95 

96 

97 

98 

99 

100 

101 

Disease 

Coefficients 

HCC100 

Disease 

Coefficients 

HCC101 

Disease 

Coefficients 

HCC104 

Disease 

Coefficients 

HCC105 

Disease 

Coefficients 

HCC107 

Disease 

Coefficients 

HCC108 

Disease 

Coefficients 

HCC111 

Disease 

Coefficients 

HCC112 

Disease 

Coefficients 

HCC119 

Disease 

Coefficients 

HCC130 

Disease 

Coefficients 

HCC131 

Disease 

Coefficients 

HCC132 

Disease 

Coefficients 

HCC148 

Disease 

Coefficients 

HCC149 

Disease 

Coefficients 

HCC150 

Disease 

Coefficients 

HCC154 

Disease 

Coefficients 

HCC155 

1 128 Set to "1" if applicable, 

otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Hemiplegia/Hemiparesis 

Cerebral Palsy and Other 

Paralytic Syndromes 

Vascular Disease with 

Complications 

Vascular Disease 

Cystic Fibrosis 

Chronic Obstructive Pulmonary 

Disease 

Aspiration and Specified 

Bacterial Pneumonias 

Pneumococcal Pneumonia, 

Empyema, Lung Abscess 

Proliferative Diabetic 

Retinopathy and Vitreous 

Hemorrhage 

Dialysis Status 

Renal Failure 

Nephritis 

Decubitus Ulcer of Skin 

Chronic Ulcer of Skin, Except 

Decubitus 

Extensive Third-Degree Burns 

Severe Head Injury 

Major Head Injury 


Data File



102 

103 

104 

105 

106 

107 

108 

109 

110 

111 

112 

113 

114 

115 

116 

117 

118 

119 

120 

Disease 

Coefficients 

HCC157 

Disease 

Coefficients 

HCC158 

Disease 

Coefficients 

HCC161 

Disease 

Coefficients 

HCC164 

Disease 

Coefficients 

HCC174 

Disease 

Coefficients 

HCC176 

Disease 

Coefficients 

HCC177 

Disabled Disease 

HCC5 


HCC44 


HCC51 


HCC52 


HCC107 

Disease 

Interactions INT1 

Disease 


Disease 


Disease 


Disease 


Disease 



otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Vertebral Fractures without 

Spinal Cord Injury 

Hip Fracture/Dislocation 

Traumatic Amputation 

Major Complications of Medical 

Care and Trauma 

Major Organ Transplant Status 

Artificial Openings for Feeding or 

Elimination 

Amputation Status, Lower 

Limb/Amputation Complications 

1 152 Set to "1" if applicable, Disabled (Age


F.12.3 Detail Record Type B 


1 Record Type 

Code 

2 Health 

Insurance 

Claim Account 

Number 

1 1 Set to "B" 1 = Header 

A = Details for old V12 PTC MOR 

B = Details for new V21 PTC 

MOR 

3 = Trailer 

12 2-13 Also known as HICAN This is the Health Insurance Claim 

Account Number (known as 

HICAN) identifying the primary 

Medicare Beneficiary under the 

SSA or RRB programs. The 

HICAN, consisting of Beneficiary 

Claim Number 

(BENE_CAN_NUM) along with 

the Beneficiary Identification Code 

(BIC_CD), uniquely identifies a 

Medicare Beneficiary. For the 

RRB program, the claim account 

number is a 12-byte account 

number. 

3 Beneficiary 

Last Name 

4 Beneficiary 

First Name 

12 14-25 First 12 bytes of the Bene 

Last Name 

7 26-32 First 7 bytes of the bene 

First Name 



5 Beneficiary 

Initial 

1 33 1-byte Initial Beneficiary Initial 

6 Date of Birth 8 34-41 Formatted as yyyymmdd The date of birth of the Medicare 

Beneficiary 

7 Sex 1 42 0=unknown, 1=male, 

2=female 

Represents the sex of the Medicare 

Beneficiary. Examples include 

Male and Female. 

8 Social Security 

Number 

9 RAS ESRD 

Indicator 

Switch 

10 Age Group 

Female0_34 

9 43-51 Also known as 

SSN_NUM 

1 52 Y = ESRD 

N = not ESRD 


otherwise "0" 

The beneficiary's current 

identification number that was 

assigned by the Social Security 

Administration 

The beneficiary's ESRD status as of 

the model run. Also indicates if the 

beneficiary was processed by the 

ESRD models in the model run. 




34, inclusive 


Data File



11 Age Group 

Female35_44 

12 Age Group 

Female45_54 

13 Age Group 

Female55_59 

14 Age Group 

Female60_64 

15 Age Group 

Female65_69 

16 Age Group 

Female70_74 

17 Age Group 

Female75_79 

18 Age Group 

Female80_84 

19 Age Group 

Female85_89 

20 Age Group 

Female90_94 

21 Age Group 

Female95_GT 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 




44, inclusive 




54, inclusive 




59, inclusive 




64, inclusive 




69, inclusive 




74, inclusive 




79, inclusive 















date: female, age 95 or greater 


Data File



22 Age Group 

Male0_34 

23 Age Group 

Male35_44 

24 Age Group 

Male45_54 

25 Age Group 

Male55_59 

26 Age Group 

Male60_64 

27 Age Group 

Male65_69 

28 Age Group 

Male70_74 

29 Age Group 

Male75_79 

30 Age Group 

Male80_84 

31 Age Group 

Male85_89 

32 Age Group 

Male90_94 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 




34, inclusive 




44, inclusive 




54, inclusive 




59, inclusive 




64, inclusive 




69, inclusive 




74, inclusive 




79, inclusive 




84, inclusive 




89, inclusive 




94, inclusive 


Data File



33 Age Group 

Male95_GT 

34 Medicaid 

Female 

Disabled 

35 Medicaid 

Female Aged 

36 Medicaid Male 

Disabled 

37 Medicaid Male 

Aged 

38 Originally 

Disabled 

Female 

39 Originally 

Disabled Male 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 



date: male, age 95 or greater 

Beneficiary is a female disabled 


Beneficiary is a female aged (> 64) 


Beneficiary is a male disabled and 

also entitled to Medicaid. 

Beneficiary is a male aged (> 64) 


Beneficiary is a female and original 


disability. 

Beneficiary is a male and original 


disability. 

40 HCC001 1 83 Set to "1" if applicable, 

otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

HIV/AIDS 

Septicemia, Sepsis, Systemic 

Inflammatory Response 

Syndrome/Shock 


Metastatic Cancer and Acute 

Leukemia 

Lung and Other Severe Cancers 

Lymphoma and Other Cancers 

Colorectal, Bladder, and Other 

Cancers 

Breast, Prostate, and Other Cancers 

and Tumors 

Diabetes with Acute Complications 

Diabetes with Chronic 

Complications 


Data File




otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

55 HCC028 1 98 Set to "1" if applicable, 

otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


Protein-Calorie Malnutrition 

Morbid Obesity 

Other Significant Endocrine and 

Metabolic Disorders 

End-Stage Liver Disease 

Cirrhosis of Liver 

Chronic Hepatitis 

Intestinal Obstruction/Perforation 

Chronic Pancreatitis 


Bone/Joint/Muscle 

Infections/Necrosis 

Rheumatoid Arthritis and 

Inflammatory Connective Tissue 

Disease 

Severe Hematological Disorders 

Disorders of Immunity 

Coagulation Defects and Other 

Specified Hematological Disorders 

Dementia With Complications 

Dementia Without Complication 

Drug/Alcohol Psychosis 


Data File




otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

85 HCC085 1 128 Set to "1" if applicable, 

otherwise "0" 


otherwise "0" 

Drug/Alcohol Dependence 

Schizophrenia 

Major Depressive, Bipolar, and 

Paranoid Disorders 

Quadriplegia 

Paraplegia 

Spinal Cord Disorders/Injuries 

Amyotrophic Lateral Sclerosis and 

Other Motor Neuron Disease 

Cerebral Palsy 


Muscular Dystrophy 


Parkinson’s and Huntington’s 

Diseases 

Seizure Disorders and Convulsions 

Coma, Brain Compression/Anoxic 

Damage 

Respirator 

Dependence/Tracheostomy Status 

Respiratory Arrest 

Cardio-Respiratory Failure and 

Shock 


Acute Myocardial Infarction 


Data File




otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Unstable Angina and Other Acute 

Ischemic Heart Disease 

Angina Pectoris 

Specified Heart Arrhythmias 

Cerebral Hemorrhage 

Ischemic or Unspecified Stroke 

Hemiplegia/Hemiparesis 

Monoplegia, Other Paralytic 

Syndromes 

Atherosclerosis of the Extremities 

with Ulceration or Gangrene 

Vascular Disease with 

Complications 

Vascular Disease 


Chronic Obstructive Pulmonary 

Disease 

Fibrosis of Lung and Other Chronic 

Lung Disorders 

Aspiration and Specified Bacterial 

Pneumonias 

Pneumococcal Pneumonia, 

Emphysema, Lung Abscess 

Proliferative Diabetic Retinopathy 

and Vitreous Hemorrhage 

Exudative Macular Degeneration 


Acute Renal Failure 


Data File




otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Chronic Kidney Disease, Stage 5 

Chronic Kidney Disease, Severe 

(Stage 4) 

Chronic Kidney Disease, Moderate 

(Stage 3) 

Chronic Kidney Disease, Mild or 

Unspecified (Stages 1-2 or 

Unspecified) 

Unspecified Renal Failure 

Nephritis 

Pressure Ulcer of Skin with 

Necrosis Through to Muscle, 

Tendon, or Bone 

Pressure Ulcer of Skin with Full 

Thickness Skin Loss 

Pressure Ulcer of Skin with Partial 

Thickness Skin Loss 

Pressure Pre-Ulcer Skin Changes or 

Unspecified Stage 

Chronic Ulcer of Skin, Except 

Pressure 

Severe Skin Burn or Condition 

Severe Head Injury 

Major Head Injury 

Vertebral Fractures without Spinal 

Cord Injury 

Hip Fracture/Dislocation 

Traumatic Amputations and 

Complications 

Complications of Specified 

Implanted Device or Graft 


Data File




otherwise "0" 


otherwise "0" 


otherwise "0" 

Major Organ Transplant or 

Replacement Status 

Artificial Openings for Feeding or 

Elimination 

Amputation Status, Lower 

Limb/Amputation Complications 

127 Disabled 

Disease 

HCC006 

128 Disabled 

Disease 

HCC034 

129 Disabled 

Disease 

HCC046 

130 Disabled 

Disease 

HCC054 

131 Disabled 

Disease 

HCC055 

132 Disabled 

Disease 

HCC110 

133 Disabled 

Disease 

HCC176 

134 CANCER_ 

IMMUNE 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Disabled (Age



140 Medicaid 1 183 Set to "1" if applicable, 

otherwise "0" 

Beneficiary is entitled to Medicaid. 

141 Originally 

Disabled 

142 Disabled 

Disease 

HCC039 

143 Disabled 

Disease 

HCC077 

144 Disabled 

Disease 

HCC085 

145 Disabled 

Disease 

HCC161 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 


otherwise "0" 

Beneficiary original Medicare 

entitlement was due to disability. 

Disabled (Age



154 SEPSIS_ 

ASP_SPEC_ 

BACT_ 

PNEUM 

155 SEPSIS_ 

PRESSURE_ 

ULCER 

1 197 Set to "1" if applicable SEPSIS_ASP_SPEC_BACT_ 

PNEUM 

1 198 Set to "1" if applicable SEPSIS_PRESSURE_ULCER 

156 Filler 1 199 - 200 Spaces Filler 

Total Length = 200. 

NOTE: Fields 140-155 are associated with the CMS HCC V21 Institutional Score only. 



1 Record Type 1 1 Set to "3" 1 = Header 

A = Details for old V12 

PTC MOR 

B = Details for new V21 

PTC MOR 

3 = Trailer 

2 

3 

Contract 

Number 

Total Record 

Count 

5 2-6 

9 7-15 

Also known as MCO Plan number 

Includes all header and trailer records 



Unique identification for a 

Managed Care Organization 

(MCO) enabling the MCO 

to provide coverage to 

eligible beneficiaries 

Record count in display 

format 


Data File


F.13 Risk Adjustment System (RAS) Prescription Drug Hierarchical Condition 

Category (RxHCC) Model Output Data File - aka Part D RA Model Output Data 

File 


 

 

 

Header Record 

Detail/Beneficiary Record Format 



The Contract Header Record signals the beginning of the detail/Beneficiary records for a 

Medicare Advantage or stand-alone PDP contract. 


1 

2 

Record Type 

Code 

Contract 

Number 

1 1 Set to "1" 

5 2-6 

3 Run Date 8 7-14 

4 

Payment Year 

and Month 

6 15-20 

Also known as 

MCO plan 

number 

Format as 

yyyymmdd 

Format as 

yyyymm 



1 = Header 

2 = Details 

3 = Trailer 

Unique identification for a Managed Care 

Organization (MCO) enabling the MCO to provide 

coverage to eligible beneficiaries. 

The run date when this file was created. 

This identifies the risk adjustment payment year and 

month for the model run. 

F.13.2 Detail/Beneficiary Record 

Each Detail/Beneficiary Record contains information for an HCC beneficiary in a Medicare 

Prescription Drug contract/plan, as of the last RAS model run for the current calendar/payment 

year. 

December 28, 2012 F-71 RAS RxHCC Model Output 

Data File



1 

2 

3 

4 

Record Type 

Code 

Health Insurance 

Claim Account 

Number 

Beneficiary Last 

Name 

Beneficiary First 

Name 

1 1 Set to "2" 1 = Header, 2 = Details, 3 = Trailer 

12 2-13 

12 14-25 

7 26-32 

Also known as 

HICAN 

First 12 bytes 

of the Bene 

Last Name 

First 7 bytes of 

the bene First 

Name 

This is the Health Insurance Claim Account Number 

(known as HICAN) identifying the primary Medicare 

Beneficiary under the SSA or RRB programs. The 

HICAN, consisting of Beneficiary Claim Number 

(BENE_CAN_NUM) along with the Beneficiary 

Identification Code (BIC_CD), uniquely identifies a 

Medicare Beneficiary. For the RRB program, the claim 

account number is a 12-byte account number. 



5 Beneficiary Initial 1 33 1 byte Initial Beneficiary Initial 

6 Date of Birth 8 34-41 

7 Sex 1 42 

8 

9 

10 

11 

12 

13 

14 

15 

Social Security 

Number 

Age Group 

Female 0-34 

Age Group 

Female35_44 

Age Group 

Female45_54 

Age Group 

Female55_59 

Age Group 

Female60_64 

Age Group 

Female65_69 

Age Group 

Female70_74 

9 43-51 

1 52 

1 53 

1 54 

1 55 

1 56 

1 57 

1 58 

Formatted as 

yyyymmdd 

0=unknown, 

1=male, 

2=female 

Also known as 

SSN_NUM 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

The date of birth of the Medicare Beneficiary 

Represents the sex of the Medicare Beneficiary. 

The beneficiary's current identification number that was 

assigned by the Social Security Administration. 

The sex and age group for the beneficiary based on a 

given as of date. Female between ages of 0 and 34. 


given as of date. Female between ages of 35 and 44, 

inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 


Data File



16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 


29 

30 

Age Group 

Female75_79 

Age Group 

Female80_84 

Age Group 

Female85_89 

Age Group 

Female90_94 

Age Group 

Female95_GT 

Age Group 

Male0_34 

Age Group 

Male35_44 

Age Group 

Male45_54 

Age Group 

Male55_59 

Age Group 

Male60_64 

Age Group 

Male65_69 

Age Group 

Male70_74 

Age Group 

Male75_79 

Age Group 

Male80_84 

Age Group 

Male85_89 

1 59 

1 60 

1 61 

1 62 

1 63 

1 64 

1 65 

1 66 

1 67 

1 68 

1 69 

1 70 

1 71 

1 72 

1 73 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 



inclusive. 



inclusive. 



inclusive. 



inclusive. 


given as of date. Female, age 95 and greater. 


given as of date. Male between ages of 0 and 34, 

inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 



inclusive. 


Data File



31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

44 

45 

Age Group 

Male90_94 

Age Group 

Male95_GT 

Originally 

Disabled Female 

Originally 

Disabled Male 

Disease 

Coefficients 

RXHCC1 

Disease 

Coefficients 

RXHCC5 

Disease 

Coefficients 

RXHCC8 

Disease 

Coefficients 

RXHCC9 

Disease 

Coefficients 

RXHCC10 

Disease 

Coefficients 

RXHCC11 

Disease 

Coefficients 

RXHCC14 

Disease 

Coefficients 

RXHCC15 

Disease 

Coefficients 

RXHCC18 

Disease 

Coefficients 

RXHCC19 

Disease 

Coefficients 

RXHCC20 

1 74 

1 75 

1 76 

1 77 

1 78 

1 79 

1 80 

1 81 

1 82 

1 83 

1 84 

1 85 

1 86 

1 87 

1 88 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 



inclusive. 


given as of date. Male, age 95 and greater. 

Beneficiary is a female and original Medicare 

entitlement was due to disability. 

Beneficiary is a male and original Medicare entitlement 

was due to disability. 

HIV/AIDS 


Chronic Myeloid Leukemia 

Multiple Myeloma and Other Neoplastic Disorders 

Breast, Lung, and Other Cancers and Tumors 

Prostate and Other Cancers and Tumors 

Diabetes with Complications 


Diabetes Insipidus and Other Endocrine and Metabolic 

Disorders 

Pituitary, Adrenal Gland, and Other Endocrine and 

Metabolic Disorders 

Thyroid Disorders 


Data File



46 

47 

48 

49 

50 

51 

52 

53 

54 

55 

56 

57 

58 

59 

60 

Disease 

Coefficients 

RXHCC21 

Disease 

Coefficients 

RXHCC23 

Disease 

Coefficients 

RXHCC25 

Disease 

Coefficients 

RXHCC30 

Disease 

Coefficients 

RXHCC31 

Disease 

Coefficients 

RXHCC32 

Disease 

Coefficients 

RXHCC33 

Disease 

Coefficients 

RXHCC38 

Disease 

Coefficients 

RXHCC40 

Disease 

Coefficients 

RXHCC41 

Disease 

Coefficients 

RXHCC42 

Disease 

Coefficients 

RXHCC45 

Disease 

Coefficients 

RXHCC47 

Disease 

Coefficients 

RXHCC48 

Disease 

Coefficients 

RXHCC49 

1 89 

1 90 

1 91 

1 92 

1 93 

1 94 

1 95 

1 96 

1 97 

1 98 

1 99 

1 100 

1 101 

1 102 

1 103 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Morbid Obesity 

Disorders of Lipoid Metabolism 

Chronic Viral Hepatitis 

Chronic Pancreatitis 

Pancreatic Disorders and Intestinal Malabsorption, 

Except Pancreatitis 


Esophageal Reflux and Other Disorders of Esophagus 

Aseptic Necrosis of Bone 

Psoriatic Arthropathy 

Rheumatoid Arthritis and Other Inflammatory 

Polyarthropathy 

Systemic Lupus Erythematosus, Other Connective 

Tissue Disorders, and Inflammatory Spondylopathies 

Osteoporosis, Vertebral and Pathological Fractures 

Sickle Cell Anemia 

Myelodysplastic Syndromes, Except High-Grade 

Immune Disorders 


Data File



61 

62 

63 

64 

65 

66 

67 

68 

69 

70 

71 

72 

73 

74 

75 

Disease 

Coefficients 

RXHCC50 

Disease 

Coefficients 

RXHCC54 

Disease 

Coefficients 

RXHCC55 

Disease 

Coefficients 

RXHCC58 

Disease 

Coefficients 

RXHCC59 

Disease 

Coefficients 

RXHCC60 

Disease 

Coefficients 

RXHCC61 

Disease 

Coefficients 

RXHCC62 

Disease 

Coefficients 

RXHCC63 

Disease 

Coefficients 

RXHCC65 

Disease 

Coefficients 

RXHCC66 

Disease 

Coefficients 

RXHCC67 

Disease 

Coefficients 

RXHCC68 

Disease 

Coefficients 

RXHCC71 

Disease 

Coefficients 

RXHCC72 

1 104 

1 105 

1 106 

1 107 

1 108 

1 109 

1 110 

1 111 

1 112 

1 113 

1 114 

1 115 

1 116 

1 117 

1 118 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Aplastic Anemia and Other Significant Blood Disorders 

Alzheimer's Disease 

Dementia, Except Alzheimer's Disease 

Schizophrenia 

Bipolar Disorders 

Major Depression 

Specified Anxiety, Personality, and Behavior Disorders 

Depression 

Anxiety Disorders 

Autism 

Profound or Severe Mental Retardation/Developmental 

Disability 

Moderate Mental Retardation/Developmental Disability 

Mild or Unspecified Mental Retardation/Developmental 

Disability 

Myasthenia Gravis, Amyotrophic Lateral Sclerosis and 

Other Motor Neuron Disease 

Spinal Cord Disorders 


Data File



76 

77 

78 

79 

80 

81 

82 

83 

84 

85 

86 

87 

88 

89 

90 

Disease 

Coefficients 

RXHCC74 

Disease 

Coefficients 

RXHCC75 

Disease 

Coefficients 

RXHCC76 

Disease 

Coefficients 

RXHCC78 

Disease 

Coefficients 

RXHCC79 

Disease 

Coefficients 

RXHCC80 

Disease 

Coefficients 

RXHCC81 

Disease 

Coefficients 

RXHCC83 

Disease 

Coefficients 

RXHCC86 

Disease 

Coefficients 

RXHCC87 

Disease 

Coefficients 

RXHCC88 

Disease 

Coefficients 

RXHCC89 

Disease 

Coefficients 

RXHCC93 

Disease 

Coefficients 

RXHCC97 

Disease 

Coefficients 

RXHCC98 

1 119 

1 120 

1 121 

1 122 

1 123 

1 124 

1 125 

1 126 

1 127 

1 128 

1 129 

1 130 

1 131 

1 132 

1 133 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 



Parkinson's Disease 

Intractable Epilepsy 

Epilepsy and Other Seizure Disorders, Except 

Intractable Epilepsy 

Convulsions 

Migraine Headaches 

Trigeminal and Postherpetic Neuralgia 

Pulmonary Hypertension and Other Pulmonary Heart 

Disease 


Hypertension 

Coronary Artery Disease 

Atrial Arrhythmias 

Cerebrovascular Disease, Except Hemorrhage or 

Aneurysm 

Spastic Hemiplegia 


Data File



91 

92 

93 

94 

95 

96 

97 

98 

99 

100 

101 

102 

103 

104 

105 

Disease 

Coefficients 

RXHCC100 

Disease 

Coefficients 

RXHCC101 

Disease 

Coefficients 

RXHCC103 

Disease 

Coefficients 

RXHCC104 

Disease 

Coefficients 

RXHCC105 

Disease 

Coefficients 

RXHCC106 

Disease 

Coefficients 

RXHCC111 

Disease 

Coefficients 

RXHCC113 

Disease 

Coefficients 

RXHCC120 

Disease 

Coefficients 

RXHCC121 

Disease 

Coefficients 

RXHCC122 

Disease 

Coefficients 

RXHCC123 

Disease 

Coefficients 

RXHCC124 

Disease 

Coefficients 

RXHCC125 

Disease 

Coefficients 

RXHCC126 

1 134 

1 135 

1 136 

1 137 

1 138 

1 139 

1 140 

1 141 

1 142 

1 143 

1 144 

1 145 

1 146 

1 147 

1 148 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Venous Thromboembolism 

Peripheral Vascular Disease 


Chronic Obstructive Pulmonary Disease and Asthma 

Pulmonary Fibrosis and Other Chronic Lung Disorders 

Gram-Negative/Staphylococcus Pneumonia and Other 

Lung Infections 

Diabetic Retinopathy 

Open-Angle Glaucoma 

Kidney Transplant Status 


Chronic Kidney Disease Stage 5 



Chronic Kidney Disease Stage 1, 2, or Unspecified 

Nephritis 


Data File



106 

107 

108 

109 

110 

111 

112 

113 

114 

115 

116 

117 

118 

119 

120 

Disease 

Coefficients 

RXHCC142 

Disease 

Coefficients 

RXHCC145 

Disease 

Coefficients 

RXHCC147 

Disease 

Coefficients 

RXHCC156 

Disease 

Coefficients 

RXHCC166 

Disease 

Coefficients 

RXHCC167 

Disease 

Coefficients 

RXHCC168 

Originally 

Disabled 

NONAGED 

RXHCC1 

NONAGED 

RXHCC58 

NONAGED 

RXHCC59 

NONAGED 

RXHCC60 

NONAGED 

RXHCC61 

NONAGED 

RXHCC62 

NONAGED 

RXHCC63 

1 149 

1 150 

1 151 

1 152 

1 153 

1 154 

1 155 

1 156 

1 157 

1 158 

1 159 

1 160 

1 161 

1 162 

1 163 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Chronic Ulcer of Skin, Except Pressure 

Pemphigus 

Psoriasis, Except with Arthropathy 

Narcolepsy and Cataplexy 

Lung Transplant Status 

Major Organ Transplant Status, Except Lung, Kidney, 

and Pancreas 

Pancreas Transplant Status 

The original reason for Medicare entitlement was due to 

disability. 

Non-Aged and HIV/AIDS 

Non-Aged and Schizophrenia 

Non-Aged and Bipolar Disorders 

Non-Aged and Major Depression 

Non-Aged and Specified Anxiety, Personality, and 

Behavior Disorders 

Non-Aged and Depression 

Non-Aged and Anxiety Disorders 


Data File



121 

122 

123 

124 

125 

NONAGED 

RXHCC65 

NONAGED 

RXHCC75 

NONAGED 

RXHCC78 

NONAGED 

RXHCC79 

NONAGED 

RXHCC80 

1 164 

1 165 

1 166 

1 167 

1 168 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Set to "1" if 

applicable, 

otherwise "0" 

Non-Aged and Autism 

Non-Aged and Multiple Sclerosis 

Non-Aged and Intractable Epilepsy 

Non-Aged and Epilepsy and Other Seizure Disorders, 

Except Intractable Epilepsy 

Non-Aged and Convulsions 


NOTE: Fields 113-125 are associated with the Rx HCC Continuing Enrollee Institutional Score only. 


The Contract Trailer Record signals the end of the detail/Beneficiary records for a MA or stand-alone PDP contract. 

This record has a length of 164. 


1 

2 

3 

Record 

Type Code 

Contract 

Number 

Total 

Record 

Count 

1 1 Set to "3" 

5 2-6 

9 7-15 

 

 

 

1 = Header 

2 = Details 

3 = Trailer 

Unique identification for a Managed Care 

Also known as 

Organization (MCO) enabling the MCO to provide 

MCO plan number 

coverage to eligible beneficiaries. 

Includes all header 

and trailer records 

Record count in display format 9(9). 




Data File


F.14 Daily Transaction Reply Report (DTRR) Data File 

The DTRR is created each evening, Monday through Saturday, and is available for Plans the 

following business day. All Plans receive a DTRR for all contracts whether the Plan has or has not 

submitted transactions for processing by MARx. The TRC of 000 indicates that there is no data 

within the DTRR for processing by the Plan. In turn, the Plan does not need to take any action and 

may discard this file. 

The file also contains records that report the submitted transactions verbatim back to the Plans 

(F.14.1). 

F.14.1 DTRR Data File Detailed Record Layout 


1 HICN 12 1-12 Health Insurance Claim Number 

2 Surname 12 13-24 Beneficiary Surname 

3 First Name 7 25-31 Beneficiary Given Name 

4 Middle Initial 1 32 Beneficiary Middle Initial 

5 Gender Code 1 33 Beneficiary Gender Identification Code 

‘0’ = Unknown; 

‘1’ = Male; 

‘2’ = Female. 

6 Date of Birth 8 34-41 YYYYMMDD Format 

7 Record Type 1 42 ‘T’ = TRC record 

8 Contract 

5 43-47 Plan Contract Number 

Number 

9 State Code 2 48-49 Beneficiary Residence State Code; otherwise, spaces if not 

applicable. 

10 County Code 3 50-52 Beneficiary Residence County Code; otherwise, spaces if not 

applicable. 

11 Disability 

Indicator 

12 Hospice 

Indicator 

13 Institutional/NH 

C/HCBS 

Indicator 

14 14. ESRD 

Indicator 

15 15. Transaction 

Reply Code 

(TRC) 

1 53 ‘1’ = Disabled; 

‘0’ = No Disability; 

Space = not applicable. 

1 54 ‘1’ = Hospice; 

‘0’ = No Hospice; 


1 55 ‘3’ = HCBS; 

‘1’ = Institutional; 

‘2’ = NHC; 

‘0’ = No Institutional; 

Space = not applicable 

1 56 ‘1’ = End-Stage Renal Disease; 

‘0’ = No End-Stage Renal Disease; 


3 57-59 TRC, see TRC list on page I-2 for values 

December 28, 2012 F-81 DTRR Data File



16 16. Transaction 

Code (TC) 

17 17. Entitlement 

Type Code 

18 18. Effective 

Date 

19 19. Working 

Aged (WA) 

Indicator 

2 60-61 TC 

1 62 Beneficiary Entitlement Type Code: 

‘Y’ = Entitled to Part A and B, 

‘Z’ = Entitled to Part A or B; 


Space reported with TRCs 121, 194, and 223, has no meaning. 

8 63-70 YYYYMMDD Format; 

Effective date is present for all TRCs. 

However, for UI TRCs, field content is TRC dependent: 

701 – New enrollment period start date, 

702 – Fill-in enrollment period start date, 

703 – Start date of cancelled enrollment period, 

704 – Start date of enrollment period cancelled for Plan Benefit 

Package (PBP) correction, 

705 – Start date of enrollment period for corrected PBP, 

706 – Start date of enrollment period cancelled for segment 

correction, 

707 – Start date of enrollment period for corrected segment, 

708 – Enrollment period end date assigned to existing opened ended 

enrollment, 

709 & 710 – New start date resulting from update, 

711 & 712 – New end date resulting from update, 

713 – “00000000” – End date removed. Original end date is in field 

24.X, 

091 – Previously reported incorrect death date, 

121, 194, and 223 – PBP enrollment effective date. 

305 – New ZIP Code Start Date 

293 – Enrollment End Date; Last day of the month 

1 71 ‘1’ = WA; 

‘0’ = No WA; 


3 72-74 PBP number 

20 20. Plan Benefit 

Package ID 

21 21. Filler 1 75 Spaces 

22 22. Transaction 8 76-83 YYYYMMDD Format; Present for all TRCs. For TRCs 121, 194, 

Date 

and 223, the report generation date. 

23 23. UI Initiated 1 84 ‘1’ = transaction created through user interface; 

Change Flag 

‘0’ = transaction from source other than user interface; 

24 24. Positions 85 

– 96 are 

dependent 

upon the 

TRC value. 

There are 

spaces for 

all codes 

except 

where 

indicated 

below. 


8 85-92 This field value depends on the TRC that is returned on the reply. 

See the TRC-related values below: 




a. Effective 

Date of the 

Disenrollme 

nt 

b. New 

Enrollment 

Effective 

Date 

c. Claim 

Number 

(old) 

d. Date of 

Death 

e. Hospice 

Start Date 

f. Hospice End 

Date 

g. ESRD Start 

Date 

h. ESRD End 

Date 

i. Institutional/ 

NHC Start 

Date 

j. Medicaid 

Start Date 

k. Medicaid 

End Date 

l. Part A End 

Date 

m. WA Start 

Date 

n. WA End 

Date 

o. Part A 

Reinstate 

Date 

p. Part B End 

Date 

q. Part B 

Reinstate 

Date 

r. Old State 

and County 

Codes 

s. t. Attempted 

Enroll 


u. v. PBP 

Effective 

Date 

8 85-92 YYYYMMDD Format; Present only when TRC is one of 

the following: 13, 14, 18, 293 

8 85-92 YYYYMMDD Format; Present only when TRC is 17 

12 85-96 Present only when TRC is one of the following: 22, 25, 86 

8 85-92 YYYYMMDD Format; Present only when TRC is one of the 

following: 90 (with TC 01), 92 





8 85-92 YYYYMMDD Format; Present only when TRC is one of the 

following: 48, 75, 158, 159 









5 85-89 Beneficiary’s prior state and county code; Present only when TRC is 

85 

8 85-92 The effective date of an enrollment transaction that was submitted 

but rejected. Present only when TRC is the following: 35, 36, 45, 56 

8 85-92 YYYYMMDD Format. Effective date of a beneficiary’s PBP 

change. Present only when TRC is 100. 




w. x. Correct Part 

D Premium 

Rate 

y. z. Date 

Identifying 

Information 

Changed by 

UI User 

aa. bb. Modified 

Part C 

Premium 

Amount 

cc. dd. Date of 

Death 

Removed 

ee. ff. Dialysis End 

Date 

gg. hh. Transplant 

Failure Date 

ii. jj. New ZIP 

Code 

25 District Office 

Code 

26 Previous Part D 

Contract/PBP 

for TrOOP 

Transfer. 

12 85-96 ZZZZZZZZ9.99 Format; Part D premium amount reported by HPMS 

for the Plan. Present only when the TRC is 181. 

8 85-92 YYYYMMDD Format; 

Field content is dependent on TRC: 

702 – Fill-in enrollment period end date, 

705 – End date of enrollment period for corrected PBP, blank when 

end date not provided by user, 

707 – End date of enrollment period for corrected segment, blank 

when end date not provided by user, 

709 & 710 – Enrollment period start date prior to start date change, 

711, 712, & 713 – Enrollment period end date prior to end date 

change. 

12 85-96 ZZZZZZZZ9.99 Format; Part C premium amount reported by HPMS 

for the Plan. Present only when the TRC is 182. 

8 85-92 YYYYMMDD Format; previously reported erroneous date of death. 

Present only when TRC is 091. 

8 85-92 YYYYMMDD Format; present when TRC is 268 and the dialysis 

period has an end date. 

8 85-92 YYYYMMDD Format; present when TRC is 269 and the transplant 

has an end date. 

10 85-94 #####-#### Format; present when TRC is 305 

3 97-99 Code of the originating district office; Present only when TC is 53; 

otherwise, spaces if not applicable. 

8 100-107 CCCCCPPP Format; Present only if previous enrollment exists 

within reporting year in Part D Contract. Otherwise, field is spaces. 

CCCCC = Contract Number; PPP = PBP Number. 


28 Source ID 5 116-120 Transaction Source Identifier 

29 Prior Plan 

Benefit Package 

ID 

30 Application 

Date 

31 UI User 

Organization 

Designation 

32 Out of Area 

Flag 

33 Segment 

Number 

3 121-123 Prior PBP Number; present only for TC 71; otherwise, spaces if not 

applicable. 

8 124-131 The date the plan received the beneficiary’s completed enrollment 

(electronic) or the date the beneficiary signed the enrollment 

application (paper). Format: YYYYMMDD; otherwise, spaces if not 

applicable. 

2 132-133 ‘01’ = Plan 

‘02’ = Regional Office; 

‘03’ = Central Office; 

Spaces = not UI transaction 

1 134 ‘Y’ = Out of area; 

‘N’ = Not out of area; 


3 135-137 Further definition of PBP by geographic boundaries; otherwise, 

spaces when not applicable. 




34 Part C 

Beneficiary 

Premium 

35 Part D 

Beneficiary 

Premium 

8 138-145 Cost to beneficiary for Part C benefits; otherwise, spaces if not 

applicable. 

8 146-153 Cost to beneficiary for Part D benefits; otherwise, spaces if not 

applicable. 

36 Election Type 1 154 ‘A’ = AEP; 

‘E’ = IEP; 

’I’ = ICEP; 

‘O’ = OEP; 

‘N’ = OEPNEW; 

‘T’ = OEPI; 

‘R’ = 5 Star SEP; 

‘S’ = Other SEP; 

‘U’ = Dual/LIS SEP; 

‘V’ = Permanent Change in Residence SEP; 

‘W’ = EGHP SEP; 

‘X’ = Administrative Action SEP; 

‘Y’ = CMS/Case Work SEP; 


37 Enrollment 

Source 

38 Part D Opt-Out 

Flag 

39 Premium 

Withhold 

Option/Parts C- 

D 

(MAs use I, A, N, O, R, S, T, U, V, W, X, and Y. 

MAPDs use I, A, E, N, O, R, S, T, U, V, W, X, Y. 

PDPs use A, E, R, S, U, V, W, X, and Y.) 

1 155 ‘A’ = Auto enrolled by CMS; 

‘B’ = Beneficiary Election; 

‘C’ = Facilitated enrollment by CMS; 

‘D’ = CMS Annual Rollover; 

‘E’ = Plan initiated AE; 

‘F’ = Plan initiated FE; 

‘G’ = Point-of-sale enrollment; 

‘H’ = CMS or Plan reassignment; 

‘I’ = Invalid submitted value (transaction is not rejected); 

‘J’ = State-submitted Passive Enrollment 

‘K’ = CMS-submitted passive Enrollment 

‘L’ = Beneficiary Election in Financial Alignment Demonstration 

‘M’ = Defaulted value for Financial Alignment Demonstration 


1 156 ‘Y’ = Opted out of Part D AE/FE; 

‘N’ = Not opted out of Part D AE/FE; 

Space = No change to opt-out status 

1 157 ‘D’ = Direct self-pay; 

‘S’ = Deduct from SSA benefits; 

‘R’ = Deduct from RRB benefits; 

‘O’ = Deduct from OPM benefits; 

‘N’ = No premium applicable; 

Option applies to both Part C and D Premiums; 





40 Number of 

Uncovered 

Months 

(NUNCMO) 

41 Creditable 

Coverage 

Flag 

42 Employer 

Subsidy 

Override Flag 

43 Processing 

Timestamp 


45 Secondary Drug 

Insurance Flag 

46 Secondary Rx 

ID 


Group 

3 158-160 Total months without drug coverage; otherwise, spaces if not 

applicable. 

1 161 ‘Y’ = Covered; 

‘N’ = Not Covered; 

‘R’ = Setting uncovered months to zero due to a new IEP; 

‘U’ = Setting uncovered months to the value prior to using R; 


1 162 ‘Y’ = Beneficiary is in a Plan receiving an employer subsidy, flag 

allows enrollment in a Part D Plan; 

Space = no flag submitted by Plan. 

15 163-177 Transaction processing time, or, for TRCs 121, 194, and 223, the 

report generation time. 

Format: HH.MM.SS.SSSSSS 

1 198 (TC 61) MAPD and PDP transactions: 

‘Y’ = Beneficiary has secondary drug insurance; 

‘N’ = Beneficiary does not have secondary drug insurance available; 

Space = No flag submitted by Plan. 

(TC 72) MAPD and PDP transactions: 

‘Y’ = Secondary drug insurance available 

‘N’ = No secondary drug insurance available 

Space = no change. 

Space returned with any other TC has no meaning. 

20 199-218 Beneficiary’s secondary insurance Plan’s ID number from input TC 

61 or 72; otherwise, spaces for any other TC. 

15 219-233 Beneficiary’s secondary insurance Plan’s Group ID number from 

input TC 61 or 72; otherwise, spaces for any other TC. 

48 EGHP 1 234 TC 61: 

‘Y’ = EGHP; 

Space = not EGHP. 

49 Part D Low- 

Income 

Premium 

Subsidy Level 

(Part D LIPS) 

TC 74: 

‘Y’ = EGHP; 

‘N’ = Not EGHP; 

Space = no change. 

Space reported with any other TC that has no meaning. 

3 235-237 Part D LIPS percentage category: 

‘000’ = No subsidy, 

‘025’ = 25% subsidy level; 




Spaces = not applicable. 




50 Low-Income 

Co-Pay 

Category 

51 Low-Income 

Period Effective 

Date 

52 Part D Late 

Enrollment 

Penalty (LEP) 

Amount 

53 Part D LEP 

Waived 

Amount 

54 Part D LEP 

Subsidy 

Amount 

55 Low-Income 

Part D Premium 

Subsidy 

Amount 

1 238 Definitions of the co-payment categories: 

‘0’ = none, not low-income 

‘1’ = (High); 

‘2’ = (Low); 

‘3’ = (0); 

‘4’ = 15%; 



8 239-246 Date low income period starts. 

Format: YYYYMMDD 

Spaces if not applicable. 

8 247-254 Calculated Part D LEP, not including adjustments indicated by items 

(53) and (54). 

Format: -9999.99; otherwise, spaces if not applicable. 

8 255-262 Amount of Part D LEP waived. 


8 263-270 Amount of Part D LEP low-income subsidy. 


8 271-278 Amount of Part D low-income premium subsidy as of the enrollment 

period start date. 


56 Part D Rx BIN 6 279-284 Beneficiary’s Part D Rx BIN taken from the input transaction (TC 61 

or 72); otherwise, spaces for any other TC. 

57 Part D Rx PCN 10 285-294 Beneficiary’s Part D Rx PCN taken from the input transaction (TC 

61 or 72); otherwise, spaces if not provided via a transaction. 

58 Part D Rx 

Group 

15 295-309 Beneficiary’s Part D Rx Group taken from the input transaction (TC 

61 or 72); otherwise, spaces for any other TC. 

59 Part D Rx ID 20 310-329 Beneficiary’s Part D Rx ID taken from the input transaction (TC 61 

or 72); otherwise, spaces for any other TC. 


BIN 

6 330-335 Beneficiary’s secondary insurance BIN taken from the input 

transaction (TC 61 or 72); otherwise, spaces for any other TC. 


PCN 

10 336-345 Beneficiary’s secondary insurance PCN taken from the input 

transaction (TC 61 or 72); otherwise, spaces for any other TC. 

62 De Minimis 

Differential 

Amount 

63 MSP Status 

Flag 

64 Low-Income 

Period End 

Date 

8 346-353 Amount by which a Part D de minimis Plan’s beneficiary premium 

exceeds the applicable regional low-income premium subsidy 

benchmark. 


1 354 ‘P’ = Medicare primary payer; 

‘S’ = Medicare secondary payer; 

‘N’ = Non-respondent beneficiary; 


8 355-362 Date low income period closes. The end date is either the last day of 

the PBP enrollment or the last day of the low income period itself, 

whichever is earlier. This field is blank for LIS applicants with an 

open ended award or when the TRC is not one of the LIS TRCs 121, 

194, 223. 

FORMAT: YYYYMMDD; otherwise, spaces if not applicable. 




65 LIS Source 

Code 

66 Enrollee Type 

Flag, PBP Level 

67 Application 

Date 

Indicator 

1 363 ‘A’ = Approved SSA applicant; 

‘D’ = Deemed eligible by CMS; 


1 364 Designation relative to the report generation date (Transaction Date, 

field #22) 

‘C’ = Current PBP enrollee; 

‘P’ = Prospective PBP enrollee; 

‘Y’ = Previous PBP enrollee; 

Spaces = not applicable. 

1 365 Identifies whether the application date associated with a UI 

submitted enrollment has a system generated default value: 

‘Y’ = Default value for UI enrollment; 

Space = Not applicable 

15 366-380 TRC’s short-name identifier 

68 TRC Short 

Name 

69 DRC 2 381-382 Disenrollment Reason Code, see DRC list for values 

70 MMP Opt-Out 

Flag 

1 383 “Y” = Opted out of passive enrollment into an MMP 

“N” = Not opted out of passive enrollment into MMP 

Space = Not applicable 


72 System 

11 475-485 System assigned transaction tracking ID. 

Assigned 

Transaction 

Tracking ID 

73 Plan Assigned 

Transaction 

Tracking ID 

15 486-500 Plan submitted batch input transaction tracking ID. 




F.14.2 Verbatim Plan Submitted Transaction on Daily Transaction Reply Report (DTRR) 


1 HICN 12 1-12 HICN 






‘1’ = Male; 


6 Date of Birth 8 34-41 YYYYMMDD Format 

7 Record Type 1 42 ‘P’ = Plan submitted transaction text. 

8 Contract Number 5 43-47 Plan Contract Number 

9 Plan Transaction Text 300 48-347 Copy of plan submitted transaction. 


11 Transaction Accept/Reject Status Flag 1 474 ‘A’ = System accepted transaction or 

‘R’ = System Rejected transaction. 

12 System Assigned Transaction Tracking ID 11 475-485 System assigned request tracking ID. 

13 Plan Assigned Transaction Tracking ID 15 486-500 Plan submitted batch input transaction 

tracking ID. 




F.15 Monthly Full Enrollment Data File 

This file includes all active Plan membership for the date that the file published. This file is 

considered a definitive statement of current Plan enrollment. CMS announces the availability of 

each month’s file with the proper dataset name and file transfer date. To distinguish this file from 

other TRRs, the TRC on all records is 999. 


1 HICN 12 1 – 12 HICN 

2 Surname 12 13 – 24 Beneficiary Surname 

3 First Name 7 25 – 31 Beneficiary Given Name 



0 = Unknown 

1 = Male 

2 = Female 

6 Date of Birth 8 34 – 41 YYYYMMDD – Format 

7 Medicaid Indicator 1 42 Spaces 

8 Contract Number 5 43 – 47 Plan Contract Number 

9 State Code 2 48 – 49 Beneficiary State Code 

10 County Code 3 50 – 52 Beneficiary County Code 

11 Disability Indicator 1 53 Spaces 

12 Hospice Indicator 1 54 Spaces 

13 Institutional/NHC/HCBS 

1 55 Spaces 

Indicator 

14 ESRD Indicator 1 56 Spaces 

15 TRC 3 57 – 59 TRC; Defaulted to ‘999’ 

16 TC 2 60 – 61 TC; Defaulted to ‘01’ for special reports 

17 Entitlement Type Code 1 62 Spaces 

18 Effective Date 8 63 – 70 YYYYMMDD – Format 

19 WA Indicator 1 71 Spaces 

20 Plan Benefit Package (PBP) ID 3 72 – 74 PBP number 


22 Transaction Date 8 76 – 83 Set to Current Date (YYYYMMDD ) 


24 Subsidy End Date 12 85 – 96 End date of LIS Period (Present if Bene is deemed 

for the full year, or if the Bene is losing Low Income 

status before the end of the current year.) 

25 District Office Code 3 97 – 99 Spaces 

26 Filler 8 100 – 107 Spaces 


28 Source ID 5 116 – 120 Spaces 

29 Prior Plan Benefit Package ID 3 121 – 123 Spaces 

30 Application Date 8 124 – 131 Spaces 


32 Out of Area Flag 1 134 – 134 Spaces 

33 Segment Number 3 135 – 137 Default to ‘000’ if blank 

December 28, 2012 F-90 Monthly Full Enrollment Data File



34 Part C Beneficiary Premium 8 138 – 145 Part C Premium Amount; the amount submitted on 

the enrollment record for Part C premium 

35 Part D Beneficiary 

Premium 

8 146 – 153 Part D Premium Amount: the Part D Total Premium 

Net of Rebate from the HPMS file.) 

36 Election Type 1 154 – 154 Spaces 

37 Enrollment Source 1 155 – 155 A = Auto Enrolled by CMS; 

B = Beneficiary Election; 

C = Facilitated Enrollment by CMS; 

D = CMS Annual rollover; 

E = Plan initiated auto-enrollment; 

F = Plan initiated facilitated-enrollment; 

G = Point-of-Sale enrollment; 

H= CMS or Plan reassignment; 

I = Invalid submitted value (transaction is not 

rejected). 

38 Part D Opt-Out Flag 1 156 – 156 Spaces 


40 Number of Uncovered Months 3 158 – 160 Spaces 

41 Creditable Coverage Flag 1 161 – 161 Spaces 

42 Employer Subsidy Override Flag 1 162 – 162 Spaces 

43 Rx ID 20 163 – 182 Spaces 

44 Rx Group 15 183 – 197 Spaces 

45 Secondary Drug Insurance Flag 1 198-198 Spaces 

46 Secondary Rx ID 20 199 – 218 Spaces 

47 Secondary Rx Group 15 219 – 233 Spaces 

48 EGHP 1 234 - 234 Spaces 

49 Part D LIPS Level 3 235 – 237 Part D LIPS category: 

‘000’ = No subsidy (default for blank) 

‘025’ = 25% subsidy level, 



‘100’ = 100% subsidy level 

50 

Low-Income Co-Pay Category 1 238 – 238 Definitions of the co-payment categories: 

‘0’ = none, not low-income (default for blank) 

‘1’ = (High) 

‘2’ = (Low) 

‘3’ = $0 (0) 

‘4’ = 15% 

‘5’ = unknown 

51 

Low-Income Co-Pay Effective 8 239 - 246 YYYYMMDD – Format 

Date 

52 Part D LEP Amount 8 247 - 254 Spaces 

53 Part D LEP Waived Amount 8 255 - 262 Spaces 

54 Part D LEP Subsidy Amount 8 263 - 270 Spaces 

55 Low-Income Part D Premium 8 271- 278 Part D Low-Income Premium Subsidy Amount 

Subsidy Amount 


December 28, 2012 F-91 Monthly Full Enrollment Data File


F.16 LIS/LEP Data File 





3 

Payment/Payment 

Adjustment Date 

6 9-14 

4 Data file Date 8 15-22 





PIC XXX 


PIC X(5) 

YYYYMM 

First 6 digits contain Current Payment Month 

(CPM) 

PIC 9(6) 

YYYYMMDD 

Date this data file created 

PIC 9(8) 

Item Field Name Size Position Description 

PD = Prospective Detail Record 

“Prospective” means Premium Period 

equals Payment Month reflected in Header 

Record 


AD = Adjustment Detail Record 

“Adjustment” means all Premium Periods 

other than Prospective 

*** PLAN IDENTIFICATION 


3 PBP Number 3 9-11 

4 Plan Segment Number 3 12-14 

*** BENEFICIARY 

IDENTIFICATION & 

PREMIUM SETTINGS 

5 HIC Number 12 15-26 

PIC XXX 


PIC X(5) 

PBP Number 

PIC X(3) 

Plan Segment Number 

PIC X(3) 

Member’s HIC # 

PIC X(12) 

6 Surname 7 27-33 PIC X(7) 

7 First Initial 1 34 PIC X 

8 Sex 1 35 

M = Male, F = Female 

PIC X 

December 28, 2012 F-92 LIS/LEP Data File



9 DOB 8 36-43 

10 Filler 1 44 Space 

11 

12 

13 

14 

*** PREMIUM PERIOD 

Premium/Adjustment Period Start 

Date 

Premium/Adjustment Period End 

Date 

Number of Months in 

Premium/Adjustment Period 

PD: Net Monthly Part D Basic 

Premium 

AD: Net Monthly Part D Basic 


6 45-50 

6 51-56 

2 57-58 PIC 99 

8 59-66 

15 LIPS Percentage 3 67- 69 

16 PPO 1 70 

*** ACTIVITY FOR PREMIUM 

PERIOD 

17 Premium LIS Amount 8 71-78 

YYYYMMDD 

PIC 9(8) 

PD: current processing month. 

AD: adjustment period. 

YYYYMM 

PIC 9(6) 

PD: current processing month. 

AD: adjustment period. 

YYYYMM 

PIC 9(6) 

Plan’s Part D Basic Rate in effect for this 

premium period 

Net is Monthly Part D Basic Premium 

(minus) 

DE MINIMIS DIFFERENTIAL 

Note: PD always equals AD for this field 

PIC -9999.99 

LIPS Percentage 

Subsidy percentage in effect for this 

premium period 

Valid values: 100, 075, 050, 025, Blank 

PIC 999 

Current view of PPO. 

Valid values: 

D (direct bill) 

S (SSA withhold) 

R (RRB withhold) 

O (OPM withhold) 

N (no premium applicable) 

PIC X 

PD: Premium LIS Amount – the portion of 

the Part D basic premium paid by the 

Government on behalf of a lowincome 

individual 

AD: For adjustments, compute the 

adjustment for each month in the 

affected payment period if the payment 

is already made. 

PIC -9999.99 




18 

Net LEP Amount for Direct Billed 

Members 

8 79-86 

19 Net Amount Payable to Plan 8 87-94 



PD: LEP Amount for Direct Billed 

Members owed by Beneficiary for 

premium period. This amount is net of 

any subsidized amounts for eligible LIS 

members. 

Net LEP Amount for Direct Billed 

Members = 

LEP Amount (minus) LEP Subsidy Amount 

(minus) 

Part D Penalty Waived Amount 

AD: For adjustments, compute the 

adjustment for each month in the 

(affected) payment period if the 

payment was already made. 

PIC -9999.99 

PD: 

Net Amount Payable to Plan = 

Premium LIS Amount (field 16) 

(minus) 

Net LEP Amount for Direct 

Billed Members (field 17) 

AD: 

For adjustments, compute the adjustment 

for each month in the (affected) 

payment period if the payment was 

already made. 

PIC -9999.99 



F.17 Loss of Subsidy Data File 

This is a file sent to notify Plans about Beneficiaries’ loss of LIS deemed status for the following 

calendar year based on CMS’ annual re-determination of deemed status or SSA’s redetermination 

of LIS awards. The file is sent to Plans twice per year, once in September and 

once in December. 

The September file is informational only and is used to assist Plans in reaching out to the 

affected population and encouraging them to file an application to qualify for the upcoming 

calendar year. 

The December file is for transactions and is used by Plans to determine who has lost the LIS as 

of January 1 st of the coming year. The TRC is 996, which indicates the loss of the LIS. This 

means the Beneficiary is not LIS eligible as of January 1 st of the upcoming year. 

F.17.1 Loss of Subsidy Data File Detail Record 

Item 

Field Size Position Description 

1 HICN 12 1-12 Health Insurance Claim Number 




5 

Gender Code 1 33 

Beneficiary Gender Identification Code 

0 = Unknown 

1 = Male 

2 = Female 

6 Date of Birth 8 34-41 YYYYMMDD – Format 


8 Contract Number 5 43-47 Plan Contract Number 

9 State Code 2 48-49 Beneficiary State Code 

10 County Code 3 50-52 Beneficiary County Code 


12 TRC 3 57-59 TRC ‘996’ 

13 Transaction Type 

Code 

2 60-61 Transaction Type Code ‘01’ 


15 

YYYYMMDD – Format is 01/01 of the next year. Start 

Effective Date 8 63-70 

of Beneficiary’s Loss of LIS status. 


17 Plan Benefit 

Package ID 

3 72-74 PBP number 


19 Transaction Date 8 76-83 Set to Current Date (YYYYMMDD), is the run date. 


21 Low-Income 

End Date of Beneficiary’s LIS Period (YYYYMMDD), 

8 85-92 

Subsidy End Date 

is 12/31 of the current year. 


23 Segment Number 3 135-137 ‘000’ if no segment in PBP 


December 28, 2012 F-95 Loss of Subsidy Data File



25 Part D Low-Income 

Premium Subsidy 

Level 

26 Low-Income Co- 

Pay Category 

3 235-237 

1 238 

Part D low-income premium subsidy category: 

‘000’ = No subsidy 

Co-payment category: 

‘0’ = none, not low-income 



‘A’ = Approved SSA Applicant; 

LIS Source Code 1 363 

‘D’ = Deemed eligible by CMS 



December 28, 2012 F-96 Loss of Subsidy Data File


F.18 LIS/Part D Premium Data File 


1. Claim Number 12 1-12 Beneficiary’s CAN 

2. Contract Number 5 13-17 Contract Identification Number 

3. PBP Number 3 18-20 Beneficiary’s PBP ID, blank if none 

4. Segment Number 3 21-23 Beneficiary’s Segment Identification Number, blank if none 

5. Run Date 8 24-31 

6. Subsidy Start Date 8 32-39 

7. Subsidy End Date 8 40-47 

8. Part D Premium 

Subsidy Percentage 

9. Low-Income Co- 

Payment Level ID 

10. Beneficiary 

Enrollment 


11. Beneficiary 

Enrollment End 

Date 

12. Part C Premium 

Amount 

13. Part D Premium 

Amount 

14. Part D Late 

Enrollment Penalty 

Amount 

3 48-50 

1 51 

8 52-59 

8 60-67 

8 68-75 

8 76-83 

8 84-91 

15. LIS Subsidy Amount 8 92-99 

16. LIS Penalty Subsidy 

Amount 

17. Part D Penalty 

Waived Amount 

18 Total Premium 

Amount 

19. De Minimis 

Differential Amount 

8 100-107 

8 108-115 

8 116-123 

8 124-131 

20. Filler 147 132- 278 Filler 


Data File Generation Date 

YYYYMMDD – Format 

Beneficiary’s Subsidy Start Date 


Beneficiary’s Subsidy End Date 


Beneficiary’s LIPS Percent 

‘100’ = 100% Premium Subsidy 




Co-Payment Category Definitions: ‘1’=High; ‘2’=Low; 

‘3’=$0; ‘4’=15% 

Beneficiary’s Enrollment effective date, 


Beneficiary’s Enrollment End Date 

YYYYMMDD – Format Space can remain blank 

Beneficiary’s Part C Premium Amount 

(----9.99) 

Beneficiary’s Part D Premium Amount Net of De Minimis if 

Applicable, (----9.99) 

Beneficiary’s Part D LEP Amount 

(––9.99) 

Beneficiary’s LIS Subsidy Amount 

(----9.99) 

Beneficiary’s LIS Penalty Subsidy Amount, 

(----9.99) 

Beneficiary’s Part D Penalty Waived Amount, 

(----9.99) 

Total Calculated Premium for Beneficiary 

(----9.99) 

Amount by which a Part D De Minimis Plan’s beneficiary 

premium exceeds the applicable regional low-income 

premium subsidy benchmark. 

December 28, 2012 F-97 LIS/Part D Premium Data File


F.19 LIS History Data File (LISHIST) 

The Monthly LISHIST provides the most complete picture of LIS eligibility over a period not to 

exceed 36 months. This data file includes LIS activity for past, present, and future enrollees. 

Please note the following limitations: 

The LIS History Data File displays those LIS contract history changes during active, 

contiguous enrollment over a period of time not to exceed 36 months. 

Note: This file was updated to include a Data Activity Flag in field 16 (position 80) of the Detail 

Record. 


Item Field Size Position Format Description 

1 Record Type 1 1 CHAR ‘H’ = Header Record 

2 

MCO Contract 

Number 

5 2-6 CHAR 

3 Data file Date 8 7-14 CHAR 

4 Calendar Month 6 15-20 CHAR 

5 Filler 145 21-165 CHAR SPACES 


Contract ID: 9xxxx, Exxxx, Fxxxx, Hxxxx, Rxxxx, or 

Sxxxx, where “xxxx” is the contract’s numeric 

designation. 

Date this data file created 


First six digits contain Calendar Month the report 

generated; 


December 28, 2012 F-98 LIS History Data File (LISHIST)


F.19.2 Detail Record (Transaction) 

Item Field Size Position Position Description 

1 Record Type 1 1 CHAR ‘D’ = Detail Record 

2 

MCO Contract 

Number 

5 2-6 CHAR 



designation. 

3 PBP Number 3 7-9 CHAR 

PBP Number, blank when Beneficiary premium 

profile is unavailable. 

4 HIC Number 12 10-21 CHAR Beneficiary’s HIC # 

5 Surname 12 22-33 CHAR Beneficiary’s Surname 

6 First Name 7 34-40 CHAR Beneficiary’s First Initial 

7 Middle Initial 1 41 CHAR Beneficiary’s Middle Initial 

8 Sex 1 42 CHAR M = Male, F = Female 

9 Date of Birth 8 43-50 CHAR Date of Birth YYYYMMDD – Format 

10 

11 

Low Income 

Period Start 

Date 

Low Income 

Period End Date 

8 51-58 CHAR 

8 59-66 CHAR 

12 LIPS Percentage 3 67-69 CHAR 

13 

Premium LIS 

Amount 

8 70-77 CHAR 

Start date for beneficiary’s Low Income Period 

Amount: 


End date for beneficiary’s Low Income Period 

Amount: 


Beneficiary’s LIPS Percentage 

‘100’ = 100% Premium subsidy 




The portion of the Part D basic premium paid by the 

Government on behalf of a low-income individual. A 

zero dollar amount here represents several 

possibilities: 

1. There is no Plan premium and therefore no 

premium subsidy. 

2. Although the Beneficiary is enrolled and LIS 

eligible, a system error occurred making premium data 

unavailable. 

Premium LIS Amount is entered in spaces when data 

is unavailable. 

99999.99 – Format 

14 

Low Income 

Co-pay Level 

ID 

1 78 CHAR 

Co-Payment Category Definitions: 

‘1’ = High 

‘2’ = Low 

‘3’ = $0 

‘4’ = 15% 

Co-pay level IDs 1 and 2 change each year. 

In 2007, 1 = $2.15/$5.35 and 2 = $1/$3.10. 

In 2006 1 = $2/$5 and 2 = $1/$3. 



Item Field Size Position Position Description 

15 

16 

Beneficiary 

Source of 

Subsidy Code 

LIS Activity 

Flag 

1 79 CHAR 

1 80 CHAR 

17 PBP Start Date 8 81-88 CHAR 

18 

Net Part D 

Premium 

Amount 

8 89-96 CHAR 

19 Contract Year 4 97-100 CHAR 

20 

21 

Institutional 

Status Indicator 

PBP Enrollment 

Termination 

Date 

1 101 CHAR 

8 102-109 CHAR 



Source of beneficiary subsidy. 

Valid values are: 

A = Determined Eligible for LIS by the Social 

Security Administration or a State Medicaid Agency 

D = Deemed Eligible for LIS 

‘N’ = No change in reported LIS data since last 

month’s data file 

‘Y’ = One of the following may have changed since 

the last month’s data file: 

Co-payment level 

Low-income premium subsidy level 

Low-income period start or end date 

Changes occur to low-income information that do not 

impact the Plan. The changes are not yet separable 

from variations in which the Plan is interested. 

Although it is possible that data records are flagged as 

representing a change, the data of interest to the Plan 

is unaffected. 

PBP enrollment effective start date: 


The total Part D premium net of any Part A/B rebates 

less the Beneficiary’s premium subsidy amount. 

Spaces when the premium record is unavailable. 

99999.99 – Format 

Calendar Year associated with the low income 

premium subsidy amount; 

YYYY – Format 

‘1’ (Institutionalized) 

‘2’ (Non Institutionalized) 

‘3’ (Home and Community- Based Services [HCBS]) 

‘9’ (Not applicable) 

PBP enrollment termination date: 





Item Field Size Position Format Description 

1 Record Type 1 1 CHAR ‘T’ = Trailer Record 

2 

MCO Contract 

Number 

5 2-6 CHAR 



designation. 

3 Totals 8 7-14 CHAR Total number of Detail Records 





F.20 NoRx File 

This file contains records identifying those enrollees with no current 4Rx information stored in 

CMS files. A Detail Record Type containing a value of “NRX” in positions 1 – 3 of the file 

layout indicates that this record requests the organization to send CMS 4Rx information for the 

Beneficiary. 

The NoRx File is in the same format as the 4Rx Notification File and contains records 

identifying those enrollees who do not currently have 4Rx information stored in CMS. The only 

distinction between the two files is that the NoRx file detail record shows blanks, or no 

information, in fields such as REC TYPE, DATE OF BIRTH, RX BIN, etc. 


Header Record 

Detail Record 



Note: A “Critical Field” must contain a value. A “Not Critical Field” may contain a value or all 

spaces. 

Field Size Position Form 

at 

Valid 

Values 

File ID Name 8 1-8 X(8) “CMSNRX 

0H” 

Sending Entity 8 9-16 X(8) “MBD “ 

(MBD + 5 

spaces) 

File Creation 

Date 

8 17-24 X(8) YYYYMM 

DD 

Description 

Critical Field 

This field is always set to the value "CMSNRX0H." 

This code allows recognition of the record as the 

Header Record of a NoRx File. 


This field is always set to the value “MBD “. The 

value specifically is “MBD” followed by five spaces. 


The date on which the NoRx file was created by 

CMS. This value is formulated as YYYYMMDD. 

File Control 

Number 

9 25-33 X(9) Spaces No meaningful values are supplied in this field. This 

field is set to SPACES and is not referenced for 

meaningful information. 

Filler 717 34-750 X(71 

7 

) 


Spaces 

No meaningful values are supplied in this field. This 



December 28, 2012 F-102 NoRx File




spaces. 

Field Size Position Format Valid Values Description 

Record Type 3 1-3 X(3) “NRX” Critical Field 

This field is set to the value "NRX," 

indicating that this detail record is a NoRx 

record. This code allows recognition of the 

detail record as a No Rx record from CMS. 

Record Type 

from Original 

Detail 

HICN or RRB 

Number 

5 4-8 X(5) Spaces No meaningful values are supplied in this 

field. This field is set to SPACES and is not 

referenced for meaningful information. 

12 9-20 X(9) HICN or RRB Critical Field 

This field contains either the HICN or the 

RRB Number of the Beneficiary without 

4Rx data. 

SSN 9 21-29 X(9) SSN from CMS Not a Critical Field 

This field may contain the SSN of the 

Beneficiary that does not have 4Rx data. 

Beneficiary Date 

of Birth from 

Original Detail 

Beneficiary 

Gender Code 

from Original 

Detail 

Rx BIN from 


Rx PCN from 


Rx ID Number 

from Original 

Detail 

Rx Group from 





1 38 X(1) Spaces No meaningful values are supplied in this 















Contract Number 5 90- 94 X(5) Contract Number 

from CMS 

PBP Number 3 95- 97 X(3) PBP Number from 

CMS 

PBP Enrollment 


from Original 

Detail 


This field contains the Contract Number of 

the beneficiary that does not have 4Rx data. 


This field contains the beneficiary PBP 

number but does not have 4Rx data. 







Record Sequence 

Number from 





Processed Flags 3 113-115 X(3) Spaces No meaningful values are supplied in this 



Error Return 

Codes 

Sending Entity 

from Original 

File 

File Control 

Number from 

Original File 

File Creation 

Date 










8 169-176 X(8) YYYYMMDD Critical Field 

This field contains the date the NoRx record 

was created. 

Filler 574 177-750 X(574) Spaces No meaningful values are supplied in this 

field. This field will be set to SPACES and 

should not be referenced for meaningful 

information. 






spaces. 


File ID 

Name 

Sending 

Entity 

File 

Creation 

Date 

File 

Control 

Number 

File 

Record 

Count 

8 1-8 X(8) “CMSNRX0T” Critical Field 

This field is always set to the value "CMSNRX0T.” 

This code allows recognition of the record as the 

Trailer Record of a NoRx File. 

8 9-16 X(8) “MBD “ Critical Field 

(MBD + 5 This field is always set to the value “MBD “. The 

spaces) value specifically is “MBD” followed by five spaces. 

8 17-24 X(8) YYYYMMDD Critical Field 

The date that CMS created the NoRx file. This value 

is formulated as YYYYMMDD. 

9 25-33 X(9) Spaces No meaningful values are supplied in this field. This 



7 34-40 9(7) Numeric value 

greater than 

Zero. 


The total number of NoRx records on this file. This 

value is right-justified in the field with leading zeros. 

Filler 710 41-750 X(710) Spaces No meaningful values are supplied in this field. This 






F.21 Batch Eligibility Query (BEQ) Request File 

The BEQ Request File includes transactions submitted by Plans to request eligibility information 

for prospective Plan enrollees. The file is used to conduct initial eligibility checks against CMS 

MBD system to verify member is Part A / B eligible. 

This file includes the following records: 

 

 

 

Header Record 

Detail Record 




File ID 

Name 

Sending 

Entity: 

CMS 

File 

Creatio 

n Date 

File 

Control 

Number 

8 1- 8 X(8) “MMABEQRH” Critical Field: This field is always set to the value 

"MMABEQRH.” This code identifies the file as a 

BEQ Request File and this record as the Header 

Record of the file. 

8 9-16 X(8) Sending 

Organization (left 

justified space 

filled) 

Acceptable 

Values: 

5-position 

Contract. (3 

Spaces are for 

Future use) 

Critical Field: This field provides CMS with the 

identification of the entity that is sending the BEQ 

Request File. The value for this field is provided to 

CMS and used in connection with CMS electronic 

routing and mailbox functions. The value in this field 

should agree with the corresponding value in the 

Trailer Record. 

The Sending Entity may participate in Part D. 

8 17-24 X(8) CCYYYYMMDD Critical Field: The date that the Sending Entity created 

the BEQ Request File. This value’s format is 

YYYYMMDD. For example, January 3 2010 is the 

value 20100103. This value should agree with the 

corresponding value in the Trailer Record. CMS 

returns this information to the Sending Entity on all 

Transactions (Detail Records) of a BEQ Response 

File. 

9 25-33 X(9) Assigned by 



The specific Control Number assigned by the Sending 

Entity to the BEQ Request File. CMS returns this 

information to the Sending Entity on all Transactions 

(Detail Records) of a BEQ Response File. This value 







December 28, 2012 F-106 BEQ Request File




Record 

Type 

HICN/RRB 

Number 

5 1-5 X(5) “DTL01” = BEQ 

Transaction 

Note: The value 

above is DTLzero-one. 

12 6-17 X(12) HICN 

Or 

RRB 

Filler 9 18-26 X(9) Spaces 


This field is set to the value "DTL01," which 

indicates that this detail record is a BEQ 

Transaction. This code identifies the record as a 

detail record for processing specifically for BEQ 

Service. 


This field provides either the HICN or the RRB 

Number for identification of the individual. The 

Plan should provide either the HICN or the RRB 

Number, whichever the Plan has available and 

active for the individual. The value is left justified 

in the field and does not include dashes, decimals, 

or commas. 

DOB 8 27-34 X(8) CCYYYYMMDD Critical Field 

The date of the individual’s birth; value format is 

YYYYMMDD. The value should not include 

dashes, decimals, or commas. The value should 

include only numbers. 

Gender 

Code 

Detail 

Record 

Sequence 

Number 

1 35 X(1) 0 (Zero) = 

Unknown; 

1 = Male; 

2 = Female 

7 36-42 9(7) Seven-byte 

number unique 

within the BEQ 

Request File 

Not Critical Field 

The gender of the individual. The acceptable values 

include 

0 (Zero) = Unknown, 1 = Male, 2 = Female. 


A unique number assigned by the Sending Entity to 

the Transaction (Detail Record). This number 

should uniquely identify the Transactions (Detail 

Record) within the BEQ Request File. 

Filler 708 43-750 X(708) Spaces No meaningful values are supplied in this field. 

This field is set to SPACES and is not referenced 

for or used to store meaningful information, unless 

specifically documented otherwise. 






File ID 

Name 

Sending 

Entity 

(CMS) 

8 1-8 X(8) “MMABEQRT” Critical Field 

This field is always set to the value "MMABEQRT.” 

This code identifies the record as the Trailer Record of 

a BEQ Request File. 

8 9-16 X(8) Sending 



filled) 

Acceptable 

Values: 

5-position 

Contract Identifier 

+ 3 Spaces 

(3 Spaces for 

Future use) 


This field provides CMS with the identification of the 

entity that is sending the BEQ Request File. The value 

for this field is provided to CMS and used in 

connection with CMS electronic routing and mailbox 

functions. The value in this field should agree with the 

corresponding value in the Header Record. 

The Sending Entity may participate in Part D. 

File 

Creatio 

n Date 

File 

Control 

Number 

Record 

Count 

8 17-24 X(8) CCYYYYMMDD Critical Field 

The date when the Sending Entity created the BEQ 

Request File. This value’s format is YYYYMMDD. 

For example, January 3, 2010 is the value 20100103. 

This value should agree with the corresponding value 

in the Header Record. CMS will pass this information 

back to the Sending Entity on all Transactions (Detail 

Records) of a BEQ Response File. 



7 34-40 9(7) Numeric value 

greater than Zero. 


The specific Control Number assigned by the Sending 

Entity to the BEQ Request File. CMS will return this 

information to the Sending Entity on all Transactions 

(Detail Records) of a BEQ Response File. This value 


Header Record. 


The total number of Transactions (Detail Records) 

supplied on the BEQ Request File. This value is rightjustified 

in the field, with leading zeros. This value 

should not include non-numeric characters, such as 

commas, spaces, dashes, decimals. 



meaningful information nor used to store meaningful 

information, unless specifically documented otherwise. 




F.22 BEQ Response File 

The BEQ Response File contains records produced from processing the transactions of accepted 

BEQ Request files. Detail records for all submitted records that are successfully processed 

contain Processed Flag = Y. Detail records for all submitted records that are not successfully 

processed contain Processed Flag = N. 

CMS sends BEQ Response Files to Plans in the following format. The BEQ Response Files are 

flat files created as a result of processing the Transactions, i.e., Detail Records, of Accepted 

BEQ Request Files. 


 

 

 

Header Record 

Detail Record 



Field Size Position Format Valid Values Field Definition 

File ID 

Name 

Sending 

Entity 

(MBD) 

File 

Creation 

Date 

File 

Control 

Number 

8 1-8 X(8) “CMSBEQRH” This field is always set to the value "CMSBEQRH.” This 

code identifies the record as the Header Record of a BEQ 

Response File. 

8 9-16 X(8) “MBD ” 

(MBD + 5 

Spaces) 

This field is always set to the value "MBD .” The value 

specifically is MBD + 5 following Spaces. This value 

agrees with the corresponding value in the Trailer Record. 

8 17-24 X(8) CCYYMMDD The date that CMS created the BEQ Response File. This 

value is in the format of CCYYMMDD. For example, 

January 3, 2010 is the value 20100103. This value agrees 

with the corresponding value in the Trailer Record. 



(MBD) 

The specific Control Number assigned by CMS to the 

BEQ Response File. CMS utilizes this value to track the 

BEQ Response File through CMS processing and archive. 

This value agrees with the corresponding value in the 


Filler 717 34-750 X(717) Spaces No meaningful values are supplied in this field. This field 

is set to SPACES and is not referenced for or used to store 

meaningful information, unless specifically documented 

otherwise. 


December 28, 2012 F-109 BEQ Response File




Record Type 3 1-3 X(3) "DTL" This field is set to the value "DTL," 

indicating that this is a detail record. 


Record 

42 4-45 X(42) The first 42 

positions of the 

original Transaction 

or Detail Record as 

supplied by the 

Sending Entity. 

Processed Flag 1 46 X(1) "Y" = Detail record 

accepted for 

processing. 

"N" = Detail record 

not accepted for 

processing. 

Beneficiary 

Match Flag 

Medicare Part A 

Entitlement Start 

Date 

Medicare Part A 

Entitlement End 

Date 

1 47 X(1) "Y" = Beneficiary 

matched (located) 

successfully. 

"N" = Beneficiary 

not matched 

(located) 

successfully. 

" " (SPACE) = 

Beneficiary Match 

not attempted due to 

an Invalid condition 

in the Transaction 

8 48-55 X(8) CCYYMMDD 

Spaces = Not 

currently enrolled or 

Data Not Found. 


Spaces = Not 



This field provides the meaningfully 

populated area of the BEQ Request File 

Transaction provided by the Sending Entity. 

The breakdown includes: 

Record Type X95) position 4 … 8 

Bene. HICN / RRB # X(12) position 9 … 20 

Filler position 21 … 29 

Beneficiary DOB X(8) position 30 … 37 

Beneficiary Gender Code X(1) position 38 

Detail Record Sequence # 9(7) pos 39 … 45 

A flag that indicates if the Transaction 

(Detail Record) was accepted for processing. 

A Transaction is accepted for processing if 

all critical fields contain valid values. 

A flag that indicates whether or not the 

Beneficiary in the Transaction successfully 

matched to a Beneficiary on the CMS MBD. 

The Entitlement Start Date of the 

beneficiary's most recent or active Medicare 

Part A entitlement period. 

The Entitlement End Date of the 


Part A entitlement period. 

Medicare Part B 

Entitlement Start 

Date 

Medicare Part B 

Entitlement End 

Date 

Medicaid 

Indicator 


Spaces = Not 




Spaces = Not 



1 80 X(1) "0" = Beneficiary 

with no current or 

active Medicaid 

The Entitlement Start Date of the 


Part B entitlement period. 

The Entitlement End Date of the 


Part B entitlement period. 

An indicator of the presence of current 

Medicaid coverage for the beneficiary. The 

value for this field is based upon the 




Part D 

Enrollment 


/Employer 

Subsidy Start 

Date 

(Occurrence 1) 

Part D 

Disenrollment 

Date/ Employer 

Subsidy End 

Date 


Part D 

Enrollment 

Effective Date/ 

Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 

Date / Employer 

coverage; 

"1" = Beneficiary 

has current or active 

Medicaid coverage. 


Spaces = No Drug 

coverage period for 

this occurrence or 




Coverage Period for 



8 97-104 X(8) CCYYMMDD 





8 105-112 X(8) CCYYMMDD 





8 113-120 X(8) CCYYMMDD 





8 121-128 X(8) CCYYMMDD 





8 129-136 X(8) CCYYMMDD 





8 137-144 X(8) CCYYMMDD 



presence of Medicaid reported for the 

beneficiary by states in the previous calendar 

month via the MMA State Files. 

Effective start date of the Part D Plan or the 

Start Date of the Employer Subsidy coverage 

for the beneficiary;(most recent or presently 

active. 

Effective disenrollment date of the Part D 

Plan or the End Date of the Employer 

Subsidy coverage for the beneficiary;(most 

recent or presently active. 



for the beneficiary; second most recent. 



Subsidy coverage for the beneficiary; second 

most recent. 



for the beneficiary; third most recent. 



Subsidy coverage for the beneficiary; third 

most recent. 



for the beneficiary; fourth most recent. 



Subsidy coverage for the beneficiary (fourth 




Subsidy End 

Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 

Effective Date / 

Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 



8 145-152 X(8) CCYYMMDD 





8 153-160 X(8) CCYYMMDD 





8 161-168 X(8) CCYYMMDD 





8 169-176 X(8) CCYYMMDD 





8 177-184 X(8) CCYYMMDD 





8 185-192 X(8) CCYYMMDD 





8 193-200 X(8) CCYYMMDD 





8 201-208 X(8) CCYYMMDD 




most recent). 



for the beneficiary (fifth most recent). 



Subsidy coverage for the beneficiary (fifth 

most recent). 



for the beneficiary (sixth most recent). 



Subsidy coverage for the beneficiary (sixth 

most recent). 



for the beneficiary (seventh most recent) 



Subsidy coverage for the beneficiary 

(seventh most recent) 



for the beneficiary (eighth most recent). 



Subsidy coverage for the beneficiary (eighth 

most recent). 




Date 


Part D 

Enrollment 


Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 


Part D 

Enrollment 

Effective Date / 

Employer 

Subsidy Start 

Date 


Part D 

Disenrollment 


Subsidy End 

Date 



8 209-216 X(8) CCYYMMDD 





8 217-224 X(8) CCYYMMDD 





8 225-232 X(8) CCYYMMDD 





8 233-240 X(8) CCYYMMDD 





Sending Entity 8 241-248 X(8) Sending Part D 



filled) 

Acceptable Values: 

5-position Contract 

Identifier + 3 

Spaces. 3 Spaces for 

Future Use. 

File Control 

Number 

File Creation 

Date 

Part D Eligibility 

Start Date 

Deemed / LIS 


(occurrence 1) 





for the beneficiary (ninth most recent). 



Subsidy coverage for the beneficiary (ninth 

most recent) 



for the beneficiary (tenth most recent). 



Subsidy coverage for the beneficiary (tenth 

most recent). 

The Sending Entity provided on the Header 

Record of the BEQ Request File in which 

the Transaction (Detail Record) was found. 

The Sending Entity may participate in Part 

D. 

The File Control Number provided by the 

Sending Entity on the Header record of the 

BEQ Request File in which the Transaction 

(Detail Record) was found. 

8 258-265 X(8) CCYYMMDD The File Creation Date provided on the 

Header Record of the BEQ Request File in 

which the Transaction (Detail Record) was 

found. 

8 266-273 X(8) CCYYMMDD This field identifies the date the beneficiary 

became eligible for Part D Benefits. 

8 274-281 X(8) CCYYMMDD Effective start date of the Deeming period or 

LIS. This is the first day of the month in 

which the Deeming was made or the start 

date of the LIS (most recent or presently 

active). 




Deemed / LIS 

End Date 


Co-payment 

Level Identifier 


8 282-289 X(8) CCYYMMDD The end date of the Deemed period or LIS 

(most recent or presently active). 

1 290 X(1) Deemed: This field indicates the Beneficiary copayment 

level. 


Subsidy Percent 


Deemed/Low 

Income Subsidy 



Deemed/ Low 

Income Subsidy 

End Date 

(Occurrence2) 

Co-payment 

Level Identifier 



Subsidy Percent 


RDS/Part D 

Indicator 

(Occurrence 1 

for date fields 

beginning in 

position 81) 

RDS/Part D 

Indicator 

(Occurrence 2 


beginning in 

position 97) 

RDS/Part D 

Indicator 

(Occurrence 3 


beginning in 

position 113) 

RDS/Part D 

Indicator 

(Occurrence 4 


beginning in 

position 129) 

RDS/Part D 

Indicator 

3 291-293 X(3) 

‘100’, ‘075’, ‘050’, 

‘025’ or ‘000’ 

If beneficiary is Deemed, subsidy is 100 

percent. If beneficiary is LIS, this field 

identifies the portion of Part D Premium 

subsidized. 

8 294-301 X(8) CCYYMMDD Effective start date of the Deeming period or 

LIS. This is the first day of the month in 

which the Deeming was made or the start 

date of the LIS (second most recent). 

8 302-309 X(8) CCYYMMDD The end date of the Deemed period or LIS 

(second most recent). 

1 310 X(1) Deemed: This field indicates the Beneficiary’s copayment 

level. 

3 311-313 X(3) ‘100’, ‘075’, ‘050’, 

‘025’ or ‘000’ 

1 314 X(1) R = RDS 

D = Part D 

1 315 X(1) R = RDS 

D = Part D 

1 316 X(1) R = RDS 

D = Part D 

1 317 X(1) R = RDS 

D = Part D 

1 318 X(1) R = RDS 

D = Part D 

If beneficiary is Deemed, subsidy is 100 

percent. If beneficiary is LIS, this field 

identifies the portion of Part D Premium 

subsidized. 




(Occurrence 5 


beginning in 

position 145) 

RDS/Part D 

Indicator 

(Occurrence 6 


beginning in 

position 161) 

RDS/Part D 

Indicator 

(Occurrence 7 


beginning in 

position 177) 

RDS/Part D 

Indicator 

(Occurrence 8 


beginning in 

position 193) 

RDS/Part D 

Indicator 

(Occurrence 9 


beginning in 

position 209) 

RDS/Part D 

Indicator 

(Occurrence 10 


beginning in 

position 225) 

Start Date 


Number of 

Uncovered 

Months 

(NUNCMO) 


NUNCMO 

Indicator 


NUNCMO 


Start Date 


NUNCMO 


NUNCMO 


1 319 X(1) R = RDS 

D = Part D 

1 320 X(1) R = RDS 

D = Part D 

1 321 X(1) R = RDS 

D = Part D 

1 322 X(1) R = RDS 

D = Part D 

1 323 X(1) R = RDS 

D = Part D 

8 324-331 X(8) CCYYMMDD 

3 332-334 9(3) Right justified with leading zeros. 

1 335 X(1) Right justified with leading zeros. 


8 339-346 X(8) CCYYMMDD 







NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 



8 354-361 X(8) CCYYMMDD 




8 369-376 X(8) CCYYMMDD 




8 384-391 X(8) CCYYMMDD 




8 399-406 X(8) CCYYMMDD 




8 414-421 X(8) CCYYMMDD 



3 426-428 9(3) Right justified with leading zeros. 

Start Date 8 429-436 X(8) CCYYMMDD 





NUNCMO 


NUNCMO 



NUNCMO 


Start Date 

Occurrence 9) 

NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 





8 444-451 X(8) CCYYMMDD 




8 459-466 X(8) CCYYMMDD 




8 474-481 X(8) CCYYMMDD 




8 489-496 X(8) CCYYMMDD 




8 504-511 X(8) CCYYMMDD 


NUNCMO 1 515 X(1) Right justified with leading zeros. 






NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 



8 519-526 X(8) CCYYMMDD 




8 534-541 X(8) CCYYMMDD 




8 549-556 X(8) CCYYMMDD 




8 564-571 X(8) CCYYMMDD 

NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



Total Number of 

Uncovered 

Months 



8 579-586 X(8) CCYYMMDD 








Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Start Date 


NUNCMO 


NUNCMO 



NUNCMO 


Beneficiary’s 

Retrieved Date of 

Birth 

Beneficiary’s 

Retrieved Gender 

Code 

8 594-601 X(8) CCYYMMDD 




8 609-616 X(8) CCYYMMDD 




8 624-631 X(8) CCYYMMDD Beneficiary’s Retrieved Date of Birth (as 

retrieved from CMS database for matching 

beneficiary). 

1 632 X(1) 0 = Unknown 

1 = Male 

2 = Female 

Beneficiary’s Retrieved Gender Code (as 

retrieved from CMS database for matching 

beneficiary). 

Last Name 40 633-672 X(40) CHAR Beneficiary’s Last Name 

First Name 30 673-702 X(30) CHAR Beneficiary’s First Name 

Middle Initial 1 703 X(1) CHAR First Initial of Beneficiary’s Middle Name 

Current State 

Code 

2 704-705 X(2) CHAR 

Current County 3 706-708 X(3) CHAR 

Code 

Date of Death 8 709-716 X(8) CCYYMMDD 

format 

Part C/D 

Contract Number 

(if available) 

Part C/D 

Enrollment Start 

Date (if 

available) 

5 717-721 X(5) CHAR 

8 722-729 X(8) CHAR 

Part D Indicator 1 730 X(1) CHAR Y = yes; N = no; space 

Part C Contract 

Number 

Part C 

Enrollment Start 

Date (if 

available) 

5 731-735 X(5) CHAR 

8 736-743 X(8) CHAR 

Part C Indicator 1 744 X(1) CHAR N = no; space 




(if available) 

Filler 6 745-750 X(6) SPACES No meaningful values are supplied in this 


referenced for meaningful information or 

used to store meaningful information, unless 







File ID Name 8 1-8 X(8) “CMSBEQRT” This field is always set to the value 

"CMSBEQRT.” This code identifies the 

record as the Trailer Record of a BEQ 

Response File. 

Sending Entity: 

MBD 

8 9-16 X(8) “MBD ” (MBD 

+ 5 Spaces) 

This field is always set to the value "MBD 

.” The value specifically is MBD + 5 

following Spaces. This value agrees with 

the corresponding value in the Header 

Record. 

File Creation Date 8 17-24 X(8) CCYYMMDD The date when CMS created the BEQ 

Response File. This value is formatted as 

CCYYMMDD. For example, January 3, 

2010 is the value 20100103. This value 

agrees with the corresponding value in the 


File Control 

Number 


Sending Entity: 

MBD 

Record Count 7 34-40 9(7) Numeric value 

greater than Zero. 

The specific Control Number assigned by 

CMS to the BEQ Response File. CMS 

utilizes this value to track the BEQ 

Response File through CMS processing 

and archive. This value agrees with the 


The total number of Transactions or Detail 

Records on the BEQ Response File. This 

value is right justified in the field, with 

leading zeros. This value does not include 

non-numeric characters, such as commas, 

spaces, dashes, decimals. 

Filler 710 41-750 X(710) Spaces No meaningful values are supplied in this 

field. This field is set to SPACES is not 

referenced for or used to store meaningful 

information, unless specifically 

documented otherwise. 




F.23 MA Full Dual Auto Assignment Notification File 

This cumulative monthly file identifies organizations’ enrollees who are full-benefit dual eligible. 


Header Record This first record of the file only occurs once. 

Detail Record (Transaction) This record contains Beneficiary information and 

may occur multiple times. 

Trailer Record This last record of the file only occurs once. 



File ID 

Name 

Sending 

Entity: 

MBD 

File 

Creatio 

n Date 

File 

Control 

Number 

Filler 

8 1-8 X(8) “MMAADUAH” 

8 9-16 X(8) 

“MBD ” 

(MBD + 5 

Spaces) 

8 17-24 X(8) YYYYMMDD 

9 25-33 X(9) 

67 34-100 X(67) Spaces 


Assigned by 


(MBD) 

This field is always set to the value "MMAADUAH.” 

This code identifies the record as the Header Record of an 

Auto Assignment Full Dual Notification File. 

This is always set to the value "MBD .” The value 

specifically is MBD + 5 following Spaces. This value 

agrees with the corresponding value in the Trailer Record. 

The date on which the Full Dual File was created by 

CMS. This value is in the format of YYYYMMDD. For 

example, January 3, 2010 is the value 20100103. This 

value agrees with the corresponding value in the Trailer 

Record. 

The specific Control Number assigned by CMS to the Full 

Dual Notification File. CMS utilizes this value to track the 

Full Dual Notification File through CMS processing and 

archive. This value agrees with the corresponding value in 

the Trailer Record. 

No meaningful values are supplied in this field. This field 

is set to SPACES and is not referenced for or used to store 

meaningful information, unless specifically documented 

otherwise. 

December 28, 2012 F-122 MA Full Dual Auto Assignment 

Notification File



Field Name Size Position 


(This field provides the Contract assigned to the beneficiary; CNTRCT_NUM in 

CME_SRVC_DEL_ELCT) 

Run Date 

(This field provides the creation date of the file in CCYYMMDD format) 

Filler 

(This field is all spaces) 

Beneficiary’s HICN/RRB 

(This field provides either the HICN or the RRB Number for identification of the 

individual; BENE_CAN_NUM and BIC_CD or RRB_HIC_NUM in CME_BENE) 

Beneficiary’s Surname 

(This field provides the last name of the individual; BENE_LAST_NAME in 

CME_BENE_NAME) 

Initial of Beneficiary’s First Name 

(This field provides the initial of the first name of the individual; BENE_1ST_NAME in 

CME_BENE_NAME) 

Beneficiary’s Gender 

(This field provides the gender of the individual; BENE_SEX_CD in MBD_BENE; ‘0’, 

‘1’, or ‘2’) 

Beneficiary’s Date of Birth 

(This field provides the date of birth of the individual in CCYYMMDD format; 

BENE_BIRTH_DT in CME_BENE) 

Filler 

(This field is all spaces) 



5 1-5 

8 6-13 

6 14-19 

12 20-31 

12 32-43 

1 44 

1 45 

8 46-53 

47 54-100 

Data Field 

File ID 

Name 

Sending 

Entity 

MBD 

File 

Creation 

Date 

File 

Control 

Number 

Size 

Positio 

n 

8 1- 8 X(8) 

8 9-16 X(8) 

Format Valid Values Field Definition 

“MMAADUAT 

” 

“MBD ” 

(MBD + 5 

Spaces) 

This field is always set to the value "MMAADUAT.” 

This code identifies the record as the Trailer Record of 

an Auto Assignment Full Dual Notification File. 

This field is always set to the value "MBD .” The 

value specifically is MBD + 5 following Spaces. This 

value agrees with the corresponding value in the 


8 17-24 X(8) YYYYMMDD The date on which the Full Dual Notification File was 

created by CMS. This value is formatted as 

YYYYMMDD. For example, January 3, 2010 is the 

value 20100103. This value agrees with the 


9 25-33 X(9) 

Assigned by 


(MBD) 

The specific Control Number assigned by CMS to the 

Full Dual Notification File. CMS utilizes this value to 

track the Full Dual Notification File through CMS 

processing and archive. This value agrees with the 



Notification File


Data Field 

Record 

Count 

Size 

Positio 

n 

9 34-42 9(9) 

Filler 58 43-100 X(58) Spaces 


Format Valid Values Field Definition 

Numeric value 

greater than 

Zero. 

The total number of Transactions or Detail Records 

on the Full Dual Notification File. This value is right 

justified in the field, with leading zeros. This value 

does not include non-numeric characters, such as 

commas, spaces, dashes, decimals. 

No meaningful values are supplied in this field. This 

field is set to SPACES and is not referenced for or 

used to store meaningful information, unless 



Notification File


F.24 Auto Assignment (PDP) Address Notification File 

This file contains monthly addresses of Beneficiaries that are either AE, FE, or reassigned to 

PDPs. This file contains a header record, detail records, and a trailer record. Please see the Main 

Guide section 4.4.5 for details on its use. 

Header Record This first record of the file only occurs once. 

Detail Record This record contains Beneficiary information and may 

occur multiple times. 

Trailer Record This last record of the file only occurs once. 

The full address, including city/state/zip code, is “wrapped” in the fields “Beneficiary Address 

Line 1” through “Beneficiary Address Line 6,” with the result that street address, city, and state 

may appear on different lines for different beneficiaries. Different parts of the address appears 

only on certain lines, as follows: 

 

 

 

 

 

Beneficiary Address Lines 1-6 is limited to Representative Payee Name (if applicable), 

and street address, and these elements “wrap.” 

When a Beneficiary has a Representative Payee, the Beneficiary Representative Payee 

Name prints on Address Line 1, and may use more Address Lines. 

The actual street address in such cases is printed on the line after the name concludes. 

Address Lines print on fewer than six lines with the remainder of the lines padded with 

space prior to printing. 

City/State/Zip Code data only appear in the fields labeled as City/State/Zip Code data 

fields. 


Field Size Position 

Header Code (This field used for file/record identification purposes, 

‘MMAAPDPGH’) 

Sending Entity (This field used to identify the sending entity, ‘MBD 

‘(MBD + 5 spaces) ) 

9 1-9 

8 10-17 

File Creation Date (The date the file was created in CCYYMMDD format) 8 18-25 

File Control Number (Unique file identifier created by Sending Entity) 9 26-34 

Filler (This field is all spaces) 581 35-615 


December 28, 2012 F-125 Auto Assignment (PDP) 

Address Notification File




Beneficiary’s HICN (This field provides the HICN for identification of the 

individual; RRB_HIC_NUM in MBD_BENE) 

Beneficiary’s Last Name (This field provides the first twelve characters of 

the last name of the individual; BENE_LAST_NAME in MBD_BENE) 

Beneficiary’s First name (This field provides the first seven characters of 

the first name of the individual; BENE_1ST_NAME in MBD_BENE) 

Beneficiary’s Middle Initial (This field provides the middle initial of the 

individual; MDL_INITL_NAME in MBD_BENE) 

Beneficiary’s Gender (This field provides the gender of the individual; 

BENE_SEX_CD in MBD_BENE; ‘0’, ‘1’, or ‘2’) 

Beneficiary’s DOB (This field provides the date of birth of the individual in 

CCYYMMDD format; BENE_BIRTH_DT in MBD_BENE) 

Medicaid Indicator (This field indicates the beneficiary’s Medicaid 

eligibility; MDCD_ELGBL_STUS_SW in MBQ_DUAL_MDCR; ‘Y’ or 

‘N’) 

Contract Number (This field provides the Contract assigned to the 

beneficiary; ASGN_CNTRCT_NUM in MBQ_AA) 

State Code (This field provides the beneficiary’s state of residency; 

SSA_STD_STATE_CD in MBD_BENE_ADR) 

County Code (This field provides the beneficiary’s county of residency; 

SSA_STD_CNTY_CD in MBD_BENE_ADR) 

12 1-12 

12 13-24 

7 25-31 

1 32 

1 33 

8 34-41 

1 42 

5 43-47 

2 48-49 

3 50-52 


TC (This field identifies the type of record; ‘61’) 2 60-61 

Filler (This field is all spaces) 1 62 

Effective Date (The effective date of the assignment in CCYYMMDD 

format; ASGN_EFCTV_DT in MBQ_AA) 

8 63-70 


PBP (This field notes the PBP of the auto-assigned contract; 

ASGN_PBP_NUM in MBQ_AA) 

3 72-74 


Application Date (The date of the application in CCYYMMDD format) 8 124-131 


Election Type (This field indicates the type of election; ‘S’) 1 162 

Enrollment Source (This field indicates the source of the enrollment; ‘A’) 1 163 


Premium Withhold Option/Parts C-D (This field indicates the payment 

option for payment of Part C and D premiums; PRM_WTHLD_OPT_CD 

in MBQ_PREMIUM; ‘D’) 

1 165 


Creditable Coverage Flag (This field indicates if the beneficiary has 1 169 





creditable coverage; derived from MBQ_MARX_CRED_CVRG; ‘Y’, ‘N’, 

or ‘ ‘) 


Part D Subsidy Level (This field identifies the portion of the Part D 

Premium subsidized; PTD_PRM_SBSDY_PCT in MBQ_LIS; For 

monthly, value is always ‘100’; For Facilitated, values are either ‘100’, 

‘075’, ‘050’, or ‘025’) 

Co-Payment Category (This field indicates the Subsidy Co-Payment level 

for the beneficiary; LIS_COPMT_LVL_ID in MBQ_LIS; ‘1’ or ‘4’) 

Co-Payment Effective Date (The date the LIS begins; 

SBSDY_STRT_DATE in MBQ_LIS; For monthly, is always 

MMDDYYYY; For Facilitated, value is spaces) 

Beneficiary Address Line 1 (First line in the mailing address; 

BENE_LINE_1_ADR in MBD_BENE_ADR) 

Beneficiary Address Line 2 (Second line in the mailing address; 


Beneficiary Address Line 3 (Third line in the mailing address; 


Beneficiary Address Line 4 (Fourth line in the mailing address; 


Beneficiary Address Line 5 (Fifth line in the mailing address; 


Beneficiary Address Line 6 (Sixth line in the mailing address; 


Beneficiary Address City (The city in the mailing address; 

BENE_ADR_CITY_NAME in MBD_BENE_ADR) 

Beneficiary Address State (The state in the mailing address; 

ADR_PSTL_STATE_CD in MBD_BENE_ADR) 

Beneficiary Zip Code (The zip code in the mailing address; 

BENE_ADR_ZIP_CD in MBD_BENE_ADR) 

Full Last Name (This field provides the last name of the individual; 

BENE_LAST_NAME in MBD_BENE) 

Full First Name (This field provides the first name of the individual; 

BENE_1ST_NAME in MBD_BENE) 


3 243-245 

1 246 

8 247-254 

40 255-294 

40 295-334 

40 335-374 

40 375-414 

40 415-454 

40 455-494 

40 495-534 

2 535-536 

9 537-545 

40 546-585 

30 586-615 






Trailer Code 

(This field used for file/record identification purposes, ‘MMAAPDPGT’) 


(This field used to identify the sending entity, ‘MBD ‘(MBD + 5 spaces) ) 

File Creation Date 

(The date the file was created in CCYYMMDD format) 

File Control Number 

(Unique file identifier created by Sending Entity) 

Record Count 

(Number of Detail Records, right justified with leading zeros) 

Filler 

This field is all spaces 


9 1-9 

8 10-17 

8 18-25 

9 26-34 

9 35-43 

572 44-615 

December 28, 2012 F-128 Auto Assignment (PDP) 



F.25 Plan Payment Report (PPR)/Interim Plan Payment Report (IPPR) Data 

File 

Also known as the APPS Payment Letter, this data file itemizes the final monthly payment to the 

MCO. This data file and subsequent report is produced by the APPS when final payments are 

calculated. CMS makes this report available to MCOs as part of month-end processing. 

The IPPR is provided when a Plan is approved for an interim payment outside of the normal 

monthly process. The data file/report contains the amount and reason for the interim payment to 

the Plan. 

F.25.1 

Header Record 

Item Field Position Length Type Definition 

1 Contract 

Number 

1-5 5 Character Contract Number 

2 Record 


Code 

6-6 1 Character Record Type Identifier 


3 Contract Name 7-56 50 Character Name of the Contract 

4 Payment Cycle 

Date 

57-62 6 Character Identified the month and year of payment: 

Format = YYYYMM 

5 Run Date 63-70 8 Character Identifies the date file was created: 

Format = YYYYMMDD 

6 Filler 71-200 130 Character Spaces 


December 28, 2012 F-129 PPR/IPPR Data File


F.25.2 

Capitated Payment – Current Activity 

Item Field Position Length Type Description 

7 Contract 

Number 

1-5 5 Contract Number 

8 Record 


Code 

9 Table ID 

Number 

10 Adjustment 

Reason Code 

6 1 Record Type Identifier 

C = Capitated Payment 

7 1 1 

8-9 2 Blank = for prospective pay 

For list of adjustment reasons codes consult 

section H.3 of the Medicare Advantage and 

Prescription Drug Plan Communication Guide. 

11 Part A Total 

Members 

12 Part B Total 

Members 

13 Part D Total 

Members 

14 Part A Payment 

Amount 

10-17 8 Numeric Number of beneficiaries Part A payments is being 

made prospectively. 

Format: ZZZZZZZ9 

18-25 8 Numeric Number of beneficiaries Part B payments is being 



26-33 8 Numeric Number of beneficiaries Part D payments is being 



34-46 13 Numeric Total Part A Amount 

Format: SSSSSSSSS9.99 

15 Part B Payment 

Amount 

47-59 13 Numeric Total Part B Amount 


16 Part D Payment 

Amount 

60-72 13 Numeric Total Part D Amount 


17 Coverage Gap 

Discount 

Amount 

73-85 13 Numeric The Coverage Gap Discount included in Part D 

Payment. 


18 Total Payment 86- 98 13 Numeric Total Payment 


19 Filler 99-200 102 Character Spaces 




F.25.3 

Premium Settlement 


20 Contract 

Number 

1-5 5 Character Contract Number 

21 Record 6 1 Character Record Type Identifier 


P = Premium Settlement 

Code 

22 Table ID 

Number 

7 1 Character 2 

23 Part C Premium 8-20 13 Numeric Total Part C Premium Amount 

Withholding 


Amount 

24 Part D Premium 21-33 13 Numeric Total Part D Premium Amount 

Withholding 


Amount 

25 Part D Low 

Income 

34-46 13 Numeric Total Low Income Premium Subsidy 


Premium 

Subsidy 

26 Part D Late 47-59 13 Numeric Total Late Enrollment Penalty 

Enrollment 


Penalty 

27 Total Premium 

Settlement 

60-72 13 Numeric Total Premium Settlement 


Amount 

28 Filler 73-200 128 Character Spaces 


F.25.4 

Fees 

Leng 

Item Field Position 

Type 

Description 

th 

29 Contract 1-5 5 Character Contract Number 

Number 

30 Record 6 1 Character Record Type Identifier 


F = FEES 

Code 

31 Table ID 7 1 Character 3 

Number 

32 NMEC Part A 

Subject to Fee 

33 NMEC Part A 

Rate 

34 Part A Fee 

Amount 

35 NMEC Part B 


36 NMEC Part B 

Rate 

8-20 13 Numeric Part A amount subject to National Medicare 

Educational Campaign fees. 

Format:ZZZZZZZZZ9.99 

21-27 7 Numeric Rate used to calculate the fees for Part A. 

Format: 0.99999 

28-40 13 Numeric Fee Assessed for Part A 

Format:SSSSSSSSS9.99 

41-53 13 Numeric Part B amount subject to National Medicare 


Format: ZZZZZZZZZ9.99 

54-60 7 Numeric Rate used to calculate the fees for Part B. 

Format: 0.99999 



Item Field Position 

Leng 

th 

Type 

Description 

37 Part B Fee 

Amount 

61-73 13 Numeric Fee Assessed for Part B 


38 NMEC Part D 


74-86 13 Numeric Part D amount subject to National Medicare 



39 NMEC Part D 

Rate 

87-93 7 Numeric Rate used to calculate the fees for Part D. 

Format: 0.99999 

40 Part D Fee 

Amount 

94-106 13 Numeric Fee Assessed for Part D 


41 Total NMEC 

Fee Assessed 

107- 119 13 Numeric Total NMEC Fee Assessed for Part A, B and D 


42 Total 

Prospective 

Part D 

Members 

43 Rate for COB 

Fees 

44 Amount of 

COB Fees 

45 Total of 

Assessed Fees 

120- 127 8 Numeric Total members for Part D 


128- 131 4 Numeric Rate used to calculate the COB fees. 

Format: 0.99 

132- 144 13 Numeric COB Fee 


145- 157 13 Numeric Total of all Fees Assessments 


46 Filler 158- 200 43 Character Spaces 


F.25.5 

Special Adjustments 


47 Contract 1 – 5 5 Character Contract Number 

Number 

48 Record 


6 – 6 1 Character Record Type Identifier 

S = Special Adjustments 

Code 

49 Table ID 7 – 7 1 Character 4 

Number 

50 Document ID 8 – 15 8 Numeric The document ID for identifying the adjustment. 

51 Source 16-20 5 Character The CMS division responsible for initiating the 

adjustments. 

52 Description 21 – 70 50 Character The reason the adjustment was made. 

53 Type 71 – 90 20 Character The payment component the adjustment is for: 

• CGD=Coverage Gap Discount Invoice 

• CMP=Civil Monetary Penalty 

• CST=Cost Plan Adjustment 

• PTD=Part D Risk Adjustment 

• PRS=Annual Part D Reconciliation 

• RAC=Recovery Audit Contract Adjustment 

• RSK=Risk Adjustment 

• HTC=HITECH Incentive Payment 

• OTH=default non-specific group. 




54 Adjustment to 

Part A 


Part B 


Part D or 

Adjustment to 

HITECH 

Incentive 

Payment 

57 Premium C 

Withholding 

Part A 

58 Premium C 

Withholding 

Part B 

59 Premium D 

Withholding 

60 Part D Low 

Income 

Premium 

Subsidy 

61 Total 

Adjustment 

Amount 

91 – 103 13 Numeric Adjustment amount for Part A 


104 – 116 13 Numeric Adjustment amount for Part B 


117 – 129 13 Numeric Adjustment amount for HITECH Incentive 

Payment when the adjustment type in data item 

53 is “HTC”. The adjustment amount is for Part 

D for the rest of the types. 


130 - 142 13 Numeric Adjustment amount for Premium Withholding 

Part A. 


143 – 155 13 Numeric Adjustment amount for Premium Withholding 

Part B. 


156 – 168 13 Numeric Adjustment amount for Premium D 

Withholding. 


169 - 181 13 Numeric Adjustment amount for Low Income Subsidy. 


182 – 194 13 Numeric Total Adjustments 


62 Filler 195 – 200 6 Character Spaces 


F.25.6 

Previous Cycle Balance Summary 


63 Contract Number 1 – 5 5 Character Contract Number 

64 Record 


Code 


L = Last Period Carry Over 

Amounts carried over to this month from 

previous months 

65 Table ID Number 7 – 7 1 Character 5 

66 Part A Carry 

Over Amount 

67 Part B Carry Over 

Amount 

68 Part D Carry Over 

Amount 

8 – 20 13 Numeric Part A Carry Over Amount from Table 5 ** - 

Previous Balance Column. 


21 – 33 13 Numeric Part B Carry Over Amount from Table 5 ** - 



34 – 46 13 Numeric Part D Carry Over Amount from Table 5 ** - 






69 Part C Premium 

Withholding 

Carry Over 

Amount 

70 Part D Premium 

Withholding 

Carry Over 

Amount 

71 Part D Low 

Income Premium 

Subsidy Carry 

Over Amount 


Enrollment 

Penalty Carry 

Over Amount 

73 Education User 

Fee Carry Over 

Amount 

74 Part D COB User 

Fee Carry Over 

Amount 

75 CMS Special 

Adjustments 

Carry Over 

Amount 

76 Total Carry Over 

Amount 

47 – 59 13 Numeric Part C Premium Withholding Carry Over 

Amount from Table 5 ** - Previous Balance 

Column. 


60 – 72 13 Numeric Part D Premium Withholding Carry Over 


Column. 


73 – 85 13 Numeric Part D Low Income Premium Subsidy Carry 

Over Amount from Table 5 ** - Previous Balance 

Column. 


86 – 98 13 Numeric Part D Late Enrollment Penalty Carry Over 


Column. 


99 – 111 13 Numeric Education User Fee Carry Over Amount from 

Table 5 ** - Previous Balance Column. 


112 – 124 13 Numeric Part D COB User Fee Carry Over Amount from 

Table 5 ** - Previous Balance Column. 


125 – 137 13 Numeric CMS Special Adjustments Carry Over Amount 

from Table 5 ** - Previous Balance Column. 


138 – 150 13 Numeric Sum of amounts in Previous Balance Column 


77 Filler 151 – 200 50 Character Spaces. 


F.25.7 Payment Summary 


78 Contract 

Number 

79 Record 


Code 

80 Table ID 

Number 

81 Part A 

Amount 

1 – 5 5 Character Contract Number 


A = Payment Summary 

Amounts included in this month’s payment 

from Tables 1 thru 4 plus Carry Over (from 

Previous Balance Column). 

7 – 7 1 Character 5 

8 – 20 13 Numeric Part A amount from Table 5 ** -Net Payment 

Column. 





82 Part B Amount 21 – 33 13 Numeric Part B amount from Table 5 ** -Net Payment 

Column. 


83 Part D 

Amount 

84 Part C 

Premium 

Withholding 

Amount 

85 Part D 

Premium 

Withholding 

Amount 

86 Part D Low 

Income 

Premium 

Subsidy 

Amount 


Enrollment 

Penalty 

Amount 

88 Education 

User Fee 

Amount 

89 Part D COB 

User Fee 

Amount 


Adjustments 

Amount 

91 Total Net 

Payment 

34 – 46 13 Numeric Part D amount from Table 5 ** -Net Payment 

Column. 


47 – 59 13 Numeric Part C Premium Withholding Amount from 

Table 5 ** -Net Payment Column. 


60 – 72 13 Numeric Part D Premium Withholding Amount from 



73 – 85 13 Numeric Part D Low Income Subsidy Amount from 



86 – 98 13 Numeric Part D Late Enrollment Penalty Amount from 



99 – 111 13 Numeric Education User Fee Amount from Table 5 ** - 

Net Payment Column. 


112 – 124 13 Numeric Part B COB Fee Amount from Table 5 ** -Net 

Payment Column. 


125 – 137 13 Numeric CMS Special Adjustments Amount from Table 

5 ** -Net Payment Column. 


138 – 150 13 Numeric Sum of amounts in Net Payment Column. This 

is the plan’s Net Payment Amount for this 

month. If the amount is negative, the payment 

will be carried forward. 






F.25.8 Payment Balance Carried Forward 

Item 

# 

Data Element Position Length Type Description 

93 Contract 

Number 

94 Record 


Code 

95 Table ID 

Number 

96 Part A Amount 

Carry Forward 

to Next Cycle 

97 Part B Amount 

Carry Forward 

to Next Cycle 

98 Part D Amount 

Carry Forward 

to Next Cycle 

99 Part C Premium 

Withholding 

Amount Carry 

Forward to 

Next Cycle 

100 Part D 

Premium 

Withholding 

Amount Carry 

Forward to 

Next Cycle 

101 Part D Low 

Income 

Premium 

Subsidy 

Amount Carry 

Forward to 

Next Cycle 


Enrollment 

Penalty 

Amount Carry 

Forward to 

Next Cycle 

103 Education User 

Fee Amount 

Carry Forward 

to Next Cycle 

104 Part D COB 

User Fee 

Amount Carry 

Forward to 

Next Cycle 

1 – 5 5 Character Contract Number 


N = Balance Carried Forward to Next Cycle. 

Amounts carried forward (and not paid) to next 

month from this month 

7 – 7 1 Character 5 

8 – 20 13 Numeric Part A Amount Carry Forward from Table 5 ** - 

Balance Forward Column. 


21 – 33 13 Numeric Part B Amount Carry Forward from Table 5 ** - 



34 – 46 13 Numeric Part D Amount Carry Forward from Table 5 ** - 



47 – 59 13 Numeric Part C Premium Withholding Amount Carry 

Forward from Table 5 ** -Balance Forward 

Column. 


60 – 72 13 Numeric Part D Premium Withholding Amount Carry 


Column. 


73 – 85 13 Numeric Part D Low Income Subsidy Amount Carry 


Column. 


86 – 98 13 Numeric Part D Late Enrollment Penalty Amount Carry 


Column. 


99 – 111 13 Numeric Education User Fee Amount Carry Forward 

from Table 5 ** -Balance Forward Column. 


112 – 124 13 Numeric Part B COB Fee Amount Carry Forward from 

Table 5 ** -Balance Forward Column. 




Item 

# 

Data Element Position Length Type Description 


Adjustments 

Amount Carry 

Forward to 

Next Cycle 

106 Total Carry 

Forward 

Amount 

125 – 137 13 Numeric CMS Special Adjustments Amount Carry 


Column. 


138 – 150 13 Numeric Sum of amounts in Balance Forward Column 






F.26 Long-Term Institutionalized (LTI) Resident Report Data File 

The LTI Resident Report provides Part D sponsors with a list of their beneficiaries who are LTI 

residents during July and January annually. This report contains basic information on the 

beneficiaries and their institutions, i.e., Skilled Nursing Home or Nursing Home. 

This new report provides information to Part D Sponsors on which of their enrollees are 

institutionalized, as well as the names and addresses of the particular long-term care (LTC) 

facilities in which those beneficiaries reside. This information is obtained by linking Medicare 

enrollment information with data from the Minimum Data Set (MDS) of nursing home 

assessments. The list of beneficiaries represents those who are LTI residents as of July and 

January annually with a reported length of stay of more than 90 days. 

The file is sent via HPMS to Part D sponsors in late April and late September. The report is 

provided in a fixed-length text format and the record layout is described below. 

Item 

Field 

Field 

Type 

1 Part D Contract Number CHAR 5 1-5 

2 Part D Plan Number CHAR 3 6-8 

3 Part D Plan Name CHAR 50 9-58 

Length Position Description 

Part D Contract Number associated with 

the resident during the month of the last 

nursing home assessment date. 

Part D Plan Number associated with the 

resident during the month of the last 


Part D Plan Name associated with the 

resident during the month of the last 


4 Last Name CHAR 24 59-82 Beneficiary Last Name 

5 First Name CHAR 15 83-97 Beneficiary First Name 

6 HICN CHAR 12 98109 HICN associated with the resident. 

7 Date of Birth DATE 8 110-117 

Beneficiary’s Date of Birth 

CCYYMMDD – Format 

8 Gender CHAR 1 118 

Beneficiary Gender Code 

1 = Male 

2 = Female 

0 = Unknown 

9 Nursing Home Length of Stay CHAR 6 119-124 

Nursing Home Length of Stay in days 

(0 – 999999) at the time of the last 

Nursing Home assessment. 

December 28, 2012 F-138 LTI Resident Report Data File


Item 

Field 

Field 

Type 

Length Position Description 

10 Nursing Home Admission Date DATE 8 125-132 

11 

Last Nursing Home 

Assessment Date 

DATE 8 133-140 

12 Part A Indicator CHAR 1 141 

13 Nursing Home Name CHAR 50 142-191 

14 Medicare Provider ID CHAR 12 192-203 

15 Provider Telephone Number CHAR 13 204-216 

16 Provider Address CHAR 50 217-266 

17 Provider City CHAR 20 267-286 

18 Provider State Code CHAR 2 287-288 

19 Provider Zip Code CHAR 11 289-299 


Admission date associated with the last 

assessment for the resident. 


Target date of the last assessment for 

the resident. 


Reason for assessment (AA8B) 

associated with the last assessment for 

the resident. 

0 = No 

1 = Yes 

Name of Nursing Home associated with 

the last assessment for the resident. 

Medicare Provider ID of Nursing Home 


the resident. 

Telephone Number of Nursing Home 


the resident. 

Address of Nursing Home associated 

with the last assessment for the resident. 

City of Nursing Home associated with 

the last assessment for the resident. 

State Code of Nursing Home associated 


Zip Code of Nursing Home associated 


December 28, 2012 F-139 LTI Resident Report Data File


F.27 Agent Broker Compensation Report Data File 

For Plan enrollments, MARx establishes a status of initial or renewal as well as a six-year 

compensation cycle, which provides Plans with the information necessary to determine how to 

pay agents for specific Beneficiary enrollments. Plans can pay agents an initial amount or a 

renewal amount as provided in the CMS agent compensation guidance. 

Based on the qualification rules, year 1 is the initial year and years 2 through 6 are the renewal 

years. Plans are responsible for using this information in conjunction with their internal payment 

and enrollment tracking systems to determine an agent’s use and how much to pay the agent. 

The Agent Broker Compensation Report Data File is generated and sent to Plans along with the 

first DTRR of each calendar month. 

Item Field Length Position Description 

1 

Contract 

Number** 

5 1-5 Contact identification 

2 PBP 3 6-8 Plan Benefit Package 

3 HICN 12 9-20 HICN, composed of CAN and BIC 

4 First Name 30 21-50 Beneficiary first name 

5 Middle Name 15 51-65 Beneficiary middle name 

6 Last Name 40 66-105 Beneficiary last name 


8 

9 

10 

Enrollment 

Effective Start 

Date 

Cycle-Year as 

of Enrollment 

Effective Start 

Date 

Report 

Generation Date 



8 290-297 

Date Beneficiary's Plan enrollment starts, YYYYMMDD – 

Format. 

Numeric value representing the broker compensation cycle-year 

count as of enrollment effective start date: 

'1' = first calendar year, 

'2' = second calendar year, 

'3' = third calendar year, 

'4' = fourth calendar year, 

'5' = fifth calendar year, 

'6' = sixth calendar year. 

Date report created 


December 28, 2012 F-140 Agent Broker Compensation Report

Item 

# 


Field Name Length Position Description 

Numeric value representing the broker compensation cycle-year 

as of the report generation date: 

11 

Cycle-Year as 

of Report 

Generation Date 

3 298-300 

‘-1’ = no compensation cycle exists for this enrollment because the 

report generation date does not fall within the enrollment period. 

This occurs for both the prospective and retroactive enrollments. 

‘0’ = reporting date falls within the enrollment period but the 

compensation cycle completed in a prior year, 

'1' = first calendar year, 

'2' = second calendar year, 

'3' = third calendar year, 

'4' = fourth calendar year, 

'5' = fifth calendar year, 

'6' = sixth calendar year. 

Broad classification of Beneficiary's immediately prior Plan-type: 

"None" = no prior Plan, 

"MA" = non-drug MA Plan, 

12 Prior Plan Type 7 301-307 

"MAPD" = MA Plan offering prescription drugs, 

"COST" = Non-drug Medicare COST Plan, 

"COST/PD" = Medicare COST Plan providing prescription drugs, 

"PDP" = PDP and sometimes representative of a POS transaction, 

"PACE" = Program for All-inclusive Care of the Elderly 



December 28, 2012 F-141 Agent Broker Compensation Report


F.28 Monthly Medicare Second Payer (MSP) Information Data File 

The Monthly MSP Information data file is sent directly to Plans on the first Monday after the 

MARx month-end processing completes. This file contains a subset of information to assist Plans 

with reconciling payment; the full monthly MSP COB file distributed at the beginning of each 

month contains more detail. 

F.28.1 

Header Record 

FIELD NAME SIZE POSITION TYPE COMMENTS 

Header Code 8 1-8 CHAR 

File/record identification purposes only, 

'CMSMSPIH'. 

Sending Entity 3 9-11 CHAR Hard Coded as 'MBD' 

File Creation Date 8 12-19 ZD CCYYMMDD – Format 

Filler 481 20-500 CHAR All spaces 



Detail Record 

FIELD NAME SIZE POSITION TYPE COMMENTS 

RRB-HIC-NUM 12 1-12 CHAR Use RRB_HIC_NUM if available; else, use 

first 9 bytes mapped to BENE_CAN_NUM; 

next 2 bytes mapped to BIC_CD ; 12th byte is 

a space 

Date of Birth 8 13-20 CHAR CCYYMMDD FORMAT 

Gender Code 1 21 CHAR 

Direct Mapping: 0 = Unknown, 1 = Male, 2 = 

Female 

Contract Number 5 22-26 CHAR Direct Mapping 

PBP Number 3 27-29 CHAR Direct Mapping 

MSP Coverage 


8 30-37 INT CCYYMMDD FORMAT 

MSP Coverage 

Termination Date 

8 38-45 INT CCYYMMDD FORMAT 

Primary Insurance 

Code 

COB Contractor 

Number 

1 46 CHAR 

Convert as follows: 

12…A (Working Aged) 

13…B (ESRD) 

43…G (Disabled) 

5 47-51 CHAR Direct Mapping 

Insurer Name 32 52-83 CHAR Direct Mapping 

Insurer Address Line 1 32 84-115 CHAR Direct Mapping 

Insurer Address Line 2 32 116-147 CHAR Direct Mapping 

Insurer City name 15 148-162 CHAR Direct Mapping 

Insurer State Code 2 163-164 CHAR Direct Mapping 

Insurer Zip Code 9 165-173 CHAR Direct Mapping 

Policy Number 17 174-190 CHAR Direct Mapping 

Filler 310 191-500 CHAR Hard Coded as Spaces 


December 28, 2012 F-142 MSP Information Data File




FIELD NAME SIZE POSITION SIZE COMMENTS 

Trailer Code 8 1-8 CHAR 


'CMSMSPIT'. 

Sending Entity 3 9-11 CHAR Hard Coded as 'MBD' 


Detail Record Count 9 20-28 ZD 

Number of detail records, excluding header 

and trailer 



December 28, 2012 F-143 MSP Information Data File


F.29 Other Health Coverage Information Data File 

CMS provides Plans with a file listing the beneficiaries who are enrolled in their Plan(s) where 

Medicare is listed secondary. As a monthly report, this vehicle provides Plans with regular 

updates to the MSP data. 

F.29.1 

Header Record 

Field Size Position Type Comments 

Header Code 8 1-8 CHAR 


'CMSMSPDH'. 

Sending Entity 8 9-16 CHAR Hard Coded as 'MBD ' (MBD + 5 spaces) 




F.29.2 

Detail Record 


CAN 12 1-12 CHAR Beneficiary HICN/RRB number 

BIC 2 13-14 CHAR Beneficiary HICN/RRB number 

MSP Data – Occurs 17 times 

Delete Indicator 1 15 CHAR D – Occurrence in process of deletion 

Validity Indicator 1 16 CHAR 

MSP Code 1 17 CHAR 

Validity of MSP Coverage 

Y = Beneficiary has MSP Coverage 

N = Beneficiary does not have MSP Coverage 

MSP Coverage Type 

A-Working Aged 

B-ESRD 

D-No-Fault 

E-Workers' Compensation 

F-Federal (Public Health) 

G-Disabled 

H-Black Lung 

I-Veterans 

L-Liability 

W-Worker’s Compensation Set Aside 

Contractor Number 5 18-22 CHAR Identifies Contractor Establishing Entry 

Data Entry Added 8 23-30 ZD Date Entry created (CCYYMMDD) 

Updating Contractor 5 31-35 CHAR Identifies Contractor that updated entry 

December 28, 2012 F-144 Other Health Coverage 

Information Data File



Maintenance Date 8 36-43 ZD Date Entry created (CCYYMMDD) 

CWF Occurrence Number 2 44-45 ZD Number of occurrence as provided by CWF 

Filler 4 46 – 49 CHAR Spaces 

Insurer Type 1 50 CHAR 

Type of Primary Insurer 

A – M, Spaces 

Insurer’s Name 32 51-82 CHAR Primary Insurer’s Name 

Insurer’s Address -1 32 83-114 CHAR Primary Insurer’s Address Line 1 

Insurer’s Address -2 32 115-146 CHAR Primary Insurer’s Address Line 2 

Insurer’s City 15 147-161 CHAR Primary Insurer’s City 

Insurer’s State Code 2 162-163 CHAR Primary Insurer’s State Code 

Insurer’s Zip Code 9 164-172 CHAR Primary Insurer’s Zip Code 

Policy Number 17 173-189 CHAR Primary Insurance Policy Number of Insured 

MSP Effective Date 8 190-197 CHAR 

Effective Date of MSP Coverage 

(CCYYMMDD) 

MSP Termination 8 198-205 ZD 

Termination Date of MSP Coverage 

(CCYYMMDD) 

Patient Relationship 2 206-207 CHAR 

Relationship of Patient to Insured 

01-Patient is Ins 

02-Spouse 

03-Natural Child, Insured has Financial 

Responsibility 

04-Natural Child, Insured does not have 

Financial Responsibility 

05-Step Child 

06-Foster Child 

07-Ward of the Court 

08-Employee 

09-Unknown 

10-Handicapped Dependent 

11-Organ Donor 

12-Cadaver Donor 

13-Grandchild 

14-Niece/Nephew 

15-Injured Plaintiff 

16-Sponsored Dependent 

17-Minor Dependent of a Minor Dependent 

18-Parent 

19-Grandparent dependent 

20-Life Partner 

Subscriber First Name 9 208-216 CHAR First Name of Policy Holder 

Subscriber Last Name Policy 

holder 

16 217-232 CHAR Last Name of Policy Holder 





Employee ID Number 12 233-244 CHAR Employee ID Number assigned by Employer 

Source Code 2 245-246 CHAR 

First Byte of Source Code: 

A-Claim Processing 

B-IRS/SSA/CMS Data Match 

C-First Claim Development 

D-IRS/SSA/CMS Data Match II 

E-Black Lung (DOL) 

F-Veterans (VA) 

G-Other Data Matches 

H-Worker's Compensation 

I-Notified by Beneficiary 

J-Notified by Provider 

K-Notified by Insurer 

L-Notified by Employer 

M-Notified by Attorney 

N-Notified by Group Health Plan/Primary 

Payer 

O-Initial Enrollment Questionnaire 

P-HMO Rate Cell Adjustment 

Q-Voluntary Insurer Reporting 

R-Office of Personnel Management Data 

Match 

S-Miscellaneous Reporting 

T-IRS/SSA/CMS Data Match III 

U-IRS/SSA/CMS Data Match IV 

V-IRS/SSA/CMS Data Match V 

W-IRS/SSA/CMS Data Match VI 

X-Self reports 

Y-411.25 

SPACES-Unknown 

Second Byte of Source Code: 

0-COB Contractor 

1-Initial Enrollment questionnaire 

2-IRS/SSA/CMS/data match 

3-HMO Rate cell 

4-Litigation settlement 

5-Employer Voluntary Reporting 

6-Insurer Voluntary Reporting 

7-First claim development 

8-Trauma Code development 

9-Secondary claims investigation 

Employee Data Code 1 247 CHAR 

To Whom the Employment Data Applies: 

P-Patient 

S-Spouse 

M-Mother 

F-Father 

Employer Name 32 248-279 CHAR Employer providing coverage 

Employer’s Address1 32 280-311 CHAR Employer’s Street Address 1 

Employer’s Address2 32 312-343 CHAR Employer’s Street Address 2 





Employer’s City 15 344-358 CHAR Employer’s City 

Employer’s State 2 359-360 CHAR Employer’s State 

Employer’s Zip Code 9 361-369 CHAR Employer’s Zip Code 

Insurance Group Number 20 370-389 CHAR Group Number Assigned by Primary Payer 

Insurance Group 17 390-406 CHAR Name of Group Plan 

Prepaid Health Plan Date 8 407-414 ZD 

Date Beneficiary notified that Medicare is 

secondary payer for services performed 

outside the prepaid health Plan when a prepaid 

health Plan provider can perform the services. 

(CCYYMMDD) 

Remarks Code -1 2 415-416 CHAR 

'1-3', '01-12', '20-26', '30-44', '50-62', '70-72', 

and spaces 


'1-3', '01-12', '20-26', '30-44', '50-62', '70-72', 



'1-3', '01-12', '20-26', '30-44', '50-62', '70-72', 


Diagnosis Codes – Occurs 25 Times 

Diagnosis Code Indicator 1 421 CHAR ‘9’ – ICD-9 code default 

Diagnosis Code 7 422-428 CHAR Diagnosis code ICD-9 

Diagnosis Code Occurrence 2 8 429-436 CHAR 








Diagnosis Code Occurrence 

10 

8 493-500 CHAR 


11 

8 501-508 CHAR 


12 

8 509-516 CHAR 


13 

8 517-524 CHAR 


14 

8 525-532 CHAR 


15 

8 533-540 CHAR 


16 

8 541-548 CHAR 


17 

8 549-556 CHAR 


18 

8 557-564 CHAR 


19 

8 565-572 CHAR 

Diagnosis Code Occurrence 8 573-580 CHAR 





20 


21 

8 581-588 CHAR 


22 

8 589-596 CHAR 


23 

8 597-604 CHAR 


24 

8 605-612 CHAR 


25 

8 613-620 CHAR 

Payer ID 10 621-630 CHAR 

MSP Data Occurrence 

Number 2 

616 631-1246 CHAR 


Number 3 

616 1247-1862 CHAR 


Number 4 

616 1863-2478 CHAR 


Number 5 

616 2479-3094 CHAR 


Number 6 

616 3095-3710 CHAR 


Number 7 

616 3711-4326 CHAR 


Number 8 

616 4327-4942 CHAR 


Number 9 

616 4943-5558 CHAR 


Number 10 

616 5559-6174 CHAR 


Number 11 

616 6175-6790 CHAR 


Number 12 

616 6791-7406 CHAR 


Number 13 

616 7407-8022 CHAR 


Number 14 

616 8023-8638 CHAR 


Number 15 

616 8639-9254 CHAR 


Number 16 

616 9255-9870 CHAR 


Number 17 

616 9871-10486 CHAR 

Filler 515 

10487- 

11000 





F.29.3 


FIELD NAME SIZE POSITION SIZE COMMENTS 

Trailer Code 8 1-8 CHAR 

Sending Entity 8 9-16 CHAR 


'CMSMSPDT'. 

Identifies the sending entity, ‘MDB “ (MBD 

+ 5 spaces” 


Record Count 7 25-31 ZD Total number of detail records 






F.30 No Premium Due Data File Layout 

MA enrollees who elect optional supplemental benefits may also elect SSA premium 

withholding. In mid-November, MARx begins preparing the premium records for the next year. 

Since MARx cannot anticipate which optional premiums an enrollee may elect for next year, an 

enrollee only paying optional premiums may convert from “SSA Premium Withholding” status 

in one year to “No Premium Due” status for the next year. Plans should use the No Premium Due 

Data File to identify enrollees in a “No Premium Due” status for the next year. Plans should 

review the report and submit both a Part C Premium Update (TC 78) to update the Part C 

premium Amount, and a PPO Update (TC 75) to request SSA Withholding Status, for enrollees 

who are renewing both elections for the next year. 


HICN 12 1-12 Health Insurance Claim Number 

Surname 12 13-24 Beneficiary Surname 

First Name 7 25-31 Beneficiary Given Name 

Middle Initial 1 32 Beneficiary Middle Initial 

Gender Code 1 33 Beneficiary Gender Identification Code 


‘1’ = Male; 


Date of Birth 8 34-41 YYYYMMDD – Format 

Filler 1 42 Space 

Contract Number 5 43-47 Plan Contract Number 

State Code 2 48-49 Spaces 

County Code 3 50-52 Spaces 

Disability Indicator 1 53 Space 

Hospice Indicator 1 54 Space 

Institutional/NHC Indicator 1 55 Space 

ESRD Indicator 1 56 Space 

TRC 3 57-59 TRC Defaulted to ‘267’ 

Transaction Code 2 60-61 TC Defaulted to ‘01’ for special reports 

Entitlement Type Code 1 62 Space 

Effective Date 8 63-70 YYYYMMDD – Format; Example: 20110101 (set to first 

of January of the upcoming year) 

WA Indicator 1 71 Space 

PBP ID 3 72-74 PBP number 

Filler 1 75 Space 

Transaction Date 8 76-83 YYYYMMDD – Format; Set to the report generation date. 

UI Initiated Change Flag 1 84 Space 

FILLER 12 85-96 Spaces 

District Office Code 3 97-99 Spaces 

Previous Part D Contract/PBP 8 100-107 Spaces 

for TrOOP Transfer. 

End Date 8 108-115 Spaces 

Source ID 5 116-120 Spaces 

Prior PBP ID 3 121-123 Spaces 

Application Date 8 124-131 Spaces 

December 28, 2012 F-150 No Premium Due Data 

File Layout



UI User Organization 

2 132-133 Spaces 

Designation 

Out of Area Flag 1 134 Space 

Segment Number 3 135-137 Further definition of PBP by geographic boundaries; 

Default to ‘000’ when blank. 

Part C Beneficiary Premium 8 138-145 Part C Premium Amount: Since this report is only reporting 

on Beneficiaries that have No Premium Due, by definition, 

this amount is zero 

Part D Beneficiary Premium 8 146-153 Part D Premium Amount: Since this report is only reporting 

on Beneficiaries that have No Premium Due, by definition, 

this amount is zero 

Election Type 1 154 Space 

Enrollment Source 1 155 Space 

Part D Opt-Out Flag 1 156 Space 

Premium Withhold Option/Parts 1 157 ‘N’ = No premium applicable; 

C-D 

Number of Uncovered Months 3 158-160 Spaces 

Creditable Coverage Flag 1 161 Space 

Employer Subsidy Override Flag 1 162 Space 

Processing Timestamp 15 163-177 The report generation time. Format: HH.MM.SS.SSSSSS 

Filler 20 178-197 Spaces 

Secondary Drug Insurance Flag 1 198 Space 

Secondary Rx ID 20 199-218 Spaces 

Secondary Rx Group 15 219-233 Spaces 

EGHP 1 234 Space 

Part D LIPS Level 3 235-237 Spaces 

Low-Income Co-Pay Category 1 238 Space 

Low-Income Period Effective 8 239-246 Spaces 

Date 

Part D LEP Amount 8 247-254 Spaces 

Part D LEP Waived Amount 8 255-262 Spaces 

Part D LEP Subsidy Amount 8 263-270 Spaces 

Low-Income Part D Premium 

Subsidy Amount 

8 271- 

278 

Spaces 

Part D Rx BIN 6 279-284 Spaces 

Part D Rx PCN 10 285-294 Spaces 

Part D Rx Group 15 295-309 Spaces 

Part D Rx ID 20 310-329 Spaces 

Secondary Rx BIN 6 330-335 Spaces 

Secondary Rx PCN 10 336-345 Spaces 

De Minimis Differential Amount 8 346-353 Spaces 

MSP Status Flag 1 354 Space 

Low Income Period End Date 8 355-362 Spaces 

LIS Source Code 1 363 Space 

Enrollee Type Flag, PBP Level 1 364 Space 

Application Date Indicator 1 365 Space 

Filler 135 366-500 Spaces 


December 28, 2012 F-151 No Premium Due Data 

File Layout


F.31 Failed Payment Reply Report (FPRR) Data File 

Along with the other monthly payment reports, MARx generates the FPRR. If payment 

calculation for a beneficiary cannot complete, MARx identifies the beneficiary and time period 

for which the payment calculation is not performed. The records in this file are the same length 

as those in the TRR and contain their own unique reply codes. 


1.HICN 12 1-12 Beneficiary’s HICN, included with PRC 264 

2. Surname 12 13-24 Beneficiary’s last name, included with PRC 264 

3. First Name 7 25-31 Beneficiary’s given name, included with PRC 264 

4. Middle Name 1 32 First initial of beneficiary’s middle name, included with PRC 264 

5. Gender Code 1 33 Beneficiary’s gender identification code, included with TRC 264: 

‘0’ = Unknown, ‘1’ = Male, ‘2’ = Female 

6. Date of Birth 8 34-41 Beneficiary’s birth date, formatted YYYYMMDD, included with 

PRC 264 

7. FILLER 1 42 Spaces 

8. Contract Number 5 43-47 Plan Contract Number, included with TRC 000 and TRC 264 

9. State Code 2 48-49 Beneficiary’s residence SSA state code, included with TRC 264; 

otherwise, spaces if not available 

10. County Code 3 50-52 Beneficiary’s residence SSA county code, included with TRC 264; 


11. FILLER 4 53-56 Spaces 

12. Payment Reply 

Code 

3 57-59 “000” = no missing payments; “264” = payment not yet completed 

“299” = Correction to Previously Failed Payment 


14 Effective Date 8 63-70 Enrollment effective date, formatted YYYYMMDD and included 

with TRC 264 


16. PBP ID 3 72-74 PBP number, included with both TRC 000 and TRC 264 


18. Transaction Date 8 76-83 Report generation date, formatted YYYYMMDD and included with 

both TRC 000 and TRC 264 


20. CPM 12 85- 96 CPM, formatted YYYYMM, left justified with six spaces 

completing the field, and included with both TRC 000 and TRC 

264, and TRC 299 


22. Segment Number 3 135-137 Segment in PBP, included with TRC 264 


24. Processing 

Timestamp 

15 163-177 Report generation time, formatted HH.MM.SS.SSSSSS and 

included with both TRC 000 and TRC 264 


26. PRC Short Name 15 366-380 TRC short name associated with TRC 000 is “NO REPORT,” with 

TRC 264 is “NO PAYMENT,” and with TRC 299 is “RESTORED 

PYMT.” Text is left justified with following spaces completing the 

field. 



December 28, 2012 F-152 FPRR Data File


F.32 Missing Payment Exception Report (MPER) Data File 

Along with the other monthly payment reports, MARx generates a Plan communication in a 

report named the MPER. If payment calculation for a beneficiary cannot complete, MARx 

identifies the beneficiary and time period for which the payment calculation was not performed. 


1 Claim Number 12 1 – 12 Beneficiary’s HICN, included with TRC-264 

2 Surname 12 13 – 24 Beneficiary’s last name, included only with TRC-264 

3 First Name 7 25 – 31 Beneficiary’s given name, included when TRC-264 

4 Middle Name 1 32 First initial of beneficiary’s middle name, included with TRC-264 

5 Sex Code 1 33 Beneficiary’s gender identification code, included with TRC-264: 

‘0’ = Unknown 

‘1’ = Male 

‘2’ = Female 

6 Date of Birth 8 34 – 41 Beneficiary’s birth date, formatted YYYYMMDD, included with 

TRC-264 

7 FILLER 1 42 Spaces 

8 Contract Number 5 43 – 47 Plan Contract Number, included with both TRC-000 and TRC- 

264 

9 State Code 2 48 – 49 Beneficiary’s residence SSA state code, included with TRC-264; 


10 County Code 3 50 – 52 Beneficiary’s residence SSA county code, included with TRC- 

264; otherwise, spaces if not available 

11 FILLER 4 53-56 Spaces 

12 TRC 3 57 – 59 “000” = no missing payments 

“264” = payment not completed 

13 FILLER 3 60 - 62 Spaces 

14 Effective Date 8 63 – 70 Enrollment effective date, formatted YYYYMMDD and include 

with TRC-264 


16 PBP ID 3 72 – 74 PBP number, included with both TRC-000 and TRC-264 


18 Transaction Date 8 76 – 83 Report generation date, formatted YYYYMMDD and included 

with both TRC-000 and TRC-264 


20 Current Payment 

Month 

12 85 – 96 CPM formatted YYYYMM, left justified with six spaces 

completing the field, and included with both TRC-000 and TRC- 

264 

21 FILLER 38 97 – 134 Spaces 

22 Segment Number 3 135 – 137 Segment in PBP, included with TRC-264 

23 FILLER 25 138 – 162 Spaces 

24 Processing 

Timestamp 

15 163 – 177 Report generation time, formatted HH.MM.SS.SSSSSS and 

included with both TRC-000 and TRC-264 

25 FILLER 188 178 – 365 Spaces 

26 TRC Short Name 15 366 - 380 TRC short name associated with TRC-000 is “NO REPORT” and 

with TRC_264 is “NO PAYMENT.” Text is left justified with 

following spaces completing the field. 

27 FILLER 120 381 - 500 Spaces 


December 28, 2012 F-153 MPER Data File


G: Screen Hierarchy 

The Common User Interface (UI) screens are accessed via the drill-down method of navigation. 

Functions are grouped together under a common menu item. For example, most of the 

Beneficiary-specific information is found under the Beneficiary menu item. Table G-1 lists the 

names of the Common UI screens accessible to Managed Care Organizations (MCOs) and their 

screen numbers, for reference only. 

Table G-1: Screen Lookup Table 

Screen Name 

Logon, Logoff, and Welcome Screens 

MARx Logout 

User Security Role Selection 

Welcome 

MARx Calendar 

Beneficiaries Screens 

Beneficiaries: Find 

Beneficiaries: Search Results 

Beneficiary Detail: Snapshot 

Beneficiary Detail: Enrollment 

Beneficiary Detail: Status 

Beneficiary Detail: Payments 

Beneficiary Detail: Adjustments 

Beneficiaries: New Enrollment 

Payment/Adjustment Detail 

Beneficiary Detail: Factors 

Beneficiaries: Update Enrollment 

Enrollment Detail 

Beneficiary Detail: Update Premiums 

Rx Insurance View 

Beneficiaries: Additional Update Enrollment 

Beneficiary Detail: Premiums 

Beneficiaries: Eligibility 

Beneficiary Detail: Utilization 

Part D AE-FE Opt-Out 

Beneficiary Detail: MSA Lump Sum 

Beneficiary Detail: Medicaid 

Beneficiary Detail: SSA/RRB Transaction Status 

Update Premium Withhold Collection 

Update SSA R&R 

Update Residence Address View 

Residence Address View 

Rx Insurance View 

Transactions Screens 

M002 

M101 

M105 

M201 

M202 

M203 

M204 

M205 

M206 

M207 

M212 

M215 

M220 

M221 

M222 

M226 

M228 

M230 

M231 

M232 

M233 

M234 

M235 

M236 

M237 

M240 

M241 

M242 

M243 

M244 

Screen Number 

December 30, 2012 G-1 Screen Hierarchy


Screen Name 

Transactions: Batch Status 

Batch File Details 

Special Batch Approval Request 

View Special Batch File Request 

Payments Screens 

Payments: MCO 

Payments: MCO Payments 

Payments: Beneficiary 

Payments: Beneficiary Search Results 

Beneficiary Payment History 

Adjustment Detail 

Payments: Premiums and Rebates 

Reports Screens 

Reports: Find 

Reports: Search Results 

Screen Number 

M307 

M314 

M316 

M317 

M401 

M402 

M403 

M404 

M406 

M408 

M409 

M601 

M602 

December 30, 2012 G-2 Screen Hierarchy


H: Validation Messages 

Table H-1 lists validation messages that appear directly on the screen during data 

entry/processing in the status line (the line just below the title line, as in Figure H-1). 

Figure H-1: Validation Message Placement on Screen 

These are common validation messages, not specific to a single screen but related to the fields 

that appear on many screens. Note that screen/function-specific messages appear in the section 

related to the specific function and are associated with the specific screen. 

Table H-1: Validation Messages 

Error Messages 

User must enter a contract number 

A contract number must start with an ‘E’, ‘H’, ‘R’, 

‘S’, ‘X,’ or ‘9’, followed by four characters 

User must enter a sex 

User must select a state 

Invalid Contract/PBP combination 

Invalid Contract/PBP/segment combination 

is invalid. Must have format 

(M)M/(D)D/YYYY 

User must enter 

PBP number must have three alphanumeric characters 

Please enter at least one of the required fields 

Please enter user ID or password 

Segment number must have three digits 

The claim number is not a valid SSA or RRB number, 

or CMS Internal number 

The last name contains invalid characters 

The user ID contains invalid characters 

You do not have access rights to this contract 

Suggested Action 

Enter the field specified by the message. 

Re-enter the field and follow the format indicated in the 

message. 



Check the combination and re-enter. 

Check the combination and re-enter. 


message. 



message. 

Make sure to enter all the required fields. 

Make sure to enter one of the fields specified by the 

message. 


message. 

Re-enter the field in SSA, RRB, or CMS Internal 

format. 

Re-enter the field using only letters, apostrophes, 

hyphens, or blanks. 


message. 

First, make sure that the Contract # correctly is entered 

correctly. If not, re-enter it. If the user did, he/she 

should have rights to this contract; see the Security 

Administrator who can update the user profile for these 

rights. 

December 28, 2012 H-1 Validation Messages




ii


I: Codes 

This appendix lists the numerical value and descriptions for codes that are highly visible to users. 

I.1 Transaction Codes 

Table I-1 lists the Medicare Advantage and Prescription Drug System (MARx) Transaction Codes and the description of each code. 

Table I-1: Transaction Codes 

Code 

Description 

01 MCO Correction 

30 Turn Bene-Level Demonstration Factor On (Demos Only) 

31 Turn Bene-Level Demonstration Factor Off (Demos Only) 

41 Update to Opt-Out Flag (Submitted by CMS) 

42 MMP Opt-Out Change (Submitted by 1-800 MEDICARE) 

51 Disenrollment (MCO or CMS) 

54 Disenrollment (Submitted by 1-800-MEDICARE) 

61 Enrollment 

72 4Rx Record Update 

73 NUNCMO Record Update 

74 EGHP s Record Update 

75 Premium Payment Option (PPO) Update 

76 Residence Address Record Update 

77 Segment ID Record Update 

78 Part C Premium Record Update 

79 Part D Opt-Out Record Update 

80 Cancellation Enrollment 

81 Cancellation Disenrollment 

82 MMP Enrollment Cancellation 

83 MMP Opt-Out Update 

December 28, 2012 I-1 Transaction Codes (TCs)


I.2 Transaction Reply Codes 

Table I-2 lists the reply codes returned for transactions found in Table I-1. 

Transaction Reply Code (TRC) Types: 

A - Accepted - A transaction is accepted and the requested action is applied (Example: enrollment or disenrollment) 

R - Rejected - A transaction is rejected due to an error or other condition. The requested action is not applied to the 

CMS System. The TRC indicates the reason for the transaction rejection. The Plan should analyze the 

rejection to validate the submitted transaction and to determine whether to resubmit the transaction with 

corrections. 

I - 

M - 

Informational - These replies accompany Accepted TRC replies and provide additional information about the 

transaction or Beneficiary. For example: If an enrollment transaction for a Beneficiary who is “out of 

area” is accepted, the Plan receives an accepted TRC (TRC 011) and an additional reply is included in 

the Transaction Reply Report (TRR) that gives the Plan the additional information that the Beneficiary 

is “Out of Area” (TRC 016). 

Maintenance - These replies provide information to Plans about the Beneficiaries enrolled in their Plans. They are sent 

in response to information received by CMS. For example: If CMS is informed of a change in a 

Beneficiary’s claim number, a reply is included in the Plan’s TRR with TRC 086, giving the Plan the 

new claim number. 

F - Failed - A transaction failed due to an error or other condition and the requested action did not occur. The TRC 

code indicates the reason for the transaction’s failure. The Plan should analyze the failed transaction and 

determine whether to resubmit with corrections. 

Legend for Type: A = Accepted R = Rejected I = Informational M = Maintenance F = Failed 

December 28, 2012 I-2 Transaction Reply Codes (TRCs)


Table I-2: Transaction Reply Codes 

Code Type Title Short Definition Definition 

000 I No Data to 

Report 

001 F Invalid 

Transaction 

Code 

002 F Invalid 

Correction 

Action Code 

003 F Invalid 

Contract 

Number 

NO REPORT 

BAD TRANS 

CODE 

BAD ACTION 

CODE 

BAD CONTRACT 

# 

This TRC can appear on both the Daily Transaction Reply Report (DTRR) and the Failed Payment 

Reply Report (FPRR) data files. 

On the TRR it indicates that none of the following occurred during the reporting period for the given 

contract/PBP, a beneficiary status change, user interface (UI) activity, or CMS or plan transaction 

processing. The reporting period is the span between the previous TRR and the current TRR. 

On the FPRR it indicates the presence of all prospective payments for the plan (contract/PBP), none 

are missing. 

Plan Action: None 

A transaction failed because the Transaction Code (field 16) contained an invalid value. 

Valid Transaction Code values are 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81. This transaction 

should be resubmitted with a valid Transaction Code. 

Note: Transaction Types 41 and 54 are valid but not submitted by the Plans. 

This TRC will be returned in the Batch Completion Status Summary (BCSS) Report along with the 

failed record and is not returned in the TRR. 

Plan Action: Correct the Transaction Code and resubmit if appropriate. 

A correction transaction (Transaction Type 01) failed because the supplied action code was an 

invalid value. The valid action code values are D, E, F and G. The transaction should be resubmitted 

with a valid action code. 

This TRC is returned in the Batch Completion Status Summary (BCSS) Report along with the failed 

record. This TRC is not returned in the TRR. 

Plan Action: Correct the Action Code and resubmit if appropriate. 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) failed because 

CMS did not recognize the contract number. 

This TRC is returned in the BCSS Report along with the failed record. This TRC is not returned in 

the TRR. 

Plan Action: Correct the Contract Number and resubmit if appropriate. 




004 R Beneficiary 

Name 

Required 

006 R Incorrect 

Birth Date 

007 R Invalid Claim 

Number 

008 R Beneficiary 

Claim 

Number Not 

Found 

NEED MEMB 

NAME 

BAD BIRTH 

DATE 

BAD HICN 

FORMAT 

CLAIM NOT 

FOUND 

A transaction (Transaction Types 01, 41, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was rejected, 

because both of the beneficiary name fields (Surname and First Name) were blank. The 

beneficiary’s name must be provided. The transaction should be resubmitted with beneficiary name 

included. 

Plan Action: Populate the Beneficiary Name fields and resubmit if appropriate. 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was rejected 

because the Birth Date, while non-blank and formatted correctly as YYYYMMDD (year, month, 

and day), is before 1870 or greater than the current year. The system tried to identify the beneficiary 

with the remaining demographic information but could not. 

Note: A blank Birth Date does not result in TRC 006 but may affect the ability to identify the 

appropriate beneficiary. See TRC 009. 

Plan Action: Correct the Birth Date and resubmit if appropriate. 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, and 81) was rejected, 

because the beneficiary claim number was not in a valid format. 

The valid format for a claim number could take one of two forms: 

HICN is an 11-position value, with the first 9 positions numeric and the last 2 positions 

alphanumeric. 

RRB is a 7 to 12 position value, with the first 1 to 3 positions alpha and the last 6 or 9 

positions numeric. 

Plan Action: Determine the correct claim number (HICN or RRB) for the beneficiary and resubmit 

the transaction if appropriate. 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, and 81) was rejected, 

because a beneficiary with this claim number was not found. The transaction should be resubmitted 

with a valid claim number. 

Plan Action: Determine the correct claim number (HICN or RRB) for the beneficiary and resubmit 





009 R No 

beneficiary 

match 

011 A Enrollment 

Accepted as 

Submitted 

013 A Disenrollmen 

t Accepted as 

Submitted 

NO BENE 

MATCH 

ENROLL 

ACCEPTED 

DISENROL 

ACCEPT 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, and 81) attempted to 

process but the system was unable to find the beneficiary based on the identifying information 

submitted in the transaction. 

A HICN is required, along with a match on 3 of the following 4 fields: surname, first initial, date of 

birth and sex code. 

Plan Action: Correct the beneficiary identifying information and resubmit if appropriate. 

The new enrollment (Transaction Type 61) has been successfully processed. The effective date of 

the new enrollment is reported in TRR data record field 18. 

This is the definitive enrollment acceptance record. Other accompanying replies with different 

TRCs may give additional information about this enrollment. 

Plan Action: Ensure the Plan’s system matches the information included in the TRR record. Take 

the appropriate actions as per CMS enrollment guidance. 

A disenrollment transaction (Transaction Type 51) has been successfully processed. The last day of 

the enrollment is reported in TRR data record fields 18 and 24. 

The disenrollment date is always the last day of the month. 

Plan Action: Ensure the Plan’s system matches the information included in the TRR record and 

that the beneficiary’s disenrollment date matches the date in field 24. Take the appropriate actions 

as per CMS enrollment guidance. 





t Due to 

Enrollment in 

Another Plan 


Cancelled 

DISNROL-NEW 

MCO 

ENROLL 

CANCELED 

This TRC is returned on a reply with the successful processing of Transaction Type 51 

(disenrollment) and Transaction Type 61 (enrollment). 

The last day of the enrollment is reported in TRR data record fields 18 and 24. This date will 

always be the last day of the month. 

For the Transaction Type 51 transaction, the beneficiary has been disenrolled from this Plan because 

they were successfully enrolled in another Plan The Source ID (field 28) contains the Contract 

number of the Plan that submitted the new enrollment which caused this disenrollment. 

For the Transaction Type 61 transaction, the TRC is issued whenever a retroactive enrollment runs 

into an existing enrollment that prevails according to application date edits. The Source ID (field 28) 

contains the Contract number of the prevailing plan. 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s information 

matches the data included in the TRR record and that the beneficiary’s disenrollment date matches 

the date in field 24. Take the appropriate actions as per CMS enrollment guidance. 

An existing enrollment was cancelled. The effective date of the enrollment which has been 

cancelled is reported in the TRR data record Effective Date field (18). This is always a 

disenrollment Transaction Type 51. 

A cancellation may be the result of an action on the part of the beneficiary, CMS or another Plan. 

When an enrollment is cancelled, it means that the enrollment never occurred. 

Plan Action: Because it was cancelled, this entire enrollment that was scheduled to begin on the 

date in field 18 should be removed from the Plan’s enrollment records. Take the appropriate actions 

as per CMS enrollment guidance. 




016 I Enrollment 

Accepted, 

Out Of Area 


Accepted, 

Payment 

Default Rate 

018 A Automatic 

Disenrollmen 

t 

019 R Enrollment 

Rejected - No 

Part A & Part 

B Entitlement 

ENROLL-OUT 

AREA 

ENROLL-BAD 

SCC 

AUTO 

DISENROLL 

NO ENROLL-NO 

AB 

The beneficiary’s residence state and county codes placed the beneficiary outside of the Plan’s 

approved service area. 

This TRC provides additional information about a new enrollment or PBP change (Transaction 

Type 61) for which an acceptance was sent in a separate Transaction Reply record with an 

enrollment acceptance TRC. The Effective Date of the enrollment for which this information is 

pertinent is reported in TRR data record field 18. 

Plan Action: Investigate the apparent discrepancy and take the appropriate actions as per CMS 

enrollment guidance. 

CMS was unable to derive a valid state and county code for the beneficiary who has been 

successfully enrolled. Part C payment for this beneficiary is at the Plan bid rate with no geographic 

adjustment. 


Type 61) for which an acceptance was sent in a separate Transaction Reply with an enrollment 

acceptance TRC. The effective date of the new enrollment for which this information is pertinent is 

reported in TRR data record fields 18 and 24. 

Plan Action: Contact your CMS Central Office Health Insurance Specialist for assistance. 

The beneficiary has been disenrolled from the Plan. The last day of enrollment is reported in TRR 

data record fields 18 and 24. This date is always the last day of the month. 

The disenrollment may result from an action on the part of the beneficiary, CMS or another Plan. 

A TRR reply with this TRC is usually accompanied by one or more replies, which make the reason 

for automatic disenrollment evident. For example, in the case of beneficiary death, the reply with 

TRC 018 is accompanied by two replies with TRC 090. 

Plan Action: Update the Plan’s records to reflect the disenrollment using the date in field 24. Take 


A submitted enrollment or PBP change transaction (Transaction Type 61) was rejected because the 

beneficiary does not have Medicare entitlement as of the effective date of the transaction. 

Plan Action: Take the appropriate actions as per CMS enrollment guidance. 





Rejected - 

Under 55 

022 A Transaction 

Accepted, 

Claim 

Number 

Change 


Accepted, 

Name 

Change 

NO ENROLL- 

NOT55 

NEW HICN 

NEW NAME 

A submitted enrollment or PBP change transaction (Transaction Type 61) for a PACE plan was 

rejected because the beneficiary is not yet 55 years of age. 


A transaction (Transaction Types 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) has been successfully 

processed. The effective date of the transaction is shown in TRR data file field 18. 

Additionally, the claim number for this beneficiary has changed. The new claim number is in TRR 

data file field 1 and the old claim number is reported in field 24. 

For enrollment acceptance (Transaction Type 61), TRC 022 is reported in lieu of TRC 011. Other 

accompanying replies with different TRCs may give additional information about this enrollment. 


the appropriate actions as per CMS guidance. Change the beneficiary’s claim number in the Plan’s 

records. Any future submitted transactions for this beneficiary must use the new claim number. 

A transaction (Transaction Types 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) has been successfully 

processed. The effective date of the transaction is reported in TRR data record field 18. 

Additionally, the beneficiary’s name has changed. The new name is reported in TRR data file 

fields 2, 3 and 4. 

For enrollment acceptance (Transaction Type 61), TRC 023 is reported in lieu of TRC 011. Other 

accompanying replies with different TRCs may give additional information about this enrollment. 


the appropriate actions as per CMS enrollment guidance. Change the beneficiary’s name in the 

Plan’s records. To ensure accurate identification of the beneficiary, future submitted transactions 

for this beneficiary should use the new name. 





t Accepted, 

Claim 

Number 

Change 


t Accepted, 

Name 

Change 

032 R Transaction 

Rejected, 

Beneficiary 

Not Entitl 

Part B 

DISROL-NEW 

HICN 

DISROL-NEW 

NAME 

MEMB HAS NO B 

A disenrollment transaction (Transaction Type 51) submitted by the Plan has been successfully 

processed. The effective date of the disenrollment is reported in TRR data file field 18. The 

disenrollment date will always be the last day of the month. 

Additionally, the claim number for this beneficiary has changed. The new claim number is in TRR 

data file field 1 and the old claim number is reported in field 24. 


the appropriate actions as per CMS enrollment guidance. Change the beneficiary’s claim number in 

the Plan’s records. Future submitted transactions for this beneficiary must use the new claim 

number. 

A disenrollment transaction (Transaction Type 51) submitted by the Plan has been successfully 

processed. The effective date of the disenrollment is reported in the TRR data record field 18. The 

disenrollment date will always be the last day of the month. 

Additionally, The beneficiary’s name has changed. The new name is reported in TRR data file 

fields 2, 3 and 4 and in the corresponding columns in the printed report. 


the appropriate actions as per CMS enrollment guidance. Change the beneficiary’s name in the 

Plan’s records. To ensure accurate identification of the beneficiary, future submitted transactions 

for this beneficiary should use the new name. 

This TRC is returned for an enrollment or PBP change transaction (Transaction Type 61) or a 

disenrollment cancellation transaction (Transaction Type 81) [enrollment reinstatement] . Part B 

entitlement is required for enrollment in a MCO. (MA, MAPD, HCPP, Cost 1, Cost 2 or Demos). 

TC61 – transaction was rejected because the submitted enrollment date is outside the 

beneficiary’s Part B entitlement period 

TC81 – transaction was rejected because the enrollment reinstatement period is outside the 

beneficiary’s Part B entitlement period 






Rejected, 

Beneficiary 

Not Entitl 

Part A 


Rejected, 

Beneficiary is 

Not Age 65 


Rejected, 


in Hospice 


Rejected, 


Deceased 

MEMB HAS NO A 

MEMB NOT AGE 

65 

MEMB IN 

HOSPICE 

MEMB 

DECEASED 

This TRC is returned for an enrollment or PBP change transaction (Transaction Type 61) or a 

disenrollment cancellation transaction (Transaction Type 81) [enrollment reinstatement] . Part A 

entitlement is required for enrollment in a MCO (MA, MAPD, or Demos). 


beneficiary’s Part A entitlement period 


beneficiary’s Part A entitlement period 



beneficiary was not age 65 or older. The age requirement is Plan-specific. 



beneficiary was in Hospice status. The Hospice requirement is Plan-specific (e.g. applies only to 

MSA/MA, MSA/Demo, OFM Demo, ESRD I Demo, ESRD II Demo, and PACE National Plans). 

The attempted enrollment date is reported in TRR data record field 18 and 24. 

Plan Action: Update the Plan records accordingly and take the appropriate actions as per CMS 


A submitted enrollment or PBP change transaction (Transaction Type 61) or disenrollment 

cancellation transaction (Transaction Type 81) enrollment reinstatement was rejected because the 

beneficiary is deceased. The beneficiary DOD is reported in TRR data record fields 18 and 24. 

Plan Action: Update the Plan records accordingly and take the appropriate actions as per CMS 






Rejected, 

Incorrect 

Effective 

Date 


Rejected, 

Duplicate 

Transaction 


Rejected, 

Currently 

Enrolled in 

Same Plan 


Rejected, 

Blocked 

BAD ENROLL 

DATE 

DUPLICATE 

ALREADY 

ENROLL 

ENROLL 

BLOCKED 

A transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was rejected 

because the submitted effective date is not appropriate. Inappropriate effective dates include: 

For all transaction types, date is not first day of the month 

For all transaction types, date is greater than current calendar year plus one, or, date does 

not meet Current Calendar Month (CCM) constraints 

For Transaction Type 61, non-EGHP enrollment, date is more than one month prior to 

CCM or greater than three months after CCM 

For Transaction Type 61 transaction, EGHP enrollment, date is more than three months 

prior to the CCM or greater than three months after CCM 

Transaction Type 72 4Rx Record Update transaction with an effective date not equal to the 

effective date of an existing enrollment period 

Transaction Type 73 Uncovered Months Change transaction (Creditable Coverage Flag = N 

or Y) with an effective date not equal to the effective date of an existing enrollment period 

Transaction Type 80 Enrollment Cancellation transaction with an effective date not equal to 

the effective date of an existing enrollment 

Transaction Type 81 Disenrollment Cancellation transaction with an effective date not 

equal to the effective date of an existing disenrollment 

Plan Action: Correct the Effective Date and resubmit if appropriate. If this is a retroactive 

transaction, contact CMS for instructions on submitting retroactive transactions. 

An enrollment transaction (Transaction Type 61) was rejected because it was a duplicate 

transaction. CMS has already processed another enrollment transaction submitted for the same 

contract, PBP, application date and effective date. 

Plan Action: None required 

An enrollment or PBP change transaction (Transaction Type 61) was rejected because the 

beneficiary is already enrolled in this contract/PBP. 


An enrollment or PBP change transaction (Transaction Type 61) or disenrollment cancellation 

transaction (Transaction Type 81) [enrollment reinstatement] was rejected because the Plan is 

currently blocked from enrolling new beneficiaries. 

Plan Action: Check HPMS and contact CMS. 





Rejected, 

Outside 

Contracted 

Period 

NO CONTRACT This TRC is returned for an enrollment or PBP change transaction (Transaction Type 61) , 

enrollment cancellation transaction (Transaction Type 80) or a disenrollment cancellation 

transaction (Transaction Type 81) enrollment reinstatement. 


Plan’s contracted period 

TC80 and TC81 – transaction was rejected because the enrollment reinstatement period is 

outside the Plan’s contracted period 


Rejected, 


in ESRD 

048 A Nursing 

Home 

Certifiable 

Status Set 

050 R Disenrollmen 

t Rejected, 

Not Enrolled 

MEMB HAS 

ESRD 

NHC ON 

NOT ENROLLED 

Plan Action: Check HPMS and contact CMS. 

An enrollment or PBP change transaction (Transaction Type 61) was rejected because the 

beneficiary is in ESRD (end-stage renal disease) status. The attempted enrollment effective date is 

reported in TRR data file field 18 and 24. 

Affected Plans cannot enroll ESRD members unless the individual was previously enrolled in the 

commercial side of the plan or the plan has been previously approved for such enrollments. 

Plan Action: Review full CMS guidance on enrollment of ESRD beneficiaries in the Medicare 

Managed Care Manual (MMCM) or PDP Enrollment Guidance. If the Plan has approval to enroll 

ESRD members, they should resubmit the enrollment with an A in the Prior Commercial Indicator 

field (position 80). 

A correction transaction (Transaction Type 01) placed the beneficiary in Nursing Home Certifiable 

(NHC) status. The NHC health status is Plan specific, e.g., applies to SHMO I, Mass. Dual Eligible, 

MDHO and MSHO plans. The effective date of the NHC status is reported in TRR data record field 

18 and 24. 

Note: This TRC is only applicable for effective dates prior to 1/1/2008. 

Plan Action: Update the Plan records. 

A disenrollment transaction (Transaction Type 51) was rejected, because the beneficiary was not 

enrolled in the contract as of the effective date of the disenrollment. 

Plan Action: Verify the Plan’s enrollment information for this beneficiary. 





t Rejected, 

Incorrect 

Effective 

Date 


t Rejected, 

Duplicate 

Transaction 


t Rejected, 

Retroactive 

Effective 

Date 

BAD DISENR 

DATE 

DUPLICATE 

RETRO DISN 

DATE 

A disenrollment transaction (Transaction Type 51) or a disenrollment cancellation transaction 

(Transaction Type 81) was rejected because the submitted enrollment effective date was either: 

Not the first day of the month, or 

More than three months beyond the Current Calendar Month (CCM+3) 

Note: Transactions with effective dates prior to CCM are returned with TRC 054. 


transaction, contact CMS for instructions on submitting retroactive transactions 

A disenrollment transaction (Transaction Type 51), enrollment cancellation transaction (Transaction 

Type 80), or disenrollment cancellation transaction (Transaction Type 81) was rejected because it 

was a duplicate transaction. CMS has already processed another a similar transaction submitted for 

the same contract with the same effective date. 

The effective date of the disenrollment is reported in the Effective Date field (18) on the TRR data 

file. 


A disenrollment transaction (Transaction Type 51 or 54) was rejected because the submitted 

effective date was prior to the earliest allowed date for disenrollment transactions. Effective dates 

for disenrollment transactions (Transaction Type 51) can be no earlier than one month prior to the 

Current Calendar Month (CCM) or two months prior for Transaction Type 54 transactions. 

The requested disenrollment effective date is reported in the Effective Date field (18) on the TRR 

data file. 


transaction, contact CMS for instructions on submitting retroactive transactions. 




055 M ESRD 

Cancellation 

056 R Demonstratio 

n Enrollment 

Rejected 

ESRD 

CANCELED 

FAILS DEMO 

REQ 

This TRC is returned on a reply with Transaction Type 01. It is not a reply to a submitted 

transaction but is intended to supply the Plan with additional information about the beneficiary. 

This beneficiary was previously in End State Renal Disease (ESRD) status. That status has been 

cancelled. The effective date of the ESRD status cancellation is reported in TRR data file field 18 

and 24. 

Plan Action: Update the Plan records. 

An enrollment transaction (Transaction Type 61) was rejected because the beneficiary did not meet 

the Demonstration requirements. For example, the beneficiary is currently known to be Working 

Aged or not known to be ESRD. These requirements are Plan specific. 

The attempted enrollment effective date is reported in TRR data file fields 18 and 24. 


Rejected, Not 

Enrolled 


NOT ENROLLED A Correction (Transaction Type 01), Cancellation of Enrollment (Transaction Type 80), 

Cancellation of Disenrollment (Transaction Type 81), or change transaction (Transaction Types 74, 

75, 76, 77, 78, 79) was rejected because the beneficiary was not enrolled in a Plan as of the 

submitted effective date. 

062 R Correction 

Rejected, 

Overlaps 

Other Period 

INS-NHC 

OVERLAP 

For NUNCMO Change transactions, Transaction Type 73, either the beneficiary is not enrolled in 

the plan submitting this transaction as of the month of the submission, or, the submitted effective 

date does not fall within a Part D plan enrollment. 

Plan Action: Verify the beneficiary identifying information and resubmit the transaction with 

updated information, if appropriate. 

A correction transaction (Transaction Type 01) was rejected because this transaction would have 

resulted in overlapping Institutional and Nursing Home Certifiable (NHC) periods. The beneficiary 

is not allowed to be in both Institutional and NHC status. These two types of periods are mutually 

exclusive. 


Plan Action: Ensure that the Plan’s records reflect the correct dates. 




071 M Hospice 

Status Set 

072 M Hospice 

Status 

Terminated 

HOSPICE ON 

HOSPICE OFF 

This TRC is returned on a reply with Transaction Type 01 and occasionally with Transaction Type 

51, and Transaction Type 61. When returned with Transaction Type 01, the TRC is in response to a 

change in beneficiary Hospice status. It is not a reply to a submitted transaction but is intended to 

supply the Plan with additional information about the beneficiary. 

In the case of Transaction Type 01, a notification has been received that this beneficiary is in 

Hospice status. The date on which Hospice Status became effective is reported in TRR data file 

fields 18 and 24. 

The effective date for Hospice Status is not restricted to the first or last day of the month. It may be 

any day of the month. 

When this TRC is returned with Transaction Type 61 the TRC is in response to a retroactive 

enrollment and is identifying the fact that an enrollment end date has been established due to the 

beneficiary’s hospice status. The enrollment start date is in TRR data file field 18 and the 

enrollment end date is in field 24. In this circumstance it is accompanied by TRC 018, Automatic 

Disenrollment, as well. 

Plan Action: Update the Plan’s records. Take the appropriate actions as per CMS enrollment 

guidance. 



A notification has been received that this beneficiary’s Hospice Status has been terminated. The end 

date for the Hospice Status is reported in TRR data file fields 18 and 24. 

The date for termination of Hospice Status is not restricted to the first or last day of the month. It 

may be any day of the month. 


guidance. 




073 M ESRD Status 

Set 

074 M ESRD Status 

Terminated 

075 A Institutional 

Status Set 

ESRD ON 

ESRD OFF 

INSTITUTION ON 


61. When returned with Transaction Type 01, the TRC is in response to a change in beneficiary 

ESRD status. It is not a reply to a submitted transaction but is intended to supply the Plan with 

additional information about the beneficiary. 

In the case of Transaction Type 01, a notification has been received that this beneficiary is in End 

Stage Renal Disease (ESRD) status. The date on which ESRD Status became effective reported in 

TRR data file fields 18 and 24. 



beneficiary’s ESRD status. The enrollment start date is in TRR data file field 18 and the enrollment 

end date is in field 24. In this circumstance it is accompanied by TRC 018, Automatic 



guidance. 



A notification has been received that this beneficiary’s End Stage Renal Disease (ESRD) Status has 

been terminated. The end date for the ESRD Status is reported in TRR data file fields 18 and 24. 


guidance. 

A correction transaction (Transaction Type 01) placed the beneficiary in Institutional status. The 

effective date of the Institutional status is shown in TRR data record field 24. 

Institutional status automatically ends each month; therefore, there is no Institutional Status 

termination transaction. This TRC is only applicable for application dates prior to 01/01/2008. 

Plan Action: Update the Plan records. Take the appropriate actions as per CMS enrollment 

guidance. 





077 M Medicaid 

Status Set 

MEDICAID ON A reply with this TRC is seen for plan submitted retroactive Transaction Type 01 and 30 

transactions and occasionally Transaction Type 61 enrollment transactions. 


Status 

Terminated 

MEDICAID OFF 

In the case of Transaction Type 01, this beneficiary has been placed in Medicaid Status by the plan. 

The effective date of the Medicaid Status is reported in the TRR in field 18. This date is always the 

first of the month and is retroactive. 

When this TRC is returned with Transaction Type 61, the TRC is in response to a retroactive 


beneficiary having a Medicaid status. The enrollment start date is in TRR data file field 18 and the 



Transaction type 30, when provided with the request type 22, is a rate recalculation for a Medicaid 

status change. 


guidance. 

A reply with this TRC may be informational from CMS Transaction Type 30 or in response to a 

Transaction Type 01 transaction submitted by the Plan. 

This beneficiary’s Medicaid Status has been terminated. The effective date of the termination of 

Medicaid Status is reported in TRR data file fields 18 and 24 of the TRR. This date is always the 

last day of the month. 

Transaction type 30, when provided with the request type 22, is a rate recalculation for a Medicaid 

status change. 


guidance. 




079 M Part A 

Termination 

MEDICARE A 

OFF 


61. When returned with Transaction Type 01, the TRC is in response to a change in beneficiary Part 

A Entitlement. It is not a reply to a submitted transaction but is intended to supply the Plan with 

additional information about the beneficiary. 

In the case of Transaction Type 01, this beneficiary’s Part A Entitlement has been terminated. The 

effective date of the termination is reported in TRR data file fields 18 and 24. 

When this TRC is returned with Transaction Type 61, the TRC is in response to a retroactive 


beneficiary’s termination of Part A. The enrollment start date is in TRR data file field 18 and the 



Note: A TRR record with this reply code is only reported to the Plan in which the beneficiary is 

currently enrolled, even if it affects periods of enrollment in other Plans. 

080 M Part A 

Reinstatemen 

t 

MEDICARE A ON 


guidance. 



This beneficiary’s Part A Entitlement has been reinstated. The effective date of the start of Part A 

entitlement is reported in fields TRR data file 18 and 24. 


currently enrolled, even if it affects periods of enrollment in other Plans. If, as a result of a loss of 

Part A entitlement, the beneficiary has been disenrolled and does not continue to be enrolled in 

some managed care contract, the reply code is not issued. 


guidance. 




081 M Part B 

Termination 

MEDICARE B 

OFF 


51 and Transaction Type 61. When returned with Transaction Type 01, the TRC is in response to a 

change in beneficiary Part B Entitlement. It is not a reply to a submitted transaction but is intended 

to supply the Plan with additional information about the beneficiary. 

In the case of Transaction Type 01, this beneficiary’s Part B Entitlement has been terminated. The 

effective date of the termination is reported in TRR data file fields 18 and 24. 

When this TRC is returned with Transaction Types 51 or 61, the TRC is in response to a retroactive 


beneficiary’s termination of Part B. The enrollment start date is in TRR data file field 18 and the 





082 M Part B 

Reinstatemen 

t 

MEDICARE B ON 


guidance. 



This beneficiary’s Part B Entitlement has been reinstated. The effective date of the start of Part B 

entitlement is reported in TRR data file fields 18 and 24. 



Part B entitlement, the beneficiary has been disenrolled, but not re-enrolled, the reply code is not 

issued. 


guidance. 




085 M State and 

County Code 

Change 

086 M Claim 

Number 

Change 

087 M Name 

Change 

088 M Sex Code 

Change 

NEW SCC 

NEW HICN 

NEW NAME 

NEW SEX CODE 

This TRC is returned either on a reply with Transaction Type 01. It is intended to supply the Plan 

with additional information about the beneficiary. 

This beneficiary’s State and County Code (SCC) information has changed. The new SCC 

information will be reported in TRR data record fields 9 (state code), 10 (county code), and together 

in field 24. 

Plan Action: Update the Plan’s records. 



This beneficiary’s HICN has changed. The new claim number is reported in TRR data record field 

1 and the old claim number is in Field 24. 

Plan Action: Update the Plan’s records. The new claim number must be used on all future 

transactions for this beneficiary. 



This beneficiary’s name has changed. The new name is reported in the TRR data record name fields 

(2, 3 and 4), SURNAME, FIRST NAME and MI. The effective date field (field 18) reports the date 

the name change was processed by CMS. 

Plan Action: Update the Plan’s records. To ensure accurate identification of the beneficiary, future 

submitted transactions for this beneficiary should use the new name. 



This beneficiary’s sex code has changed. The new sex code is reported in TRR data file field 5. The 

effective date field (field 18) reports the date the sex code change was processed by CMS. 


submitted transactions for this beneficiary should use the new sex code. 




089 M Date of Birth 

Change 

090 M Date of Death 

Established 

NEW BIRTH 

DATE 

MEMB 

DECEASED 



This beneficiary’s date of birth has changed. The new date of birth is reported in TRR data file field 

6 (DOB) and field 24. Field 18 (Effective Date) reports the date the DOB change was processed by 

CMS. 


submitted transactions for this beneficiary should use the new date of birth. 

This TRC is not a reply to a submitted transaction but is intended to supply the Plan with additional 

information about the beneficiary. 

When CMS is notified of a beneficiary’s death, the Plan receives three replies in their TRR. 

Transaction Type 01 with TRC 090 - only received by the Plan in which the beneficiary is 

enrolled during the CPM. 

Transaction Type 51 with TRC 090 

Transaction Type 51 with TRC 018 or TRC 015 

Transaction replies with other TRCs may also accompany these three replies. Examples 

include status terminations and SSA responses. 

On a Transaction Type 01 transaction with TRC 090, the beneficiary’s actual date of death is 

reported in TRR data file fields 18 and 24. 

On a Transaction Type 51 transaction with TRC 090, fields 18 and 24 report the effective date of the 

disenrollment that results from the death. This will always be the 1 st of the month following the 

death if the beneficiary is actively enrolled in a plan. If the Plan’s enrollment is not yet effective, 

these fields will report the effective date of the enrollment being cancelled. 

Plan Action: Update the Plan’s records with the beneficiary’s date of death from the Transaction 

Type 01 transaction. It is the Transaction Type 51 transaction with TRC 018 or 015 that should be 

processed as the auto-disenrollment or cancellation. Take the appropriate actions as per CMS 


Note: The above three transaction replies may not appear in the same weekly TRR 




091 M Date Of 

Death 

Removed 

092 M Date of Death 

Corrected 

097 R Medicaid 

Previously 

Turned On 

DEATH DATE 

OFF 

NEW DEATH 

DATE 

MCAID PREV ON 



Although the Plan has previously received a transaction reply reporting a date of death for this 

beneficiary, the date of death has been removed. The beneficiary is still alive. TRR data file fields 

18 and 24 contain the date of death that was previously reported to the Plan. 

If the date of death is removed after the auto disenrollment has taken effect, the Plan will not receive 

this transaction reply. The removal of the Date of Death may initiate the reinstatement of an 

enrollment. (See TRC 287) 

Plan Action: Update the Plan’s records and restore the beneficiary’s enrollment with the original 

enrollment start and end dates. Take the appropriate actions as per CMS enrollment guidance. 



The date of death for this beneficiary has been corrected. The corrected date of death is reported in 

TRR data file field 24. The correction of the DOD may initiate the reinstatement of an enrollment. 

(See TRC 287) 


guidance. 

A correction transaction (Transaction Type 01) was rejected because this transaction attempted to 

set the Medicaid status for the beneficiary to ON. The Medicaid status for the beneficiary was 

already ON for the month in question. 

Note: This TRC is only applicable for submitted correction transactions (01) with effective dates 

prior to 1/1/2008. 

Plan Action: None required. Verify the Plan records. 




098 R Medicaid 

Previously 

Turned Off 

MCAID PREV 

OFF 

A correction transaction (Transaction Type 01) was rejected because this transaction attempted to 

set the Medicaid status for the beneficiary to OFF. The Medicaid status for the beneficiary was 

already OFF for the month in question. 

Note: This TRC is only applicable for submitted correction transactions (Transaction Type 01) with 

effective dates prior to 1/1/2008. 


Period 

Change/Canc 

ellation 

100 A PBP Change 

Accepted as 

Submitted 

102 R Rejected; 

Incorrect or 

Missing 

Application 

Date 

MCAID CHANGE 

PBP CHANGE OK 

BAD APP DATE 

Plan Action: None required. Verify the Plan records. 

A change has been made to a period of Medicaid status information for the beneficiary. 

Plan Action: Plan should update beneficiary record. 

A submitted PBP Change transaction (Transaction Type 61) has been successfully processed. The 

beneficiary has been moved from the original PBP to the new PBP. The effective date of 

enrollment in the new PBP is reported in fields 18 and 24 of the TRR data record. The effective 

date will always be the first day of the month. 

This is the definitive PBP Change acceptance record. Other accompanying replies with different 

TRCs may give additional information about this accepted PBP Change. 

Field 20 (Plan Benefit Package ID) contains the new PBP identifier. The old PBP is reported in 

field 29 (Prior Plan Benefit Package ID). 



If the Application Date on an enrollment transaction (Transaction Type 61) is blank or contains a 

valid date that is not appropriate for the submitted transaction, TRC 102 is returned in the TRR 

record. Examples of inappropriate application dates: 

Date is blank 

Date is later than the submitted Effective Date. 

Date does not lie within the election period specified on the submitted transaction 

Note: Plans should see Chapter 2 of the MMCM or the PDP Guidance on Eligibility, Enrollment 

and Disenrollment for detailed descriptions of the Election Periods. 

Plan Action: Correct the Application Date and resubmit if appropriate. 




103 R ICEP/IEP 

Election, 

Missing A/B 

Entitlement 

Date 


Invalid or 

Missing 

Election Type 

ICEP/IEP NO ENT 

BAD ELECT TYPE 

An enrollment transaction (Transaction Type 61) was rejected because the beneficiary does not have 

entitlement for Part A and/or enrollment in Part B on record (required for enrollment transactions). 

This TRC is only returned on enrollment transactions submitted with election type I (Initial 

Coverage Election Period) or E (Initial Enrollment Period for Part D). 

Plan Action: Verify the beneficiary’s Part A / Part B entitlement / enrollment. Take the 

appropriate actions as per CMS enrollment guidance. 

An enrollment (Transaction Type 61) or disenrollment (Transaction Type 51) was rejected because 

the submitted Election Type is either missing, contains an invalid value or is not appropriate for the 

plan or for the transaction type. 

The valid Election Type values are: 

A - Annual Election Period (AEP) 

D - MA Annual Disenrollment Period (MADP) 

E - Initial Enrollment Period for Part D (IEP) 

F - Second Initial Enrollment Period for Part D (IEP2) 

I - Initial Coverage Election Period (ICEP) 

O - Open Enrollment Period (OEP) (Valid through 3/31/2010) 

N - Open Enrollment for Newly Eligible Individuals (OEPNEW) (Valid through 12/31/2010) 

T - Open Enrollment Period for Institutionalized Individuals (OEPI) 

Special Enrollment Periods 

U - SEP for Loss of Dual Eligibility or for Loss of LIS 

V - SEP for Changes in Residence 

W - SEP EGHP (Employer/Union Group Health Plan) 

Y - SEP for CMS Casework Exceptional Conditions 

X - SEP for Administrative Change 

Plan Submitted “Rollover” 

Involuntary Disenrollment 

PPO Change 

Plan-submitted “Canceling” Transaction 




104 

Con’t 

R 

Rejected; 

Invalid or 

Missing 

Election Type 

BAD ELECT TYPE 

Z - SEP for: 

Auto-Enrollment (Enrollment Source Code = A) 

Facilitated Enrollment (Enrollment Source Code = C) 

Plan-Submitted Auto-Enrollment (Enrollment Source Code = E) and Transaction 

Type 61 (PBP Change) and MA or Cost Plan (all conditions must be met) 

POS Enrollment (Enrollment Source Code = G) 

S - Special Enrollment Period (SEP) 

The value expected in Election Type depends on the Plan and transaction type, as well as on when 

the beneficiary gains entitlement. Each Election Type Code can be used only during the election 

period associated with that election type. Additionally, there are limits on the number of times each 

election type may be used by the beneficiary. 


Invalid 

Effective 

Date for 

Election Type 

BAD ELECT 

DATE 

Plan Action: Review the detailed information on Election Periods in Chapter 2 of the MMCM or 

the PDP Guidance on Eligibility, Enrollment and Disenrollment. Determine the appropriate 

Election Type value and resubmit, if appropriate. 

An enrollment or disenrollment transaction (Transaction Types 61, 51) was rejected because the 

effective date was not appropriate for the election type or for the submitted application date. 

Examples of inappropriate effective dates: 

Date is outside of the election period defined by the submitted election type. 

(ex: Election Type = A and Effective Date = 2/1/2007) 

Date is not appropriate for the application date 

(ex: App date = 6/10/2007 & Eff Date =11/01/2007) 

Plan Action: Correct the Effective Date or Election Type and resubmit if appropriate. Review 

Chapter 2 of the MMCMor the PDP Guidance on Eligibility, Enrollment and Disenrollment for 

detailed descriptions of the Election Periods and corresponding effective dates. 




106 R Rejected, 

Another 

Trans Rcvd 

with Later 

App Date 


Invalid or 

Missing PBP 

Number 


Election 

Limits 

Exceeded 

LATER APPLIC 

BAD PBP 

NUMBER 

NO MORE 

ELECTS 

An enrollment transaction (Transaction Type 61) was rejected because a transaction with a more 

recent application date or same date as another application date was received for the same effective 

date. The submitted enrollment has been overridden by an enrollment in another contract/PBP. 

When multiple transactions are received for the same beneficiary with the same effective date but 

with different contract/PBP #s, the application date is used to determine which enrollment to accept. 

If the application dates are different, the system will accept the election containing the most recent 

date. . 

Plan Action: The beneficiary is not enrolled in the Plan. Update the Plan records. 

An enrollment or Record Update transaction (Transaction Types 61, 72, 73, 74, 75, 77, 78, 79, 80) 

was rejected because the PBP # was missing or invalid. The PBP # must be of the correct format 

and be valid for the contract on the transaction. 

Note: PBP # is not required on Disenrollment, Residence Address, and Disenrollment Cancellation 

transactions, (Transaction Types 51, 76, 81) but when submitted it must be valid for the contract 

number on the transaction. 

Plan Action: Correct the PBP # and resubmit the transaction if appropriate. 

A transaction for which an election type is required (Transaction Types 51, 61) was rejected because 

the transaction will exceed the beneficiary’s election limits for the submitted election type. 

The valid Election Type values which have limits are: 

A - Annual Election Period (AEP) 

1 per calendar year 

E - Initial Enrollment Period for Part D (IEP) 

1 per lifetime 

F - Initial Enrollment Period for Part D (IEP2) 


I - Initial Coverage Election Period (ICEP) 


Plan Action: Review the discussion of election type requirements in Chapter 2 of the MMCMor the 

PDP Guidance on Eligibility, Enrollment and Disenrollment. Correct the election type and resubmit 






Duplicate 

PBP Number 

110 R Rejected; No 

Part A and 

No EGHP 

Enrollment 

Waiver 

114 R Drug 

Coverage 

Change 

Rejected; not 

AEP or OEPI 

ALREADY 

ENROLL 

NO PART 

A/EGHP 

RX NOT 

AEP/OEPI 

An enrollment transaction (Transaction Type 61) was rejected because the member is already 

enrolled in the PBP # on the transaction. 

The effective date of the requested enrollment is reported in TRR data file field 18. 

Plan Action: If the submitted PBP was correct, no Plan action is required. If another PBP was 

intended, correct the PBP # and resubmit if appropriate. 

A PBP enrollment change transaction (Transaction Type 61) was rejected because the beneficiary 

lacks Part A and there was no EGHP Part B-only waiver in place. 

Plans can offer a PBP for EGHP members only, and, if the Plan chooses, it can define such PBPs for 

individuals who do not have Part A. 

Plan Action: Review CMS enrollment guidance in Chapter 2 of the MMCMor the PDP Guidance 

on Eligibility, Enrollment and Disenrollment and notify the beneficiary. 

An enrollment change transaction (Transaction Type 61) was rejected because the beneficiary is not 

allowed to add or drop drug coverage using an O (OEP) or N (OEPNEW) election types. 

Using O or N, a beneficiary who is in a Plan that includes drug coverage may only move to another 

Plan with drug coverage. Likewise, if in a Plan without drug coverage, the beneficiary may not 

enroll in a Plan with drug coverage or a PDP. 

Occasionally, if a beneficiary is moving from a Plan with drug coverage to a combination of standalone 

MA and PDP plans, the enrollment transaction in the MA-only plan may be processed prior 

to the enrollment transaction in the PDP plan. Since this appears to CMS as if the beneficiary is 

trying to drop drug coverage, the enrollment into the MA only Plan will be rejected with TRC 114. 

Once the enrollment in the PDP is processed, the enrollment in the MA-only may be resubmitted. 

Plan Action: Review CMS enrollment guidance on the O and N election type limitations in 

Chapter 2 of the MMCMor the PDP Guidance on Eligibility, Enrollment and Disenrollment. Take 


Note: If TRC 114 is received by an MA-only Plan when using the OEP or OEPNEW, the Plan 

should determine if the beneficiary is enrolled in an accompanying PDP. Once that enrollment is 

complete, the MA-Only Plan may resubmit their enrollment transaction. 





Rejected; 

Invalid Segmt 

num 

BAD SEGMENT 

NUM 

An enrollment transaction (Transaction Type 61) rejects because the enrollment is for a Segmented 

PBP, and the Segment number on the submitted transaction is invalid 

-OR- 

A Segment change transaction (Transaction Type 77) is submitted with an invalid Segment number, 

for a Segmented PBP 

-OR- 

A disenrollment cancellation transaction (Transaction Type 81) [enrollment reinstatement] is 

submitted and the reinstated enrollment has a non-blank Segment, which is no longer valid for the 

PBP. 

Plans must submit a valid Segment number for the Contract/PBP combination. A Segment number is 

not required for a disenrollment transaction (Transaction Type 51). 

Plan Action: Correct or delete the Segment number and resubmit the transaction if appropriate for 

Transaction Type 61. Correct the Segment number and resubmit the transaction if appropriate for 

Transaction Type 77. Submit enrollment for Transaction Type 81 if appropriate. An enrollment 

transaction (Transaction Type 61) was rejected because the enrollment is for a PBP that has been 

segmented, and the segment number on the submitted transaction was missing or invalid. 

-OR- 

A segment change transaction (Transaction Type 77) was submitted with a non-blank segment 

number, and the segment number was invalid for the PBP. 

‘OR’ 

A disenrollment cancellation transaction (Transaction Type 81) [enrollment reinstatement] was 

submitted and the enrollment being reinstated has a non-blank segment which is no longer valid for 

the PBP. 

Any submitted segment number must be valid for the Contract / PBP combination. Segment number 

is not required for a disenrollment transaction (Transaction Type 51). 

Plan Action: Correct the Segment number and resubmit the transaction if appropriate for 

transaction types 61 and 77. Submit enrollment for transaction type 81 if appropriate. 

December 28, 2012 I-28 Transaction Reply Codes (TRCs)



117 A FBD Auto 

Enrollment 

Accepted 

118 A LIS 

Facilitated 

Enrollment 

Accepted 

119 A Premium 

Amount 

Change 

Accepted 

FBD AUTO 

ENROLL 

LIS FAC ENROLL 

PREM AMT CHG 

This new enrollment transaction (Transaction Type 61) was the result of a Plan-submitted or CMSinitiated 

auto-enrollment of a full-benefit dual-eligible beneficiary into a Part D Plan. The 

enrollment was accepted. The effective date of the new enrollment is shown in the Effective Date 

(field 18) of the TRR data record. 

Other accompanying replies with different TRCs may give additional information about this new 

enrollment. 



This new enrollment transaction (Transaction Type 61) was the result of a Plan-submitted or CMSinitiated 

facilitated enrollment of a low income beneficiary into a Part D Plan. The effective date of 

the new enrollment is shown in the Effective Date (field 18) of the TRR data record. 

Other accompanying replies with different TRCs may give additional information about this new 

enrollment. 



A Part C Premium Change transaction (Transaction Type 78) was accepted. The Part C premium 

amount has been updated with the amount submitted on the transaction. The amount may have also 

been updated by CMS. 

The effective date of the new premium will be reported in TRR data record field 18. The amount of 

the new Part C premium will be reported in field 19 of the TRR record. 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s premium 

amounts are implemented as of the effective date in field 18. Take the appropriate actions as per 

CMS enrollment guidance. 




120 A PPO Change 

Sent to W/H 

Agency 

WHOLD UPDATE 

As a result of an accepted Plan-submitted transaction (Transaction Types 51, 61, 73, 74, 75) or UI 

update to a beneficiary’s records, information has been forwarded to SSA/RRB to update SSA/RRB 

records and implement any requested premium withholding changes. 

Any requested change will not take effect until an SSA/RRB acceptance is received. Plans are 

notified of the SSA/RRB acceptance with a TRC 185 in a future TRR data file. 

Plan Action: None required. Take the appropriate actions as per CMS enrollment guidance. 

Note: The Plan will not see the result of any PPO change until they have received a TRC 185 on a 

future TRR. 




121 M Low Income 

Period Status 

LIS UPDATE 

This TRC is returned on a reply with Transaction Types 01, 51, 61, 80, and 81. It is not a reply to a 

submitted transaction but is intended to supply the Plan with additional information about the 

beneficiary. It is created in response to an enrollment transaction or change in a beneficiary’s low 

income profile. Each TRC 121 returns start and end dates if the beneficiary is Deemed (start date 

only if the beneficiary is an SSA Applicant), premium subsidy percentage, and copayment category 

for one low income period affecting a PBP enrollment. There may be more than one TRC 121 

returned. 

TRC 121 is issued for all periods of low income benefits that fall within the Plan’s enrollment 

period. The enrollment period description is identified in Field 66 with a ‘C’ for current enrollees, 

‘P’ for prospective enrollees, and ‘Y’ for previous enrollees. 

The beneficiary’s Low-Income Subsidy source will be identified in Field 65 with an ‘A’ for 

Approved SSA Applicants or a ‘D’ for Deemed beneficiary by CMS. 

The following LIS information is displayed on the Transaction Reply Report (TRR) for TRC 121: 

PBP Enrollment Effective Date (Field 18) 

Part D Low-income Premium Subsidy Level (Field 49) 

Low-income Co-Pay Category (Field 50) 

Low-income Period start date (Field 51) 

Low-income Period End Date (Field 64) 

Low-income Period Subsidy Source (Field 65) 

Enrollment Period Description (Field 66) 

Low income subsidy TRC 223 may accompany TRC 121. These three TRCs convey the 

beneficiary’s low income subsidy profile affecting the identified PBP enrollment period. 

Plan Action: Update the Plan’s records to reflect the given data for the beneficiary’s LIS period. 

Take the appropriate actions as per CMS enrollment guidance. 




122 R Enrollment/C 

hange 

Rejected, 

Invalid 

Premium 

Amount 


hange 

Rejected, 

Invalid Prm 

Pay Opt Cd 

BAD PREMIUM 

AMT 

BAD W/HOLD 

OPT 

An enrollment or premium change transaction (Transaction Type 61, or 78) was rejected because 

the submitted Part C premium amount was non-blank and not numeric. 

If the Part C premium field is blank on a submitted enrollment transaction (Transaction Type 61), 

the blank will be converted to zeros. Any submitted value must be numeric. 

A blank or invalid Part C premium field is not permitted on the Part C premium change transaction 

(Transaction Type 78). 

Plan Action: Correct the Part C premium amounts and resubmit if appropriate. 

An Enrollment or PPO Change transaction (Transaction Types 61, 75) was rejected because the 

value submitted in the PPO Code field was an invalid value. 

The valid values include: 

D - Direct Bill - Self Pay 

R - Deduct from RRB benefits 

S - Deduct from SSA benefits 

N - No premium applicable 

O (Deduct from OPM benefits) is not currently available. It is scheduled for future implementation. 

Plan Action: Correct the PPO code and resubmit if appropriate. 





hange 

Rejected; 

Invalid 

Uncov 

Months 


hange 

Rejected; 

Invalid Cred 

Cvrg Flag 

127 R Part D 

Enrollment 

Rejected; 

Employer 

Subsidy 

Status 

BAD UNCOV 

MNTHS 

BAD CRED COV 

FL 

EMP SUB REJ 

An enrollment or number of uncovered months change transaction (Transaction Types 61, 73) was 

rejected because the Number of Uncovered Months field was not correctly populated. 

This rejection could be the result of the following conditions: 

The field contained a non-numeric value 

The Uncovered Months field was zero when the Creditable Coverage Switch was set to N 

For Transaction Type 61, the Uncovered Months field was greater than zero when the 

Creditable Coverage Switch was set to Y or blank. 

For Transaction Type 73, the Uncovered Months field was greater than zero when the 

Creditable Coverage Switch was set to Y. 

Plan Action: Correct the Number of Uncovered Months value and resubmit the transaction if 

appropriate. Verify that the Creditable Coverage Flag and Number of Uncovered Months 

combination is valid. 

An enrollment or number of uncovered months change transaction (Transaction Types 61, 73) was 

rejected because the Creditable Coverage Flag field was not correctly populated. 

For Transaction Type 61, the valid values for the Creditable Coverage Flag are Y, N, and blank. 

For Transaction Type 73, the valid values for the Creditable Coverage Flag are Y and N. 

Plan Action: Correct the Creditable Coverage Flag value and resubmit the transaction if 

appropriate. Verify that the Creditable Coverage Flag and Number of Uncovered Months 

combination is valid. 

An enrollment transaction (Transaction Type 61) was rejected because the beneficiary has employer 

subsidy periods overlapping with the requested enrollment period. 

The requested effective date is reported in TRR data file field 18. 

Plan Action: Take the appropriate actions as per CMS enrollment guidance. Contact the 

beneficiary to explain the potential consequences of this enrollment. If the beneficiary elects to join 

the Part D plan anyway, the enrollment should be resubmitted with the Employer Subsidy Override 

Flag set to Y. 




128 R Part D Enroll 

Reject; 

Emplyr 

Sbsdy set: No 

Prior Trn 

EMP SUB OVR 

REJ 

An enrollment transaction (Transaction Type 61) was rejected because the beneficiary has employer 

subsidy periods overlapping with the requested enrollment period. 

Even through this transaction was submitted with the Employer Subsidy Override Flag set to Y, the 

override is not valid because there is no record that the enrollment was previously submitted and 

rejected with TRC 127 (Part D Enrollment Rejected; Employer Subsidy Status). 

CMS enforces this two-step process to ensure that the Plan discusses the potential consequences of 

the Part D enrollment (i.e. possible loss of employer health coverage) with the beneficiary before 

CMS accepts the employer subsidy override. 

129 I Part D Enroll 

Accept;Emp 

Sbsdy set; 

Prior Trn 

Reject 

EMP SUB ACC 

Plan Action: Take the appropriate actions as per CMS enrollment guidance. Contact the 

beneficiary to explain the potential consequences of this enrollment. If the beneficiary elects to join 

the Part D plan anyway, the enrollment should be resubmitted with the Employer Subsidy Override 

Flag set. 

This TRC provides additional information about a new enrollment (Transaction Type 61). The 

effective date of the enrollment for which this information is pertinent is reported in TRR data 

record field 18. 

This newly enrolled beneficiary had employer subsidy periods overlapping with the requested 

enrollment period. A prior enrollment transaction was rejected with TRC 127 or 128. The Plan 

resubmission of the enrollment transaction with the Employer Subsidy Override Flag set to Y 

indicates that the Plan has contacted the beneficiary to explain the potential consequences of this 

enrollment, and that the beneficiary elected to join the Part D Plan anyway. 

Plan Action: No action required. Process the accompanying transaction enrollment acceptance 

transaction. 




130 R Part D Opt- 

Out Rejected, 

Opt-Out Flag 

Not Valid 

131 A Part D Opt- 

Out Accepted 

BAD OPT OUT 

CD 

OPT OUT OK 

An opt-out from CMS, disenrollment, PBP enrollment change, or plan submitted Opt-Out 

transaction (Transaction Types 41, 51, 54, 61, 79) was rejected because the Part D Opt-Out Flag 

field was not correctly populated. 

The valid values for Part D Opt-Out Flag are: 

Transaction Types 41 or 79 transactions - ‘Y’ or ‘N’ 

All other Transaction Types - ‘Y,’ ‘N,’ or blank 

Plan Action: If submitted by the Plan (Transaction Types 51, 61, 79), correct the Part D Opt-Out 

Flag value and resubmit the transaction if appropriate. If submitted by CMS (Transaction Types 41, 

54), no Plan action is required. 

A transaction (Transaction Types 51, 79) was received that specified a Part D opt-out flag value or a 

change to the Part D opt-out flag value. The Part D opt-out flag has been accepted. 

The new Part D Opt-Out Flag value is reported in TRR data record field 38. 

133 R Part D Enroll 

Rejected; 

Invalid 

Secndry Insur 

Flag 

Plan Action: No action necessary. 

BAD 2 INS FLAG An enrollment, PBP change transaction or 4Rx record update transaction (Transaction Types 61, 72) 

was rejected because the TRR data file’s Secondary Drug Coverage Flag field was not correctly 

populated. 

The valid values for Secondary Drug Coverage Flag are Y, N or blank. 

Plan Action: Correct the Secondary Drug Coverage Flag and resubmit the transaction if 

appropriate. 




134 I Missing 

Secondary 

Insurance 

Information 

135 M Beneficiary 

Has Started 

Dialysis 

Treatments 


Has Ended 

Dialysis 

Treatments 

NO 2 INS INFO 

DIALYSIS START 

DIALYSIS END 

An Enrollment, PBP Change, or 4Rx Record Update transaction (Transaction Types 61, 72) was 

submitted with the Secondary Insurance Flag set to Y, but the associated secondary insurance fields 

(Secondary RxID and Secondary RxGroup) were not populated. No changes to the beneficiary’s 

secondary insurance information were made. 

This is not a transaction rejection. The submitted transaction was accepted and a reply was 

provided in the TRR with an appropriate acceptance TRC. This reply provides additional 

information about the transaction. The Effective Date of the transaction for which this information 

is pertinent is reported in TRR data record field 18. The Transaction Type will reflect the 

Transaction Type of the submitted transaction. (Transaction Types 61 or 72). 

Plan Action: If appropriate, submit a 4Rx Record Update transaction (Transaction Type 72) with 

the correct Secondary Insurance RxID and Secondary Insurance RxGroup values. 



CMS has been notified that the beneficiary has ESRD and has begun dialysis treatments. The 

effective date of the change is reported in TRR data file field 18. 

Plan Action: Update the Plan’s beneficiary records with the information in the TRR. Take the 




CMS has been notified that the beneficiary has ESRD and is no longer receiving dialysis treatments. 

The effective date of the change is reported in DTRR data file field 18. 

Plan Action: Update the Plan’s beneficiary records with the information in the DTRR. Process the 

TRC 136 to remove the prior period , if the effective date of the TRC 136 (field 18) is equal to the 

“start” date of an ESRD period reported to the Plan previously. Alternatively, process the TRC 136 

to update the prior period, if the effective date of the TRC 136 (field 18) is not equal to the “start” 

date of an ESRD period reported to the Plan in a prior DTRR. Then process the TRC 135 to add the 

new corrected period as of the start date in field 18. The end date of the new, corrected period, if 

there is one, is not included.. Take the appropriate actions as per CMS enrollment guidance. 





Has Received 

a Kidney 

Transplant 


Address 

Change to 

Outside the 

U.S. 

139 A EGHP Flag 

Change 

Accepted 

TRANSPLANT 

ADD 

ADDR NOT U.S. 

EGHP FLAG CHG 



CMS has been notified that the beneficiary has ESRD and has received a transplanted kidney. The 

effective date of the change is reported in TRR data file field 18. 





CMS has been notified that the beneficiary’s address is now outside of the U.S. The effective date 

of the change is reported in TRR data record field 18. 

Plan Action: Research the beneficiary’s new address and update the Plan’s beneficiary records. 


An EGHP Update transaction (Transaction Type 74) was accepted. This transaction changed the 

beneficiary’s EGHP flag. 

The EGHP Update transaction may have been submitted by the Plan or initiated by a CMS User. 

The value in TRR data record field 48 on the TRR record will contain the new EGHP flag. The 

effective date of the change is reported in field 18 of the TRR record and in the EFF DATE column 

on the printed report. 

All data provided for change other than the EGHP Flag fields has been ignored. 






140 A Segment ID 

Change 

Accepted 

141 A Uncovered 

Months 

Change 

Accepted 

143 A Secondary 

Insurance Rx 

Number 

Change 

Accepted 

SEGMENT ID 

CHG 

UNCOV MNTHS 

CHG 

4RX SCD INS 

CHG 

A Segment ID Update transaction (Transaction Type 77) was accepted. This transaction changed 

the Segment ID for the beneficiary. 

The value in TRR data record field 33 contains the new Segment ID. The effective date of the 

change is reported in field 18 

All data provided for change other than the Segment ID field has been ignored. 



A Number of Uncovered Months Record Update transaction (Transaction Type 73) was accepted. 

This transaction updated the creditable coverage information (Creditable Coverage Flag and/or 

Number of Uncovered Months) for the beneficiary. 

The values in TRR data record fields 40 and 41 on the TRR record will contain the new creditable 

coverage values. The effective date of the change is reported in field 18. Total uncovered months 

are displayed in field 24. 

All data provided for change, other than the Uncovered Months fields, has been ignored. 



A 4Rx Record Update transaction (Transaction Type 72) was accepted. This transaction updated 

the secondary drug insurance information (Secondary RxID, Secondary RxBIN, Secondary Rx 

Group, Secondary RxPCN) for the beneficiary. The 4Rx Record Update transaction may have been 

submitted by the Plan or initiated by a CMS User. 

The values in TRR data record fields 46, 47, 60 & 61 on the TRR record will contain the new 

secondary drug insurance information. The effective date of the change is reported in field 18. 

All data provided for change, other than the 4Rx fields, has been ignored. 






144 M PPO changed 

to Direct Bill 


accepted, 

Exceeds 

Capacity 

Limit 

PREM WH OPT 

CHG 

OVER CAP LIMIT 

CMS has changed the Premium Payment Option (PPO) specified on the transaction to “D – Direct 

Bill” for one of the following reasons: 

Retroactive premium withholding was requested. 

The beneficiary’s retirement system [Social Security Administration (SSA), RRB or Office of 

Personnel Management (OPM)] was unable to withhold the entire premium amount from the 

beneficiary’s monthly check. 

The beneficiary has a BIC of M or T and chose “SSA” as the withhold option. SSA cannot 

withhold premiums for these beneficiaries as there is no benefits check from which to 

withhold. 

The beneficiary chose “OPM” as the withhold option. OPM is not withholding premiums at 

this time. 

The Plan has submitted a Part C premium amount that exceeds the maximum Part C premium 

value provided by HPMS. 

RRB Withholding was requested for an effective date prior to 06/01/2011. 

The beneficiary is Out-of-Area for a segmented Contract/PBP. 

Retroactive premium withhold was requested and during one of the periods the beneficiary was 

Out-of-Area for a segmented Contract/PBP. 

This TRC may generate in response to an accepted Enrollment, PBP change, or PPO Change 

transaction (Transaction Types 61, 75) or CMS may initiate it. 

Plan Action: Update the Plan’s beneficiary records to reflect the direct bill payment method. Take 


Although a submitted enrollment or PBP change transaction (Transaction Type 61) was accepted, 

the resulting enrollment count exceeds the capacity limit for the contract or PBP. 


Type 61) for which an acceptance was sent in a separate TRR data record with an enrollment 

acceptance TRC. The effective date of the new enrollment for which this information is pertinent is 

reported in field 18. 

Plan Action: Follow the procedures in CMS enrollment guidance and contact your CMS Central 

Office Health Insurance Specialist. 




152 M Race Code 

Change 

154 M Out of Area 

Status 

155 M Incarceration 

Notification 

Received 

156 F Transaction 

Rejected, 

User Not 

Authrzed for 

Cntrct 

NEW RACE 

CODE 

OUT OF AREA 

INCARCERATED 

BAD USR FOR 

PLN 



CMS has been notified that the beneficiary’s race code has changed. The effective date of the 

change is reported in TRR data file field 18. The new race code will be reported in the next 

Monthly Membership Detail Report (MMR). 


matches the data included in the TRR record. 

This TRC is returned either on a reply with Transaction Type 01 in response to a state and county 

code change or ZIP Code change. It is intended to supply the Plan with additional information about 

the beneficiary. 

In the case of the 01 transaction, CMS has information that the beneficiary is no longer in the Plan’s 

service area. This can be the result of: 

A change in the Plan’s service area and the beneficiary’s address is outside the new area 

A change in the beneficiary’s address which places them Out of area 





CMS has been notified that the beneficiary is incarcerated. The effective date of the change is 

reported in TRR data file field 18. 

Plan Action: Contact the beneficiary to confirm the incarceration. Review full CMS guidance on 

enrollment of incarcerated beneficiaries in the MMCMor PDP Enrollment Guidance and take 

appropriate actions. 

This transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was failed 

because it was submitted by a user who is not authorized to submit transactions for the contract. 

This TRC will not be returned in the TRR. 

Plan Action: Resubmit using the correct submitter if appropriate. 




157 R Contract Not 

Authorized 

for 

Transaction 

Code 

158 M Institutional 

Period 

Change/Canc 

ellation 

159 M NHC Period 

Change/Canc 

ellation 

162 R Invalid 

EGHP Flag 

Value 

165 R Processing 

delayed due 

to MARx 

system 

problems 

UNAUT 

REQUEST 

INST CHANGE 

NHC CHANGE 

BAD EGHP FLAG 

SYSTEM DELAY 

A transaction (Transaction Types 41, 51, 54, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was rejected 

because the Plan is not authorized to submit that type of transaction. 

Plan Action: Correct the Transaction Type and resubmit if appropriate. 



CMS has changed or cancelled an Institutional period for the beneficiary. 





CMS has changed or cancelled a NHC period for the beneficiary. 



An enrollment or EGHP change transaction (Transaction Types 61, 74) was rejected because the 

submitted EGHP Flag value was invalid. 

The valid values for EGHP Flag is Y or blank for enrollment Transaction Type 61. Y or N id 

accepted for EGHP change Transaction Type 74. 

Plan Action: Correct the EGHP Flag value and resubmit if appropriate. 

Processing of this transaction has been delayed due to CMS system conditions. No action is required 

by the user. CMS will process the transaction as soon as possible. 

Plan Action: Wait for further information from CMS. 




166 R Part D FBD 

Auto Enroll 

or Facilitated 

Enroll Reject 

169 R Reinsurance 

Demonstratio 

n Enrollment 

Rejected 

170 I Premium 

Withhold 

Option 

Changed to 

Direct Billing 

171 R Record 

Update 

Rejected, 

Invalid Chg 

Effective Dt 

PARTD AUTO 

REJ 

EMP SUBSIDY 

PREM WH OPT 

CHG 

BAD CHG EFF 

DT 

A plan-submitted auto or facilitated Part D enrollment was rejected because CMS has a record of an 

‘opt out’ option on file for the beneficiary. This beneficiary has “opted out” of auto or facilitated 

enrollment. 

Plan Action: Update the Plan’s records to ensure that the beneficiary is not enrolled in the Plan. 


An enrollment transaction (Transaction Type 61) placing the beneficiary into a reinsurance 

demonstration Plan was rejected because the beneficiary has employer subsidy periods overlapping 

with the requested enrollment period. 

This TRC is equivalent to TRC 127 except that it applies to Reinsurance Demonstration Plans only. 

The requested effective date is reported in TRR data file field 18. 

Plan Action: Contact the beneficiary to explain the potential consequences of this enrollment. If 

the beneficiary elects to join the Part D plan anyway, the enrollment should be resubmitted with the 

Employer Subsidy Override Flag set to Y. 

The beneficiary’s PPO was changed to Direct Billing (D) because the beneficiary is a member of an 

employer group. Retirees who are members of an employer group cannot elect SSA withholding. 

This TRC provides additional information about an enrollment, PBP change, or PPO Change 

transaction (Transaction Types 61, 75) for which an acceptance was sent in a separate Transaction 

Reply with an enrollment acceptance TRC. The Effective Date of the enrollment for which this 

information is pertinent is reported in TRR data record field 18. 

Plan Action: Update the Plan’s billing method and contact the beneficiary to explain the 

consequences of this change. 

An EGHP Change, PPO Change, Segment ID Change, or Part C Premium Change (Transaction 

Types 74, 75, 77, 78) was rejected because the submitted transaction effective date was incorrect. 

The Effective Date on the Transaction Type 75 must be in the CPM to CPM+2 range. 

The Effective Date on the Transaction Types 78 must be in the CPM-3 to CPM+2 range. 

The Effective date on the Transaction Types 74, 76 must be in the CCM-1 to CCM+3 range. 

Plan Action: Correct the effective date and resubmit the transaction if appropriate. 




172 R Change 

Rejected; 

Creditable 

Coverage/2 

Drug Info NA 

173 R Change 

Rejected; 

Premium Not 

Previously 

Set 


Rejected, 

Another 

Transaction 

Accepted 

CRED COV/RX 

NA 

NO PREMIUM 

INFO 

TRANS REJ 

A 4RX or Number of Uncovered Months transaction (Transaction Type 72 or 73) was rejected 

because the information was not applicable to the selected plan type (Mas and other plans without 

drug coverage). Non-drug plans should not submit drug plan information. 

The inappropriate information included on the transaction could be any or all of the following: 

Creditable Coverage Information (Creditable Coverage Flag and Number of Uncovered 

Months) 

Primary Drug Insurance Information (Rx ID, Rx GRP, Rx PCN and Rx BIN) 

Secondary Drug Insurance Information (Secondary Insurance Flag, Rx ID, Rx GRP, Rx PCN 

and Rx BIN) 

Plan Action: Verify that the above fields are not populated and resubmit the transaction if 

appropriate. 

An Uncovered Months, PPO, or Part C premium amount change transaction (Transaction Types 73, 

75, 78) was rejected because the beneficiary’s premium was not established as of the transaction 

effective date. 

Plan Action: Review the beneficiary’s premium data and resubmit if appropriate. 

An enrollment transaction (Transaction Type 61) was rejected. 

A transaction enrolling the beneficiary into another contract was previously accepted. That 

transaction and this submitted one had the same effective and application dates. 

The beneficiary is not enrolled in the Plan in this newly submitted transaction. 





177 M Change in 

Late 

Enrollment 

Penalty 

178 M Late 

Enrollment 

Penalty 

Rescinded 


Accepted, No 

Change to 

Premium 

Record 

NEW PENALTY 

AMT 

PNLTY 

RESCINDED 

NO CHNG TO 

PREM 

This TRC is intended to supply the Plan with additional information about the beneficiary. 

The beneficiary’s total late enrollment penalty has changed. This may be the result of: 

A change to the beneficiary’s number of uncovered months (but there are still uncovered 

months); 

A change to the beneficiary’s LIS status; 

A new Initial Election Period (IEP); or 

The addition, withdrawal, or change in the CMS-granted waiver of penalty. 

Plan Action: Adjust the beneficiary’s payment amount. The new total penalty amount can be 

determined by subtracting amounts in TRR data record fields 53 (waived amount) and 54 

(subsidized amount) from field 52 (base penalty). Take the appropriate actions as per CMS 


This TRC is intended to supply the Plan with additional information about the beneficiary. 

The incremental number of uncovered months associated with the specified effective date has been 

rescinded to zero. The resulting LEP penalty amount reported in TRR data record field 52 (base 

penalty) is the computed penalty associated with all remaining periods of uncovered months. 

Plan Action: Adjust the beneficiary’s payment amount. Take the appropriate actions as per CMS 


A Record Update transaction (Transaction Type 73, 75, 78) was submitted, however, no data change 

was made to the beneficiary’s premium. The submitted transaction contained premium data values 

that matched those already on record with CMS for the specified period. 

This transaction had no effect on the beneficiary’s records. 

Plan Action: Ensure that the Plan’s system reflects the amounts in the TRR record. 




182 I Invalid PTC 

Premium 

Submitted, 

Corrected 


Rejected, 


in Medicaid 

PTC PRM 

OVERIDE 

MBR IN 

MEDICAID 

The Part C premium submitted on the enrollment, PBP change, Enrollment Cancellation, 

Disenrollment Cancellation or Part C Premium Record Update transaction (Transaction Types 61, 

78, 80, 81) does not agree with the Plan’s defined Part C premium rate. The premium has been 

adjusted to reflect the defined rate. The correct Part C premium rate is reported in TRR data record 

field 24. 

If the submitted Part C premium is less than the Basic Part C premium for the plan, MARx will reset 

the premium to the Part C Basic plus Mandatory Supplemental Premium Rate, Net of Rebate from 

the HPMS file. 

This TRC provides additional information about an enrollment, PBP change, Enrollment 

Cancellation, Disenrollment Cancellation or Part C Premium Record Update transaction 

(Transaction Types 61, 78, 80, 81) for which an acceptance was sent in a separate Transaction Reply 

with an enrollment acceptance TRC. The effective date of the enrollment for which this information 

is pertinent is reported in TRR data record field 18. 

Plan Action: Update the Plan’s beneficiary records with the premium information in the TRR 

record. Take the appropriate actions as per CMS enrollment guidance. 

An enrollment transaction (Transaction Type 61) was rejected because the beneficiary was in 

Medicaid status and the Plan is not eligible to enroll Medicaid beneficiaries. 

This TRC is Plan specific. It only applies to MSA/MA and MSA/Demo plans. 

Plan Action: Update the Plan’s beneficiary records to reflect the fact that the beneficiary is not 

enrolled in the Plan. Take the appropriate actions as per CMS enrollment guidance. 




185 M Withholding 

Agency 

Accepted 

Transaction 

ACCEPTED 

CMS submitted information on a beneficiary to SSA/RRB (See TRC 120). TRC 185 is sent to the 

Plan when SSA/RRB acknowledges that they have accepted and processed the beneficiary data. 

If the submittal to SSA/RRB was the result of a requested premium withholding change, TRC 185 

informs the Plan that SSA/RRB has accepted and processed the change. The beneficiary’s PPO is 

reported in DTRR field 39. The effective date of the PPO change is reported in field 18. 

Note: The reported new PPO may be the same as the existing PPO. 

Plans will not see the results of any requested premium withholding changes until TRC 185 is 

received. 

186 I Withholding 

Agency 

Rejected 

Transaction 

REJECTED 

Plan Action: Ensure the Plan’s system matches the information, primarily the PPO, included in the 

DTRR. 

CMS submitted information on a beneficiary to SSA/RRB (See TRC 120). This data transmittal 

was rejected by SSA/RRB. 

This is exclusive to the communication between CMS and SSA/RRB. CMS will continue to 

interface with SSA/RRB to resolve the rejection. 

If CMS is unable to resolve this rejection and the Beneficiary-requested PPO is changed, the Plan 

may receive a TRC 144. 

187 R No Change in 

Number of 

Uncovered 

Mths 

Information 

DUP NO UNCV 

MTH 

Plan Action: No action required. 

A Number of Uncovered Months Record Change transaction (Transaction Type 73) was rejected. 

No data change was made to the beneficiary’s record. The submitted transaction contained Number 

of Uncovered Months Information that matched those already on record with CMS. 


Plan Action: None required. 




188 A No Change in 

Segment ID 


EGHP Flag 


Secondary 

Drug 

Information 

DUP SEGMENT 

ID 

DUP EGHP FLAG 

DUP SECNDARY 

RX 

A Segment ID Update transaction (Transaction Type 77) was accepted, however, no data change 

was made to the beneficiary’s record. The submitted transaction contained a Segment ID value that 

matched the Segment ID already on record with CMS. 



An EGHP Record Update transaction (Transaction Type 74) was submitted, however, no data 

change was made to the beneficiary’s record. The submitted transaction contained an EGHP Flag 

value that matched the EGHP Flag already on record with CMS. 



A 4Rx Record Update transaction (Transaction Type 72) was submitted, however, no data change 

was made to the beneficiary’s record. The submitted transaction contained Secondary Drug 

Insurance Information (Secondary Drug Insurance flag, Secondary Rx ID, Secondary Rx Group, 

Secondary Rx BIN, Secondary Rx PCN) that matched the Secondary Drug Insurance values already 

on record with CMS. 







Premium 

Withhold 

Option 

DUP PRM WH 

OPTN 

A PPO Change transaction (Transaction Type 75) was submitted, however, no data change was 

made to the beneficiary’s record for one of the following reasons: 

1. The submitted transaction contained a PPO value that matched the PPO already on record 

with CMS. 

2. Beneficiary has a premium. Setting the PPO to “no premium”, “N”, is not acceptable. 

Beneficiary premium may be due wholly or in part to a late enrollment penalty. 

3. Beneficiary premiums are zero. Withholding cannot be established. 

4 .A PPO request of ‘Deduct from SSA (S)’ or ‘Deduct from RRB (R)’ was submitted on a 

PPO Change transaction (Transaction Type 75) when the beneficiary has ‘No Premiums’. The 

PPO was set to ‘N’, which matches the PPO already on record with CMS. 






194 M Deemed 

Correction 

DEEMD CORR 



CMS has manually added or updated a co-pay period for this beneficiary. This added or updated 

co-pay period occurs within a period during which the beneficiary is DEEMED by CMS. This is a 

correction. 

Each TRC 194 returns start and end dates, premium subsidy percentage, and copayment category 

for one low income subsidy period affecting a beneficiary’s PBP enrollment. There may be more 

than one TRC 194 returned. The effective date for the added or updated deemed low-income 

subsidy period is shown in the Transaction Reply Report data record Low-Income Period Effective 

Date field (field 51). The new co-pay level is reported in the Low-Income Co-Pay Category field 

(field 50). The Effective Date field (field 18) contains the PBP enrollment period start date. 

Low income scenarios TRC 121 and/or TRC 223 may accompany TRC 194. These three TRCs 

convey the beneficiary’s low income subsidy profile at the time of report generation. They provide 

a full replacement set of low income subsidy data affecting the identified PBP enrollment period. 

This code is considered obsolete as of 1/1/2010. 

195 M SSA 

Unsolicited 

Response 

SSA WHOLD 

UPDT 



An unsolicited response has been received from SSA. The PPO for this beneficiary is set to Direct 

Bill. This action is not in response to a Plan-initiated transaction. 

The effective date of the change is reported in TRR data record field 18. 

Plan Action: Change the beneficiary to direct bill as of the effective date in field 18. Take the 






Rejected, 

Bene not 

Eligible for 

Part D 

197 M Part D 

Eligibility 

Termination 

NO PART D 

PART D OFF 

An enrollment transaction or PBP change transaction (Transaction Type 61) or disenrollment 

cancellation transaction (Transaction Type 81) [enrollment reinstatement] was rejected. Part D 

eligibility is required for Part D plan enrollment. 


beneficiary’s Part D eligibility period 


beneficiary’s Part D eligibility period 



51 and Transaction Type 61. When returned with Transaction Type 01, the TRC is in response to a 

change in beneficiary Part D Eligibility. It is not a reply to a submitted transaction but is intended to 

supply the Plan with additional information about the beneficiary. 

In the case of Transaction Type 01, this beneficiary’s Part D eligibility has been terminated. The 

effective date of the termination is reported in TRR data record fields 18 and 24. 

If applicable, CMS will automatically disenrolls the beneficiary from the plan. A Transaction Type 

51 transaction will be sent in this or another TRR. 



beneficiary’s termination of Part D. The enrollment start date is in TRR data record field 18 and the 










198 M Part D 

Eligibility 

Reinstatemen 

t 

200 R Rx BIN 

Blank or Not 

Valid 

201 R Rx ID Blank 

or Not Valid 

202 R Rx Group 

Not Valid 

PART D ON 

BIN 

BLANK/INVLD 

ID 

BLANK/INVLID 

RX GRP INVALID 



This beneficiary’s Part D eligibility has been reinstated. The effective date Part D eligibility start 

date is reported in TRR data record fields 18 and 24. 



Part D eligibility, the beneficiary has been disenrolled, but not re-enrolled, the reply code is not 

issued. 



An enrollment transaction or 4Rx change transaction (Transaction Types 61, 72) was rejected 

because the primary drug insurance Rx BIN field was either blank or did not have a valid value. 

Exception: Rx Bin for primary drug insurance is not a mandatory field for enrollments transactions 

for PACE National Part D plans. 

Plan Action: Correct the Primary Rx BIN value and resubmit the transaction if appropriate. 


because the primary drug insurance Rx ID field was either blank or does not have a valid value. 

Exception: Rx ID for primary drug insurance is not a mandatory field for enrollments transactions 

for PACE National Part D plans. 

Plan Action: Correct the Primary Rx ID value and resubmit the transaction if appropriate. 


because the primary drug insurance Rx GRP field does not have a valid value. 

Plan Action: Correct the Primary Rx GRP value and resubmit the transaction if appropriate. 




203 R Rx PCN Not 

Valid 

204 A Record 

Update for 

Primary 4Rx 

Data 

Successful 

205 I Invalid 

Disenrollmen 

t Reason 

Code 

206 I Part C 

Premium has 

been 

corrected to 

zero 

RX PCN INVALID 

4RX CHNG 

ACPTED 

INV DISENRL 

RSN 

PTC PREM 

ZEROED 

An enrollment or 4Rx change transaction (Transaction Types 61, 72) was rejected because the 

primary drug insurance Rx PCN field does not have a valid value. 

Plan Action: Correct the Primary Rx PCN value and resubmit the transaction if appropriate. 

A submitted 4Rx Record Update transaction (Transaction Type 72) included a request to change 

primary drug insurance 4Rx data. The 4Rx data were successfully changed. 

Note: At a minimum, values must be provided for both of the mandatory primary 4Rx fields, RX 

BIN and RX ID 


A disenrollment transaction (Transaction Type 51) was submitted with a blank or invalid 

disenrollment reason code. CMS substituted the default value of ‘99’ for the disenrollment reason 

code. 

See Page I-103 for CMS enrollment guidance regarding valid disenrollment reason codes. 

This TRC provides the Plan with additional information on a disenrollment that was processed 

successfully. It is received in addition to the appropriate disenrollment acceptance TRC. 


An enrollment, PBP change or Part C Premium Update transaction (Transaction Types 61, 78) was 

submitted and accepted for a Part D only Plan. This transaction contained an amount other than 

zero in the Part C premium field. Since a Part C premium does not apply to a Part D only Plan, the 

Part C premium has been corrected to be zero. 

This TRC provides additional information about an enrollment, PBP change, or Part C Premium 

Update transaction (Transaction Types 61, 78) for which an acceptance was sent in a separate 

Transaction Reply with an acceptance TRC. The effective date of the enrollment for which this 

information is pertinent is reported in TRR data record field 18. 


matches zero Part C premium amount included in the TRR record. 




209 R 4Rx Change 

Rejected, 

Invalid 

Change 

Effective 

Date 

210 A POS 

Enrollment 

Accepted 

211 R Re- 

Assignment 

Enrollment 

Rejected 

212 A Re- 

Assignment 

Enrollment 

Accepted 

NO ENROLL 

MATCH 

POS 

ENROLLMENT 

RE-ASN ENRL 

REJ 

REASSIGN 

ACCEPT 

A 4Rx change transaction (Transaction Type 72) for 4Rx information for primary drug insurance 

was rejected because the beneficiary was not enrolled as of the submitted transaction effective date. 

Plans may only submit 4Rx data for periods when the beneficiary is enrolled in the Plan. 

Plan Action: Correct the dates and resubmit the transaction if appropriate. 

An enrollment into a POS designated Part D plan that was submitted by a Point Of Sale (POS/POS 

10) contractor or CMS (MBD) has been successfully processed. The effective date of the new 

enrollment is shown in the Effective Date (field 18) of the TRR data record. The date in field 18 

will always be the first day of the month. 



A reassignment enrollment request transaction (Transaction Type 61) which would move the 

beneficiary into another Part D plan was rejected because CMS has record of an “Opt-Out” option 

on file for the beneficiary. The beneficiary has ‘opted out’ of auto or facilitated enrollment. 

Plan Action: Do not move the beneficiary’s enrollment to the new Plan. Keep the beneficiary in 

the Plan in which they are currently enrolled. Take the appropriate actions as per CMS enrollment 

guidance. 

A reassignment enrollment request transaction (Transaction Type 61) to move the beneficiary into a 

new Part D Plan has been successfully processed. The beneficiary has been moved from the 

original contract and PBP to the new contract and PBP. The effective date of enrollment in the new 

PBP is reported in fields 18 and 24 of the TRR data record. 

Other accompanying replies with different TRCs may give additional information about this 

accepted reassignment. 

Field 20 (Plan Benefit Package ID) contains the new PBP identifier and the old PBP is reported in 

field 29 (Prior Plan Benefit Package ID). 

Plan Action: Update the Plan’s records accordingly with the information in the TRR record, 

ensuring that the Plan’s beneficiary’s information reflects enrollment in the new contract and PBP. 




213 I Premium 

Withhold 

Exceeds 

Safety Net 

Amount 

215 R Uncovered 

Months Chng 

Rejected, 

Incorrect Eff 

Date 

216 I Uncovered 

months 

exceeds max 

possible 

value 

217 R Cant Change 

number of 

uncovered 

months 

EXCEED SNET 

AMT 

BAD NUNCMO 

EFF 

NUNCMO EXDS 

MAX 

CANT CHG 

NUNCMO 

CMS has changed the PPO specified on the transaction to “D – Direct Bill” because the transaction 

would result in SSA withholding exceeding the Safety Net amount from the beneficiary’s check in 

one month. 

This TRC may be generated in response to an accepted enrollment or PBP change (Transaction 

Type 61), NUNCMO Record Update (Transaction Type 73), Part C Premium Update (Transaction 

Type 78), PPO Change (Transaction Type 75), or may be initiated by CMS. 

Plan Action: Change the beneficiary to Direct Bill and contact them to explain the consequences of 

the PPO change. Take the appropriate actions as per CMS enrollment guidance. 

A NUNCMO Change (Transaction Type 73) transaction was rejected because the submitted 

effective date is incorrect. The date may have been incorrect for one of the following reasons: 

The submitted effective date is prior to August 1, 2006; 

The submitted effective date is after the Current Calendar Month (CCM) plus 3; or 

The submitted effective date falls within a Part D plan enrollment but does not match the 

contract enrollment start date. 

Plan Action: Correct the effective date and resubmit the transaction if appropriate. If the Plan is 

trying to correct the uncovered months value for a beneficiary who is no longer enrolled in the Plan, 

contact their CMS Representative. 

The NUNCMO provided on an accepted enrollment transaction (Transaction Type 61) exceeds the 

maximum possible value. 

This will NOT cause the rejection of the enrollment transaction but zero uncovered months (000) is 

associated with the effective date of the enrollment. 

This informational TRC is generated in addition to the transaction’s acceptance TRC. 

Plan Action: Update the Plan’s beneficiary records to reflect the zero uncovered months. If the 

NUNCMO should be another value, review CMS enrollment guidance and correct the NUNCMO 

value using a new NUNCMO Record Update (Transaction Type 73) transaction. 

An uncovered months change transaction (Transaction Type 73) was rejected because the submitted 

transaction attempted to change the number of uncovered months for an effective date 

corresponding to a “LEP Reset” transaction in the CMS database. 

Plan Action: Review CMS enrollment guidance. If appropriate, submit a Number of Uncovered 

Months Record Update transaction (Transaction Type 73) to UNDO the LEP Reset. 




218 M LEP Reset 

Undone 

219 M LEP Reset 

Accepted 


Rejected; 

Invalid POS 

Enroll Source 

CD 

222 I Bene 

Excluded 

from 

Transmission 

to SSA/RRB 

LEP RESET 

UNDNE 

LEP RESET 

BAD POS 

SOURCE 

BENE 

EXCLUSION 

CMS has reestablished the beneficiary’s late enrollment penalty (LEP). The previous LEP RESET 

was removed. 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s LEP 

information matches the data included in the TRR record. Take the appropriate actions as per CMS 


CMS has reset the beneficiary’s number of uncovered months to zero. The Late Enrollment Penalty 

(LEP) amount is now zero. 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s LEP 

information matches the data included in the TRR record. Take the appropriate actions as per CMS 


Enrollment source code submitted by a POS/POS 10 contractor for a POS/POS 10 enrollment 

transaction was other than ‘G’. Transaction rejected. 

Plan Action: Correct the Enrollment Source Code and resubmit transaction if appropriate. 

This TRC can be returned on a reply with various Transaction Types (51, 61, 73, 78) and the 

maintenance Transaction Type (01). It is intended to supply the Plan with additional information 

about the beneficiary. 

CMS has excluded beneficiary from transmission to SSA/RRB. 






Period 

Removed 

from 

Enrollment 

Period 

LIS REMOVED 


transaction but is intended to supply the Plan with additional information about the beneficiary. It is 

returned for each low income subsidy period removed and not replaced over the course of a PBP 

enrollment. 

The enrollment period description is identified in Field 66 with a ‘C’ for current enrollees, ‘P’ for 

prospective enrollees, and ‘Y’ for previous enrollees. 

The beneficiary’s Low-Income Subsidy source will be identified in Field 65 with an ‘A’ for 

Approved SSA Applicants or a ‘D’ for Deemed beneficiary by CMS. 

The following LIS information is displayed on the Transaction Reply Report (TRR) for TRC 223: 

PBP Enrollment Effective Date (Field 18) 

Part D Low-income Premium Subsidy Level (Field 49) 

Low-income Co-Pay Category (Field 50) 

Low-income Period start date (Field 51) 

Low-income Period End Date (Field 64) 

Low-income Period Subsidy Source (Field 65) 

Enrollment Period Description (Field 66) 

Low income subsidy TRC 121 may accompany TRC 223. These three TRCs convey the 

beneficiary’s low income subsidy profile at the time of report generation. They provide a full 

replacement set of low income subsidy data affecting the PBP enrollment period. 



224 A A/D MSP 

Beneficiary 

Transaction 

Accepted 

MSP ACCEPTED 

Aged/Disabled MSP Beneficiary transaction (85) accepted. 

Plan Action: None Required. 




225 I Exceeds SSA 

Benefit & 

Safety Net 

Amount 

INSUF 

FUND&SNET 

CMS has changed the PPO specified on the transaction to “D – Direct Bill” because the transaction 

would result in the SSA benefit being insufficient to cover the withholding and the withholding 

would exceed the Safety Net amount. 

This TRC may be generated in response to an accepted enrollment or PBP change (Transaction 

Type 61), NUNCMO Record Update (Transaction Type 73), Part C Premium Update (Transaction 

Type 78), PPO Change (Transaction Type 75), or may be initiated by CMS. 

235 I SSA 

Accepted Part 

B Reduction 

Transaction 

236 I SSA Rejected 

Part B 

Reduction 

Transaction 

SSA PT B 

ACCEPT 

SSA PT B REJECT 

Plan Action: Change the beneficiary to direct bill and contact them to explain the consequences of 

the PPO change. Take the appropriate actions as per CMS enrollment guidance. 

CMS submitted Part B Reduction information on a beneficiary to SSA (See TRC 237). TRC 235 is 

sent to the Plan when SSA acknowledges that they have accepted and processed the beneficiary 

data. 

If the submittal to SSA was the result of a requested Part B Reduction change, TRC 235 informs the 

Plan that SSA has accepted and processed the change. 

Plans will not see the results of any requested Part B Reduction changes until TRC 235 is received. 


CMS submitted Part B Reduction information on a beneficiary to SSA (See TRC 237). This data 

transmittal was rejected by SSA. 

This is exclusive to the communication between CMS and SSA. CMS will continue to interface 

with SSA to resolve the rejection. 





237 I Part B 

Premium 

Reduction 

Sent to SSA 

PT B RED 

UPDATE 

As a result of an accepted Plan-submitted transaction (Transaction Types 51, 61, 72, 73, 75, 78) or 

UI update to a beneficiary’s records, information has been forwarded to SSA to update SSA records 

and implement any requested Part B premium reduction changes. 

Any requested change will not take effect until an SSA acceptance is received. Plans are notified of 

the SSA acceptance with a TRC 235 on a future TRR. 

Plan Action: None required. Take the appropriate actions as per CMS enrollment guidance. 


Received, 

Withholding 

Pending 

241 I No Change in 

Part D Opt 

Out Flag 

WHOLD UPDATE 

DUP PTD OPT 

OUT 

Note: The Plan will not see the result of any Part B Reduction change until they have received a 

TRC 235 on a future TRR. 

As a result of an accepted Plan-submitted transaction to update a beneficiary’s PPO (Transaction 

Type 75) or a UI update of same, a request will soon be forwarded to SSA. 

Plans will receive TRC 120 when this request is forwarded to SSA. Plans are notified of the 

subsequent SSA acceptance or rejection of the PPO change with a TRC 185 or 186, respectively, on 

a future TRR. 

All data provided for change other than the PPO field was ignored. 


Note: The Plan will not see the result of any PPO change until they have received a TRC 185 on a 

future TRR. 

A Part D Opt-Out Record Update transaction (Transaction Type 79) was submitted, however, no 

data change was made to the beneficiary’s record. The submitted transaction contained a Part D Opt 

Out Flag value that matched the Part D Opt Out Flag already on record with CMS. 







Primary Drug 

Information 

DUP PRIMARY 

RX 

A 4Rx Record Update transaction (72) was submitted, however, no data change was made to the 

beneficiary’s record. The submitted transaction contained Primary Drug Insurance Information 

(Primary Rx ID, Primary Rx Group, Primary Rx BIN, Primary Rx PCN) that matched the Primary 

Drug Insurance values already on record with CMS. 


243 R Change to 

SSA 

Withholding 

rejected due 

to no SSN 

NO SSN AT CMS 


A PPO Change transaction (Transaction Type 75) was submitted to change the beneficiary’s PPO to 

SSA withholding, however, there is no Social Security Number (SSN) on file at CMS. The 

beneficiary’s PPO is not changed to SSA withholding. 

The beneficiary’s records were unchanged. 

245 M Member has 

MSP period 

252 I Prem 

Payment 

Option 

Changed to 

Direct Bill; 

No SSN 

253 M Changed to 

Direct Bill; 

no Funds 

Withheld 

MEMBER IS MSP 

W/O CHG;NO 

SSN 

W/O CHG;NO 

W/H 

Plan Action: Update the Plan’s beneficiary record accordingly. Take the appropriate action with 

member as per CMS enrollment guidance. 

The beneficiary has other insurance and Medicare is secondary payer. 

All plans whose payments are impacted by the MSP notification will receive the TRC. 

Plan Action: Update the Plan’s records accordingly. 

CMS has changed the PPO specified on the transaction to “D – Direct Bill” because the beneficiary 

does not have a Social Security number on file at CMS. 

This TRC may be generated in response to an accepted Enrollment, PBP change or PPO Change 

transaction (Transaction Types 61 or, 75) or may be initiated by CMS. 


the appropriate actions with member as per CMS enrollment guidance. 

CMS has changed the PPO to “D-Direct Bill” because no funds have been withheld by the 

withholding agency in the two months since withholding was accepted. 


the appropriate actions with member as per CMS enrollment guidance. 




254 I Beneficiary 

set to Direct 

Bill, spans 

jurisdiction 

DIR BIL 

JRSDCTN 

CMS has changed the PPO to “D-Direct Bill” because the withholding request spans two different 

withholding agency jurisdictional periods. This could occur for one of the following reasons: 

SSA is the beneficiary’s current withholding agency but the withholding request contains 

one or more periods from when RRB was the beneficiary’s withholding agency. 

RRB is the beneficiary’s current withholding agency but the withholding request contains 

one or more periods from when SSA was the beneficiary’s withholding agency. 

255 I Plan 

Submitted 

RRB W/H for 

SSA 

Beneficiary 

256 I Plan 

Submitted 

SSA W/H for 

RRB 

Beneficiary 

257 F Failed; Birth 

Date Invalid 

for Database 

Insertion 

RRB WHOLD 4 

SSA 

SSA WHOLD 4 

RRB 

Plan Action: Update the Plan’s beneficiary records to reflect the Direct Bill payment method. 

Take the appropriate actions with member as per CMS enrollment guidance. 

CMS has changed the PPO to “S-SSA Withhold” because SSA is the correct withholding agency for 

this beneficiary. 


CMS has changed the PPO to “R-RRB Withhold” because RRB is the correct withholding agency 

for this beneficiary. 


INVALID DOB An Enrollment transaction (Transaction Type 61), change transaction (Transaction Types 72, 73, 74, 

75, 77, 78, 79), residence address transaction (Transaction Type 76), or cancellation transaction 

(Transaction Types 80, 81) failed because the submitted birth date was either 

Not formatted as YYYYMMDD (e.g., “Aug 1940”), or 

Formatted correctly but contained a nonexistent month or day (e.g., “19400199”). 

As a result, the beneficiary could not be identified. The transaction record will not appear on the 

TRR (TRR) data file but will be returned on the Batch Completion Status Summary (BCSS) data 

file along with the failed record. 

Plan Action: Correct the date format and resubmit transaction. 




258 F Failed; Efctv 

Date Invalid 

for Database 

Insertion 

INVALID EFF DT 

A disenrollment transaction (Transaction Types 51, 54), enrollment transaction (Transaction Type 

61), change transaction (Transaction Types 72, 73, 74, 75, 77, 78, 79), residence address transaction 

(Transaction Type 76), or cancellation transaction (Transaction Types 80, 81) failed because the 

submitted effective date was either, 

Blank, 

Not formatted as YYYYMMDD (e.g., “Aug 1940”), or 

Formatted correctly but contained a nonexistent month or day (e.g., “19400199”). 

The transaction record does not appear on the TRR data file is returned on the BCSS data file along 

with the failed record. 

259 F Failed; End 

Date Invalid 

for Database 

Insertion 

INVALID END 

DT 


A residence address transaction (Transaction Type 76) failed because the submitted end date was 

either not formatted as YYYYMMDD (e.g., “Aug 1940”) or was formatted correctly but contained a 

nonexistent month or day (e.g., “19400199”). The transaction record does not appear on the TRR 

data file is returned on the BCSS data file along with the failed record. 

260 R Rejected; Bad 

End Date on 

Residence 

Address 

Change 

BAD RES END 

DT 


A residence address transaction (Transaction Type 76) was rejected because the End Date is not 

appropriate for one or more of the following reasons: 

It is earlier than address change start date, 

It is not the last day of the month, or 

It is not within the contract enrollment period. 

Plan Action: Correct the End Date and resubmit. 





Incomplete 

Residence 

Address 

Information 

BAD RES ADDR 

A residence address transaction (Transaction Type 76) was rejected for one of the following 

reasons: 

The residence address information was incomplete – 

Residence Address Line 1 was empty, 

Residence City was empty, 

USPS state code was missing, 

Residence zip code was missing or non-numeric, 

The value specified for the Address Update/Delete Flag was blank or not valid, 

The supplied residence address information could not be resolved in terms of identifiable 

address components, or 

The address was not a U.S. address. 

262 R Bad RRB 

Premium 

Withhold 

Effective 

Date 

263 F Failed; 

Aplctn Date 

Invalid for 

Database 

Insertion 

264 I Payment Not 

Yet 

Completed 

INVALID EFF 

DTE 

INVALID APP DT 

NO PAYMENT 

Plan Action: Correct address information and resubmit. 

A PPO Change Transaction (Transaction Type 75) was rejected because request for RRB 

withholding is NOT allowed for effective date prior to 6/1/2011. 

Plan Action: Correct the Effective date and resubmit. 

An enrollment transaction (Transaction Type 61) failed and did not process because the submitted 

application date was either not formatted as YYYYMMDD (e.g., “Aug 1940”) or was formatted 

correctly but contained a nonexistent month or day (e.g., “19400199”). The transaction record does 

not appear on the TRR data file is returned on the BCSS data file along with the failed record. 


A transaction was accepted requiring a payment calculation. This calculation was not completed. 

Plan Action: No action is required. 




265 A Residence 

Address 

Change 

Accepted, 

New SCC 

266 R Unable to 

Resolve SSA 

State County 

Codes 

267 M PPO set to N 

due to No 

Premium 


Has Dialysis 

Period 

RES ADR SCC 

SCC 

UNRESOLVED 

PPO SET TO N 

DIALYSIS 

EXISTS 

A residence address change transaction (Transaction Type 76) was accepted. This beneficiary’s 

state and county code (SCC) information may have changed. SCC values are returned in TRR data 

record fields 9 (state code) and 10 (county code) and together in field 24. The residence address 

period start date is in field 18. Any provided end date is in field 24. 

This TRC is accompanied by TRC 085 if the submitted residence address has changed the 

beneficiary’s SCC. 

This TRC may be accompanied by TRC 154 if the submitted residence address has placed the 

beneficiary outside the plan’s service area. 


A residence address transaction (Transaction Type 76) was rejected because SSA state and county 

codes (SCC) could not be resolved. The beneficiary’s residence address was not changed. 

Plan Action: Confirm the address specified in the transaction. Update and resubmit the transaction 

if necessary; otherwise, contact your district office for assistance. 

The beneficiary’s PPO was set to N because their premium is $0. This occurs as part of an end-ofyear 

process based on the Plan’s basic Part C premium for the upcoming year. 

Plan action: Submit a transaction to reset the Part C premium and to renew a request for 

withholding status if appropriate. 

This TRC is returned on an enrollment. It is intended to supply the Plan with additional information 

about the beneficiary. Each TRC 268 returns start and end dates for each dialysis period that 

overlaps the enrollment period. There may be more than one TRC 268 returned. 

The effective date for the dialysis period is shown in the Effective Date field (field 18). The end 

date, if one exists, is in the Open Data field (field 24). 







Has 

Transplant 

TRNSPLNT 

EXISTS 

This TRC is returned on an enrollment. It is intended to supply the Plan with additional information 

about the beneficiary. Each TRC 269 returns transplant and failure dates for each kidney transplant 

that overlaps the enrollment period. There may be more than one TRC 269 returned. 

The transplant date is shown in the Effective Date field (field 18). The end date, if one exists, is 

shown in Transplant End Date (field 24). 


Transplant 

Has Ended 

280 I Member MSP 

Period Ended 

282 A Residence 

Address 

Deleted 

283 R Residence 

Address 

Delete 

Rejected 

TRANSPLANT 

END 

MEMBER NOT 

MSP 

RES ADR DELTD 

RJCTD ADR 

DELT 





CMS was notified that the beneficiary’s transplant s failed or was an error. The effective date of 

the failure or removal is reported in field 18 of the TRR record and in the EFF DATE column on the 

printed report. 



The beneficiary’s Medicare as Secondary Payer period has ended. 

All plans whose payments are impacted by the MSP notification will receive the TRC. 


The residence address associated with the TRR data record effective date (in field 18) has been 

deleted and is no longer valid. 

The address was removed either through “delete” action via the 76 transaction or because an 

overlapping residence address change was submitted with the same or earlier effective date. 


The residence address delete attempted was rejected. No residence address exists for the effective 

date provided. See TRR data record, field 18. 

Plan Action: Correct effective date and resubmit. 




284 R Cancellation 

Rjctd, Prior 

Enroll/Disenr 

oll Changed 

285 I Enrollment 

Cancellation 

Accepted 

286 R Enrollment 

Cancellation 

Rejected 

287 A Enrollment 

Reinstated 

NO REINSTATE 

ACPT ENROLL 

CAN 

RJCT ENROLL 

CAN 

ENROLL 

REINSTAT 

A Disenrollment Cancellation (Transaction Type 81) was rejected. The cancellation action 

attempted the reinstatement of the enrollment and this reinstatement could not be accomplished. 

The reinstatement could not be accomplished because some aspect of the enrollment, or the 

beneficiary’s status during that enrollment, has been changed by the Plan (examples include: 4Rx, 

Residence Address or Segment ID) prior to their issuance of this current cancellation transaction. 

Plan Action: Enroll the beneficiary using a Transaction Type 61, Enrollment. 

An Enrollment Cancellation (Transaction Type 80) transaction was accepted. The identified 

enrollment is cancelled. The start date of the cancelled enrollment period is reported in the TRR data 

record Effective Date field, field 18. 


An Enrollment Cancellation (Transaction Type 80) transaction was rejected. Rejection occurred for 

one of the following reasons: The cancellation was submitted more than one month after the 

enrollment became active, the transaction attempts to cancel a Rollover, Auto or Facilitated 

Enrollment, or when the transaction attempts to cancel a closed enrollment period. 

Plan Action: Submit a Disenrollment transaction. 

The identified enrollment period was reinstated. The start date of the reinstated period is reported in 

the TRR data record Effective Date field, field 18. The reinstatement occurred for one of the 

following reasons: 

For Transaction Type 80, cancellation of another plan’s enrollment; 

For Transaction Type 01, change or removal of a date of death. 

If the reinstated enrollment has an end date, it is reported in the TRR data record field 24. The end 

date may or may not have existed with the enrollment originally. 

Plan Action: Update the Plan’s records accordingly following CMS guidance for enrollment 

reinstatement. 




288 A Disenrollmen 

t Cancellation 

Accepted 

289 R Disenrollmen 


Rejected 

290 I IEP 

NUNCMO 

Reset 

ACPT DISNRL 

CAN 

RJCT DISNRL 

CAN 

NUNCMO RSET 

IEP 

A Disenrollment Cancellation (Transaction Type 81) transaction was accepted. The identified 

disenrollment was cancelled. The start date of the cancelled disenrollment period is reported in the 

TRR data record Effective Date field, field 18. 

The Disenrollment Cancellation (Transaction Type 81) may have been submitted by a Plan or the 

result of a Date of Death Change or Date of Death Rescinded notification that cancels an autodisenrollment 

that was created by a Date of Death notification. 


A Disenrollment Cancellation (Transaction Type 81) transaction was rejected. Rejection occurred 

for one of the following reasons: 

Beneficiary was still enrolled in plan, never disenrolled; 

Beneficiary was not enrolled in the plan; 

Disenrollment being cancelled was not submitted by the Plan 

Cannot restore prior enrollment due to associated disenrollment reason codes 5, 6, 8, 9, 10, 13, 

15, 18, 19, 54, 56, 57, 61 

Reinstated enrollment would conflict with another existing enrollment. 

Plan Action: Submit Enrollment transaction. 

This TRC was the result of an automatic system reset, or zeroing, of the cumulative uncovered 

months for the identified beneficiary. This reset occurred for one of the following reasons: 

Disabled beneficiary became age-qualified for Medicare, 

An aged beneficiary had a retroactive NUNCMO transaction with an effective date prior to 

aged qualification at the beginning of the IEP period. 

Reset effective date is in TRR data record, field 18. 

Plan Action: Update plan records accordingly. 





Reinstated, 

Disenrollmen 



t Rejected, 

Was 

Cancellation 

Attempt 

293 A Disenroll, 

Failure to Pay 

Part D 

IRMAA 

294 I No 4Rx 

Insurance 

Changed 


NUNCMO 

RESET 

ENROLL 

REINSTAT 

NOT 

CANCELLATN 

FAIL PAY PTD 

IRMAA 

NO INSUR 

CHANGE 

NUNCMO RSET 

LIS 

A Disenrollment Cancellation (Transaction Type 81) transaction cancelled a disenrollment and the 

enrollment was reinstated. The start date of the reinstated period is reported in the TRR data record 

Effective Date field, field 18. 

If the reinstated enrollment has an end date, it is reported in the TRR data record, field 24. The end 

date may or may not have existed with the enrollment originally. 

Plan Action: Update the Plan’s records accordingly following CMS guidance for enrollment 

reinstatement. 

A Disenrollment transaction (Transaction Type 51) was rejected. The submitted disenrollment 

effective date is the same as the enrollment start date. Only Auto or Facilitated enrollments may be 

cancelled using the Transaction Type 51. 

Plan Action: Submit an Enrollment Cancellation transaction (Transaction Type 80) if it is desired 

to cancel the enrollment; otherwise, correct the disenrollment effective date and resubmit. 

A disenrollment transaction (Transaction Type 51) has been successfully processed due to failure to 

pay Part D IRMAA. The last day of the enrollment is reported in TRR data record fields 18 and 24. 

The disenrollment date is always the last day of the month. 

Plan Action: Ensure the Plan’s system matches the information included in the TRR record and that 

the beneficiary’s disenrollment date matches the date in field 24. Take the appropriate actions as 

per CMS enrollment guidance. 

A 4Rx Change (Transaction Type 72) transaction was received with no primary or secondary 

insurance information provided on the transaction. No insurance data changes took place for this 

beneficiary. 

Plan Action: Resubmit with new 4Rx data as needed. 

This TRC was the result of an automatic system reset, or zeroing, of the cumulative uncovered 

months for the identified beneficiary. This reset occurred because the beneficiary has been 

identified as having the Part D low-income subsidy. 

Reset effective date is in TRR data record, field 18. 

Plan Action: Update plan records accordingly. 




299 M Correction to 

Previously 

Failed 

Payment 

300 R NUNCMO 

Change 

Rejected, 

Exceeds Max 

Possible 

Value 

301 M Merged 

Beneficiary, 

Claim 

Number 

Change 

RESTORED 

PYMT 

NM CHG EXDS 

MAX 

BENE HICN 

MERGE 

This TRC was generated to indicate that a previously incomplete payment calculation has been 

completed. 


A NUNCMO Record Update transaction (73) was rejected because the NUNCMO provided exceeds 

the maximum possible value. The original (existing) number of uncovered months has been 

retained. 

Plan Action: Review the number of uncovered months and/or the effective date submitted. If the 

number of uncovered months and/or the effective date should be another value, review CMS 

enrollment guidance and correct the NUNCMO value using a new NUNCMO Record Update (73) 

transaction. 



This beneficiary had multiple conflicting claim numbers (HICNs) which were merged under a single 

HICN. This TRR reports the VALID HICN in field 1 and the INVALID HICN in field 24. 

302 M Enrollment 

Cancelled, 

Claim 

Number 

Change 

ENRL CNCL 

MERGE 

Plan Action: Update the Plan’s records to use the VALID HICN from field 1 for this 

beneficiary. The valid claim number must be used on all future transactions for this beneficiary. 



This beneficiary had multiple conflicting HICNs, which were merged into one. Plan enrollments for 

the conflicting HICNs have been combined under a valid HICN. This enrollment conflicted with 

another existing enrollment. As a result, the conflicting enrollment period was cancelled. The 

effective date of the enrollment which has been cancelled is reported in the Effective Date field (18). 

The termination date of the enrollment (if present) is reported in field 24. 

Plan Action: Because the enrollment period is now cancelled, the enrollment period should be 

adjusted in the Plan’s enrollment records. This change may impact premiums that you collected 

directly from the beneficiary. Take the appropriate actions as per CMS enrollment guidance. 




303 M Termination 

Date Change 

due to 

Beneficiary 

Merge 

TRM DT CHG 

MERGE 



This beneficiary had multiple conflicting claim numbers (HICNs) which were merged into 

one. Plan enrollments for the conflicting HICNs have been combined under a valid HICN. This 

enrollment conflicted with another existing enrollment. Current enrollment rules regarding the 

application signature date were applied and this enrollment’s termination date was changed from the 

original date. The effective date of the enrollment with the changed termination date is reported in 

the Effective Date field (18). The new termination date of this enrollment is reported in Field 24. 

305 M ZIP Code 

Change 

306 R NUNCMO 

Change 

Rejected, No 

Part D 

Eligibility 

307 A MMP Passive 

Enrollment 

Accepted 

ZIP CODE 

CHANGE 

NUNCMO, NO 

PTD 

PASSIVE 

ACCEPT 

Plan Action: Because the termination date has changed, the enrollment period should be adjusted 

in the Plan’s enrollment records. This change may impact premiums that you collected directly 

from the beneficiary. Take the appropriate actions as per CMS enrollment guidance. 

A notification has been received that this beneficiary’s zip code has changed. The new zip code is 

reported in field 24 of the TRR. The effective date of the change is reported in field 18. 

Note: A reply with this TRC only reports changes in the Zip Code the beneficiary has on file with 

SSA/CMS. It does not report changes in a Plan-submitted Residence Address. 



A NUNCMO Change transaction (Transaction Type 73) was rejected because beneficiary does not 

have Part D Eligibility as of the submitted effective date. 

Plan Action: Verify the beneficiary identifying information and resubmit the transaction with 

updated information, if appropriate. 

An MMP passive enrollment transaction (TC 61) successfully processed. The effective date of the 

new enrollment is reported in DTRR field 18. 

This is the definitive enrollment acceptance record. Other accompanying replies with different 

TRCs may give additional information about this enrollment. 

Plan Action: Ensure the Plan’s system matches the information included in the DTRR record. Take 





308 R MMP Passive 

Enrollment 

Rejected 


MMP Opt- 

Out Flag 

310 R MMP Opt- 

Out Rejected, 

Invalid Opt- 

Out Code 

311 A MMP Opt- 

Out Accepted 

312 A MMP 

Enrollment 

Cancellation 

Accepted 

313 R MMP 

Enrollment 

Cancellation 

Rejected 

PASSIVE REJECT 

DUP FA OPT OUT 

BAD FA OPT 

OUT 

FA OPT OUT 

ACPT 

ACPT FA 

CANCEL 

RJCT FA 

CANCEL 

An MMP passive enrollment transaction (TC 61) was rejected because the beneficiary did not meet 

the MMP requirements or the beneficiary opted out of passive enrollment. 

The attempted enrollment effective date is reported in DTRR fields 18 and 24. 


An MMP Opt-Out Record Update transaction (TCs 42, 83) was submitted; however, no data change 

was made to the beneficiary’s record. The submitted transaction contained an MMP Opt-Out Flag 

value that matched the MMP Opt-Out already on record with CMS. 

This transaction did not affect the beneficiary’s records. 


An opt-out from CMS, disenrollment, or Plan submitted Opt-Out transaction (TCs 42, 51, 54, 82, 

83) was rejected because the MMP Opt-Out Flag field was incorrectly populated. 

The valid values for MMP Opt-Out are: 

TCs 42 or 83 transactions - ‘Y’ or ‘N’ 

All other TCs - ‘Y,’ ‘N,’ or blank 

Plan Action: If submitted by the Plan (TCs 51, 82, 83), correct the MMP Opt-Out Flag value and 

resubmit the transaction if appropriate. 

A transaction (TCs 42, 51, 54, 82, 83) was received that specified an MMP Opt-Out Flag value or a 

change to the MMP Opt-Out Flag value. The MMP Opt-Out Flag was accepted. 

The new MMP Opt-Out Flag value is reported in DTRR field 70. 

Plan Action: No action necessary. 

An Enrollment Cancellation (TC 82) was accepted. The identified enrollment was cancelled. The 

start date of the cancelled enrollment period is reported in DTRR field 18. 


An MMP Enrollment Cancellation (TC 82) transaction was rejected because the cancellation was 

submitted after the enrollment became active. 

Plan Action: Submit a Disenrollment transaction. 




314 R Invalid 

Cancellation 

TC 

BAD CANCEL 

CODE 

An enrollment cancellation transaction was rejected because the wrong transaction type code (Field 

16) was used. 

TC 82 can only be used for cancelling MMP enrollments. TC 80 is only used for cancelling non- 

MMP enrollments. 

316 I Default 

Segment ID 

Assignment 

DEFAULT SEG ID 

Plan Action: Correct the TC and resubmit if appropriate. 

A default Segment ID is assigned because the beneficiary is Out-of-Area for the Contract/PBP. The 

default Segment ID is the lowest valid Segment for the Contract/PBP. 

The following fields populate in the DTRR when this TRC is returned: 

Field 1: HICN 

Field 2: Surname 

Field 3: First Name 

Field 4: Middle Initial 

Field 5: Gender Code 

Field 6: Date of Birth 

Field 7: Record Type 

Field 8: Contract Number 

Field 9: State Code 

Field 10: County Code 

Field 15: TRC 

Field 16: Transaction Type 

Field 18: Request effective Date 

Field 20: PBP ID 

Field 22: Transaction Date 

Field 24: Comment (Previous Segment Number, if applicable) 

Field 28: Source ID 

Field 30: Application Date 

Field 33: Segment Number 

Field 36: Election Type 

Field 37: Enrollment Source 

Field 43: Processing Timestamp 

Field 68: TRC Short Name 

Field 75: System-Assigned Transaction Tracking ID 

Field 76: Plan-Assigned Transaction Tracking ID 

Plan Action: Verify the beneficiary’s address is correct. Submit a Residence Address Change if 




317 I Segment ID 

Reassigned 

after Address 

Update 

SEG ID 

REASSIGN 

appropriate. 

A Segment ID is reassigned because updated address information is received. The updated address 

information either results from a Plan-submitted Residence Address Change (Transaction Type 76) 

or a SCC change notification. 

The following fields populate in the DTRR when this TRC is returned: 

Field 1: HICN 










Field 15: TRC 

Field 16: Transaction Type 

Field 18: Request effective Date 

Field 20: PBP ID 


Field 24: Comment (Previous Segment Number, if applicable) 


Field 30: Application Date 

Field 33: Segment Number 

Field 36: Election Type 

Field 37: Enrollment Source 



Field 75: System-Assigned Transaction Tracking ID 

Field 76: Plan-Assigned Transaction Tracking ID 

Plan Action: Verify the Segment ID is correct. Submit a Residence Address Change or a Segment 

ID change if appropriate. 




600 R UI 

Transaction 

Override 

UI OVERRIDE 

This TRC is used for special Enrollment Reconciliation TRRs. 

A discrepancy enrollment transaction (Transaction Type 61) was rejected because it attempted to 

change an existing enrollment record that was previously entered by a CMS User through the User 

Interface. 

601 R Casework 

Beneficiary 

602 R No 

Discrepancy 

CASEWORK 

BENE 

NO 

DISCREPANCY 

Plan Action: Update plan records accordingly and take the appropriate actions as per CMS 

enrollment guidance (send “Enrollment Status Update” notice to the beneficiary). 


A discrepancy enrollment transaction (Transaction Type 61) was rejected because the beneficiary’s 

enrollment was updated by CMS casework. 




A discrepancy enrollment transaction (Transaction Type 61) was rejected because the enrollment 

effective date and contract/PBP in the submitted transaction matches the existing enrollment on file. 

There is no update to the beneficiary’s enrollment period. 

603 R 2007 Date is 

Not Valid 


2007 DT INVALID This TRC is used for special Enrollment Reconciliation TRRs. 

A discrepancy enrollment transaction (Transaction Type 61) was rejected because 2007 effective 

dates were not considered for the 2006 enrollment reconciliation. This rejection could have been 

caused by one of the following reasons: 

A 2007 enrollment or PBP was submitted and rejected because there was not a 2006 

discrepancy submitted along with the 2007 enrollment. 

A 2006 enrollment transaction AND a 2007 PBP change record attempted to process as a 

Rollover. The transaction rejected because the enrollment record and the PBP change record did 

not have the same application signature date. 

Plan Action: Update plan records accordingly. If the Plan has a 2007 enrollment to correct, 

contact the DMS DPO representative to process a retroactive enrollment transaction. 





t 

605 R Recon 

Transaction 

Denied 

DISENROLLMEN 

T 

TRANS DENIED 


Check dates code puts in TRR fields 18 and 24(maybe) and update text. 

As a result of the Enrollment Reconciliation process, this beneficiary was disenrolled due to 

enrollment in another Plan. 




A discrepancy enrollment transaction (Transaction Type 61) was denied following reconciliation 

processing. 



606 I Direct Bill DIRECT BILL This TRC is used for special Enrollment Reconciliation TRRs. 

This beneficiary has been changed to “Direct Bill” for this enrollment period. Even though a PPO 

other than D was specified in the transaction, Direct Bill is the only valid option for reconciliation 

transactions. 

This transaction response will accompany the acceptance TRC for the submitted discrepancy 

transaction. 


Accepted as 

Submitted 

ENROLL OK 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary is in direct bill 

status for the enrollment period. Take the appropriate actions as per CMS enrollment guidance. 


The submitted discrepancy enrollment transaction (Transaction Type 61) was accepted. The 

effective date of the enrollment period is reported in TRR data record field 18. 

Plan Action: Ensure that the Plan records correctly represent this enrollment. Take the appropriate 

actions as per CMS enrollment guidance. 




608 A Enrl 

Accepted, 

CMS 

Established 

Eff and End 

Dates 


Accepted 

with CMS 

established 

Eff date 


Accepted 

with CMS 

Established 

End Date 

ENRLD/CMS DTS 

ENRLD/CMS EFF 

ENRLD/CMS 

END 


The submitted discrepancy enrollment transaction (Transaction Type 61) was accepted but the 

effective date and end date for the enrollment period were provided by CMS. The new effective 

date of the enrollment period is reported in TRR data record field 18. 

Plan Action: Update Plan records to be consistent with the dates in fields 18 and 54(?). Review 

ALL enrollment periods in the Full Enrollment file to determine the beneficiary’s status. Take the 

appropriate actions as per CMS enrollment guidance (send appropriate “Enrollment Status Update” 

notice). 


The submitted discrepancy enrollment transaction (Transaction Type 61) was accepted but the 

effective date for the enrollment period was provided by CMS. The effective date of the new 

enrollment period is reported in TRR data record field 18. 

Plan Action: Update Plan records to be consistent with the dates in fields 18. Review ALL 

enrollment periods in the Full Enrollment file to determine the beneficiary’s status. Determine if a 

premium refund is required. Take the appropriate actions as per CMS enrollment guidance (send 

appropriate “Enrollment Status Update” notice). 


The submitted discrepancy enrollment transaction (Transaction Type 61) was accepted but the end 

date for the enrollment period was provided by CMS. The submitted effective date of the enrollment 

period is reported in TRR data record field 18. 

Plan Action: Update Plan records to be consistent with the dates in fields 18. Review ALL 

enrollment periods in the Full Enrollment file to determine the beneficiary’s status. Determine if a 

premium refund is required. Take the appropriate actions as per CMS enrollment guidance (send 

appropriate “Enrollment Status Update” notice). 




611 R No 

Discrepancy 

in 2006 

701 A New UI 

Enrollment 

(Open Ended) 

702 A UI Fill-In 

Enrollment 

NO DISCREP 

2006 

UI 

ENROLLMENT 

UI FILL-IN ENRT 


A discrepancy enrollment transaction (Transaction Type 61) was rejected because the enrollment 

matched exactly what CMS has on file for the calendar year of the reconciliation. However, CMS 

has identified an enrollment discrepancy which exists in another contract or calendar year. 

Plan Action: Review ALL enrollment periods in the Full Enrollment file to confirm the status of 

the beneficiary. The Plan should work through the established retroactive process to correct 

discrepancies associated with a calendar year other than the year being reconciled. 

A CMS User or a Plan User with Update Authority enrolled this beneficiary in this contract under 

the indicated PBP (if applicable) and segment (if applicable). TRR data record, field 18 contains the 

enrollment effective date. This is an open-ended enrollment which does not have a disenrollment 

date. 

The Part C Premium amount may have been populated automatically with the base Part C premium 

amount. 

Plan Action: Update the Plan’s beneficiary records with the information in the TRR. Verify the 

Part C premium amount and submit a Record Update transaction if necessary. Take the appropriate 


A CMS User or Plan User with Update Authority enrolled this beneficiary in this contract under the 

indicated PBP (if applicable) and segment (if applicable). This enrollment is a Fill-In Enrollment 

and represents a complete enrollment period that begins on the date in TRR data record field 18 and 

ends on the date in field 24. This is a distinct enrollment period and does not affect any existing 

enrollments. 


amount. 

Plan Action: Update the Plan’s records to reflect the beneficiary’s enrollment as of the effective 

date in TRR data record field 18 and the ending on the date in field 24. This end date should not 

affect the beginning of any existent enrollment periods. Verify the Part C premium amount and 

submit a Record Update transaction if necessary. Take the appropriate actions as per CMS 





703 A UI 

Enrollment 

Cancel 

(Delete) 

704 A UI 

Enrollment 

Cancel PBP 

Correction 

705 A UI 

Enrollment 

PBP 

Correction 

UI ENROLL 

CANCL 

UI CNCL PBP 

COR 

UI ENR PBP COR 

A CMS User cancelled the beneficiary’s existing enrollment and the beneficiary is disenrolled. 

When an enrollment is cancelled, it means that the enrollment never occurred. TRR data record 

field 18 contains the effective date (start date) of the cancelled enrollment period. 

Plan Action: Remove the indicated enrollment from the Plan’s records. Take the appropriate 


A CMS User updated the PBP on an existing enrollment. This generates two transaction replies, a 

Transaction Type 51 with TRC 704 and a Transaction Type 61 with TRC 705. This reply with TRC 

704 (Transaction Type 51) represents the cancellation of the enrollment in the original PBP. The 

effective (start) and disenrollment (end) dates of the enrollment being cancelled are found in TRR 

data record fields 18 & 24, respectively. When an enrollment is cancelled it means that the 

enrollment never occurred. 

Plan Action: Remove the indicated enrollment in the original PBP from the Plan’s records. Look 

for the accompanying reply with TRC 705 to determine the replacement enrollment period. Take 


A CMS User updated the PBP on an existing enrollment. This generates two transaction replies, a 

Transaction Type 51 with TRC 704 and a Transaction Type 61 with TRC 705. This reply with TRC 

705 (Transaction Type 61) represents the enrollment in the new PBP. The effective (start) and 

disenrollment (end) dates of the enrollment in this new PBP are found in TRR data record fields 18 

& 24, respectively. This enrollment should replace the enrollment cancelled by the associated 

Transaction Type 51 transaction (TRC 704). 


amount. 

Plan Action: Update the Plan records to reflect the beneficiary’s enrollment in the new Contract, 

PBP. Look for the accompanying reply with TRC 704 to ensure that the original PBP enrollment 

was cancelled. Verify the Part C premium amount and submit a Record Update transaction if 

necessary. Take the appropriate actions as per CMS enrollment guidance. 




706 A UI 

Enrollment 

Cancel 

Segment 

Correction 

707 A UI 

Enrollment 

Segment 

Correction 

708 A UI Assigns 

End Date 

UI CNCL SEG 

COR 

UI ENR SEG COR 

UI ASSGN END 

DT 

A CMS User updated the Segment on an existing enrollment. This generates two transaction 

replies, a Transaction Type 51 with TRC 706 and a Transaction Type 61 with TRC 707. This reply 

(Transaction Type 51) represents the cancellation of the enrollment in the original Segment. When 

an enrollment is cancelled it means that the enrollment never occurred. The effective (start) and 

disenrollment (end) dates of the enrollment being cancelled are found in TRR data record fields 18 

& 24, respectively. 

Plan Action: Remove the indicated enrollment in the original Segment from the Plan’s records. 

Look for the accompanying reply with TRC 707 to determine the replacement enrollment period. 


A CMS User updated the Segment on an existing enrollment. This generates two transaction replies, 

a Transaction Type 51 with TRC 706 and a Transaction Type 61 with TRC 707. This reply 

(Transaction Type 61) represents the enrollment in the new Segment. The effective (start) and 

disenrollment (end) dates of the enrollment in this new Segment are found in TRR data record fields 

18 & 24, respectively. This enrollment should replace the enrollment cancelled by the associated 

Transaction Type 51 transaction (TRC 706). 


amount. 

Plan Action: Update the Plan records to reflect the beneficiary’s enrollment in the new Contract, 

PBP. Segment. Look for the accompanying reply with TRC 706 to ensure that the original Segment 

enrollment was cancelled. Verify the Part C premium amount and submit a Record Update 

transaction if necessary. Take the appropriate actions as per CMS enrollment guidance. 

A CMS User or Plan User with Update Authority assigned an end date to existing open-ended 

enrollment. The last day of enrollment is in TRR data record field 18. The enrollment effective 

date (start date) remains unchanged. 

Plan Action: Update the Plan records to reflect the beneficiary’s disenrollment from the Plan. 





709 A UI Moved 

Start Date 

Earlier 


Start Date 

Later 


End Date 

Earlier 

UI ERLY STRT 

DT 

UI LATE STRT 

DT 

UI ERLY END DT 

A CMS User updated the start date of an existing enrollment to an earlier date. This reply has a 

Transaction Type of 61. The new start date is reported in TRR data record field 18 (Effective Date) 

and the original start date is reported in field 24. The existing enrollment was changed to begin on 

the date in TRR data record field 18. The end date of the existing enrollment (if it exists) remains 

unchanged. 


amount. 

Plan Action: Locate the enrollment for this beneficiary that starts on the date in field 24. Update 

the Plan records for this enrollment to start on the date in field 18. Verify the Part C premium 

amount and submit a Record Update transaction if necessary. Take the appropriate actions as per 


A CMS User updated the start date of an existing enrollment to a later date. This reply has a 

Transaction Type of 51. The new start date is reported in field 18 (effective date) and the original 

start date is reported in TRR data record field 24. The existing enrollment has been reduced to 

begin on the date in TRR data record field 18. The end date of the existing enrollment (if it exists) 

remains unchanged. 

Plan Action: Locate the enrollment for this beneficiary that starts on the date in field 24. Update 

the Plan records for this enrollment to start on the date in field 18. Take the appropriate actions as 


A CMS User or Plan User with Update Authority updated the end date of an existing enrollment to 

an earlier date. This reply has a Transaction Type of 51. The new end date is reported in field 18 

(effective date) and the original end date is reported in TRR data record field 24. The existing 

enrollment was reduced to end on the date in TRR data record field 18. The start date of the 

existing enrollment remains unchanged. 

Plan Action: Locate the enrollment for this beneficiary that ends on the date in field 24. Update 

the Plan records for this enrollment to end on the date in field 18. Take the appropriate actions as 






End Date 

Later 

713 A UI Removed 

Enrollment 

End Date 

714 I UI Part D 

Opt-Out 

Change 

Accepted 

UI LATE END DT 

UI REMVD END 

DT 

UI OPT OUT OK 

A CMS User updated the end date of an existing enrollment to a later date. This reply has a 

Transaction Type of 61. The new end date is reported in field 18 (effective date) and the original 

end date is reported in TRR data record field 24. The existing enrollment was extended to end on 

the date in TRR data record field 18. The start date of the existing enrollment remains unchanged. 


amount. 

Plan Action: Locate the enrollment for this beneficiary that ends on the date in field 24. Update 

the Plan records for this enrollment to end on the date in field 18. Verify the Part C premium 

amount and submit a Record Update transaction if necessary. Take the appropriate actions as per 


A CMS User removed the end date from an existing enrollment. This reply has a Transaction Type 

of 61. TRR data record field 18 (effective date) contains zeroes (00000000) and the original end 

date is reported in field 24. The existing enrollment was extended to be an open-ended enrollment. 

The start date of the existing enrollment remains unchanged. 


amount. 

Plan Action: Locate the enrollment for this beneficiary that ends on the date in TRR data record 

field 24. Update the Plan records for this enrollment to remove the end date and to extend this 

enrollment to be an open-ended enrollment. Verify the Part C premium amount and submit a 

Record Update transaction if necessary. Take the appropriate actions as per CMS enrollment 

guidance. 

A CMS User or Plan User with Update Authority added or changed the value of the Part D Opt-Out 

Flag for this beneficiary. The new Opt-Out Flag is reported in TRR data record field 38 on the TRR 

record. 






Change 

Accepted 

716 I UI changed 

the Number 

of Uncovered 

Months 

717 I UI changed 

only the 

Application 

Date 

MCAID CHG 

ACEPT 

UI CHGD 

NUNCMO 

UI CHGD APP DT 

A CMS User changed the beneficiary’s Medicaid status. This may or may not have changed the 

beneficiary’s actual status since multiple sources of Medicaid information are used to determine the 

beneficiary’s actual Medicaid status. 

The Plan will see the result of any changes to the beneficiary’s actual Medicaid status included in 

the next scheduled update of Medicaid status. 


A CMS User or Plan User with Update Authority updated the beneficiary’s Number of Uncovered 

Months. 

Plan Action: Update the Plan’s records accordingly. Ensure that the Plan is billing the correct 

amount for the LEP. Take the appropriate actions as per CMS enrollment guidance. 

A CMS User updated only the Application Date of a beneficiary's enrollment, which results in a 

blank TC on the DTRR, Field 16. 





718 I UI MMP 

Opt-Out 

Change 

Accepted 

990 – 

995 

996 I EOY Loss of 

Low Income 

Subsidy 

Status 

UI MMP OPTOUT 

OK 

EOY LOSS 

SBSDY 

A CMS User or Plan User with Update Authority added or changed the value of the MMP Opt-Out 

Flag for this beneficiary. The new MMP Opt-Out Flag is reported in TRR data record field 70. 

The following fields populate in the daily TRR when this TRC is returned: 

Field 1: HICN 










Field 15: Transaction Reply Code 

Field 16: Transaction Type Code 

Field 18: Request Effective Date 

Field 20: Plan Benefit Package ID 



Field 31: UI User Organization Designation 



Field 70: MMP Opt Out Flag 

Field 72: System Assigned Transaction Tracking ID 

These codes appear only on special TRRs that are generated for specific purposes; for example, 

those generated to communicate Full Enrollment or to report beneficiaries losing low-income 

deeming. When a special TRR produces one of these TRCs, CMS will provide the Plans with 

communications which define the TRC descriptions and Plan actions (if applicable). 

Identifies those beneficiaries who are losing their deemed or LIS Applicant status as of December 

31 st of the current year with no low income status determined for January of the following year. 

Plan Action: Update Plan records accordingly. 




997 – 

999 

These codes appear only on special TRRs that are generated for specific purposes; for example, 

those generated to communicate Full Enrollment or to report beneficiaries losing low-income 

deeming. When a special TRR produces one of these TRCs, CMS will provide the Plans with 

communications which define the TRC descriptions and Plan actions (if applicable). 


I.3 Obsolete Transaction Reply Codes 


Table I-3 lists the obsolete TRCs marked for deletion beginning November 2006. 

Table I-3: Obsolete Transaction Reply Codes 


027 A Demonstration 

Beneficiary Factor Set 

028 A Demonstration 

Beneficiary Factor 

Terminated 

040 R Enrollment Rejected, 

Multiple Enrollment 

Trans 

041 R Invalid Demonstration 

Beneficiary Factor 

Date 

OBSOLETE 

OBSOLETE 

OBSOLETE 

OBSOLETE 

A transaction to turn on the beneficiary-level demonstration factor (Transaction Type 

30) was successfully processed. The effective start date of the factor is shown in TRR 

data record field 24. 

Note: This reply code is only applicable to transactions that update beneficiaryspecific 

risk adjustment factors for certain demonstration contracts. 


A transaction to turn off the beneficiary-level demonstration factor (Transaction Type 

31) was successfully processed. The effective end date of the factor is show in TRR 

data record field 24. 

Note: This reply code is only applicable to transactions that update beneficiaryspecific 

risk adjustment factors for certain demonstration contracts. 


An enrollment transaction (Transaction Type 61) was rejected because it was one of 

several that were submitted with the same effective date and application date. 


A beneficiary factor update request attempted to process. This was rejected because 

the effective start and/or end date was not in a valid format or the request specified an 

effective start date that was greater than the end date. 

Plan Action: If this TRC is included in the Plan’s TRR, call the MMA Helpdesk to 

request guidance. 

December 28, 2012 I-84 Obsolete Transaction Reply Code (TRCs)



057 M Risk Adjuster Factor 

Change 

111 R PBP Rejected; Invalid 


112 R Rejected; Conflicting 

Effective Dates 

115 R Enrollment Rejected; 

Plan Not Open 

OBSOLETE 

OBSOLETE 

OBSOLETE 

OBSOLETE 

This is an informational TRC. 

The Risk Adjuster System (RAS) has created new factors for this beneficiary, which 

may result in payment adjustments. 

Plan Action: Refer to the monthly RAS reports to update the Plan’s records. 

A PBP enrollment change transaction (Transaction Type 61) was rejected because the 

contract number submitted on the transaction does not match the contract number of 

the Plan in which the beneficiary is currently enrolled. The requested effective date of 

enrollment in the new PBP is reported in TRR data file field 18. 

Plan Action: If appropriate, resubmit the transaction with the correct contract 

number. If the Plan is attempting to move the beneficiary to a new contract number, 

an enrollment transaction (Transaction Type 61) must be used. 

A PBP change transaction (Transaction Type 61) was rejected because beneficiary 

was not enrolled in the submitted contract as of the effective date for the PBP change. 

A beneficiary must be enrolled in a PBP of a contract in order to change to another 

PBP. The effective date of the enrollment within the contract must be equal to or 

before the effective date of the PBP change. 

Plan Action: Correct the effective date of the PBP Change transaction and resubmit 

if appropriate. If the Plan is attempting to enroll a beneficiary in a different PBP with 

an effective date earlier than the original enrollment, the Plan must us an Enrollment 

transaction (Transaction Type 61). 

An enrollment or PBP change transaction (Transaction Type 61) was rejected because 

this Plan is closed to enrollments using an O (OEP), N (OEPNEW) or OEPI (T) 

election type. 

Plan Action: Correct the enrollment type and resubmit the transaction if appropriate. 




146 A Rollover successful OBSOLETE A termination-rollover action was processed. These actions allow all members of a 

terminating Plan (contract or PBP) to be ‘rolled over’ (automatically enrolled) in a 

new Plan. 

This normally occurs at year end if a contract or PBP changes for the new year. The 

transaction is an Enrollment Transaction (Transaction Type 61) and has the new 

contract, PBP, and segment in TRR data record fields 8, 20 and 33, respectively. The 

effective date of the rollover is reported in field 18 and in the EFF DATE column on 

the printed report. 

148 I Rollover successful, 

Secondary Drug 

Insurance 4Rxupdate 

required 

OBSOLETE 

Plan Action: Submit a 4Rx Record Update transaction (Transaction Type 72) 

supplying the beneficiary’s new insurance field (4Rx) values. If the move resulted in 

beneficiaries being moved incorrectly, contract your CMS plan representative. 

A beneficiary was “rolled over” into a new Plan (Contract and/or PBP). Updated 4RX 

drug insurance information is needed by CMS for the primary drug coverage and the 

secondary if applicable. 

This TRC provides the Plan with additional information on a rollover transaction that 

was processed successfully. It will be received by Plans which offer Part D coverage 

(PDP, MA-PD, demonstration or other Plan with Part D). The effective date of the 

new rolled-over enrollment will be reported in field 18 and in the EFF DATE column 

on the printed report. 

Plan Action: Submit a 4Rx Change transaction (Transaction Type 72) supplying the 

beneficiary’s new insurance field (4Rx) values. 




167 M Change in Beneficiary 

Low Income Premium 

Subsidy 

OBSOLETE 

This TRC is returned on a reply with Transaction Type 01. It is not a reply to a 

submitted transaction but is intended to supply the Plan with additional information 


This beneficiary’s Part D low-income subsidy amount and/or percentage have 

changed. The effective date of the change is reported in field 18 of the TRR record 

and in the EFF DATE column on the printed report. Field 55 reports the beneficiary’s 

Part D premium subsidy amount as of the effective date of the transaction. 

If the change affects the Part D low-income subsidy for the Current Payment Month 

(CPM), the new amount will be reported in field 24. 

Replies with TRC 167 are often accompanied by replies with TRC 168 and TRC 121. 

Note: Fields 24 and 49 – 54 always represent the beneficiary’s LIS and LEP values 

for the current CPM. If this change is retroactive, these values may not reflect the 

values of the period being changed. Refer to the LISHIST report to determine the 

correct values for retroactive changes. TRC167will continue to be generated for 

internal purposes and will not be sent to the plans. 

Plan Action: Adjust the beneficiary’s Part D LIS amount and/or percentage as of the 

effective date in field 18. Take the appropriate actions as per CMS enrollment 

guidance. If the change is retroactive, refer to the LISHIST report to verify the correct 

amount for the affected period. 




168 M Change in Beneficiary 

Low Income Cost 

Sharing Subsidy 

174 R Transaction Rejected; 

No Data Updates 

Submitted 

OBSOLETE 

OBSOLETE 

This TRC is returned on a reply with Transaction Type 01. It is not a reply to a 

submitted transaction but is intended to supply the Plan with additional information 


This beneficiary’s Part D low-income cost sharing level (co-pay) has changed. The 

effective date of the change is reported in field 18 of the TRR record and in the EFF 

DATE column on the printed report. 

If the change affects the Part D low-income cost sharing level for the Current Payment 

Month (CPM), the new level will be reported in field 24. 

Replies with TRC 168 are often accompanied by replies with TRC 167 and TRC 121. 

Note: Fields 24 and 49 – 54 always represent the beneficiary’s LIS and LEP values 

for the current CPM. If this change is retroactive, these values may not reflect the 

values of the period being changed. Refer to the LISHIST report to determine the 

correct values for retroactive changes. Field 55 reports the beneficiary’s Part D 

premium subsidy amount as of the effective date of the transaction. 

Plan Action: Adjust the beneficiary’s Part D LIS cost-sharing level as of the 

effective date in field 18. Take the appropriate actions as per CMS enrollment 

guidance. If the change is retroactive, refer to the LISHIST report to verify the correct 

level for the affected period. 

An EGHP, Segment ID, Part C premium, or Part D Opt-Out change transaction 

(Transaction Types 74, 77, 78, 79) was rejected because none of the change-to fields, 

EGHP Flag, Segment ID, Opt-Out Flag or Part C Premium, were populated in the 

submitted transaction. 


Plan Action: None required unless a change was intended. If a change was intended, 

populate the correct field(s) and resubmit the transaction. 




181 I Invalid PTD premium 

submitted, corrected 

192 I No Change in Part C 


199 R Rejected, Return to 

Plan for Additional 

Research 

OBSOLETE 

OBSOLETE 

OBSOLETE 

The Part D premium submitted on the enrollment or PBP change transaction 

(Transaction Type 61) does not agree with the Plan’s defined Part D premium rate. 

The premium has been adjusted to reflect the defined rate. The correct Part D 

premium rate is reported in TRR data record field 24. 

This TRC provides additional information about an enrollment or PBP change 

transaction (Transaction Type 61) for which an acceptance was sent in a separate 

Transaction Reply with an enrollment acceptance TRC. The effective date of the 

enrollment for which this information is pertinent is reported in TRR data record field 

18. 

Plan Action: Update the Plan’s beneficiary records with the premium information in 

the TRR record. Take the appropriate actions as per CMS enrollment guidance. 

A Part C Premium Update transaction (Transaction Type 78) was submitted, however, 

no data change was made to the beneficiary’s record. The submitted transaction 

contained a Part C Premium Amount value that matched the Part C Premium Amount 

already on record with CMS. 



A submitted transaction (Transaction Types 51, 61, 72, 73, 74, 75, 01, 85) was 

rejected. This transaction was placed into a pending status due to multiple 

transactions that were concurrently processed for the same beneficiary. 

Subsequent transactions may have been processed while this transaction was pending. 

As a result, this transaction may no longer be valid. 

Plan Action: Research the beneficiary’s current status and resubmit any appropriate 

transactions. 




207 I Part D Premium has 

been corrected to zero 

OBSOLETE 

An enrollment or PBP change transaction (Transaction Type 61) was submitted and 

accepted for a Part C only Plan. This transaction contained an amount other than zero 

in the Part D premium field. Since a Part D premium does not apply to a Part C only 

Plan, the Part D premium has been corrected to be zero. 

This TRC provides additional information about an enrollment or PBP change 

transaction (Transaction Type 61) for which an acceptance was sent in a separate 

Transaction Reply with an acceptance TRC. The effective date of the enrollment for 

which this information is pertinent is reported in TRR data record field 18. 

208 R Plan Change Rejected 

Both 4Rx and non 4Rx 

Changes 

OBSOLETE 

Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s 

information matches zero Part D premium amount included in the TRR record. 

A 4Rx Record Update transaction (Transaction Type 72) was rejected because it 

contained information for both 4Rx and non-4Rx record updates. 

If any of the 4Rx (primary and secondary drug insurance) fields are populated, no 

other record updates can be included on the transaction. 

Plan Action: Submit separate Record Update transactions (Transaction Type 72) for 

4Rx and non-4Rx record updates. 



I.4 Transaction Reply Code (TRC) Groupings 

Transaction Type 

Code 

TRC TITLE 

Batch TRCs 

4RX TRC GROUPING 

143A 

190A 

200R 

201R 

202R 

203R 

204A 

209R 

242I 

294I 

SECONDARY INSURANCE RX NUMBER CHANGE ACCEPTED 

NO CHANGE IN SECONDARY DRUG INFORMATION 

RX BIN BLANK OR NOT VALID 

RX ID BLANK OR NOT VALID 

RX GROUP NOT VALID 

RX PCN NOT VALID 

RECORD UPDATE FOR PRIMARY 4RX DATA SUCCESSFUL 

4RX CHANGE REJECTED, INVALID CHANGE EFFECTIVE DATE 

NO CHANGE IN PRIMARY DRUG INFORMATION 

NO 4RX INSURANCE CHANGED 

ALL TRANSACTIONS TRC GROUPING 

001 F INVALID TRANSACTION CODE 

002 F INVALID CORRECTION ACTION CODE 

003 F INVALID CONTRACT NUMBER 

004 R BENEFICIARY NAME REQUIRED 

006 R INCORRECT BIRTH DATE 

007 R INVALID CLAIM NUMBER 

008 R BENEFICIARY CLAIM NUMBER NOT FOUND 

009R NO BENEFICIARY MATCH 

022A TRANSACTION ACCEPTED CLAIM NUMBER CHANGE 

023A TRANSACTION ACCEPTED, NAME CHANGE 

037R TRANSACTION REJECTED INCORRECT EFFECTIVE DATE 

104R REJECTED; INVALID OR MISSING ELECTION TYPE 

105R REJECTED; INVALID EFFECTIVE DATE FOR ELECTION TYPE 

106R REJECTED, ANOTHER TRANS RCVD WITH LATER APP DATE 

107R REJECTED; INVALID OR MISSING PBP NUMBER 

108R REJECTED, ELECTION LIMITS EXCEEDED 

109R REJECTED, DUPLICATE PBP NUMBER 

156F TRANSACTION REJECTED, USER NOT AUTHORIZED FOR CONTRACT 

157R CONTRACT NOT AUTHORIZED FOR TRANSACTION CODE 

165R PROCESSING DELAYED DUE TO MARX SYSTEM PROBLEMS 

AUTOMATIC RESET OF NUMBER OF UNCOVERED MONTHS (NUNCMO) 

060R 

290I 

295M 

TRANSACTION REJECTED, NOT ENROLLED 

IEP NUNCMO RESET 

LOW INCOME NUNCMO RESET 

December 28, 2012 I-91 TRC Groupings


BENEFICIARY CROSS REFERENCE MERGE 

301M 

302M 

701A 

702A 

703A 

704A 

705A 

706A 

707A 

708A 

709A 

710A 

711A 

712A 

713A 

714I 

715M 

716I 

717I 

MERGED BENEFICIARY, CLAIM NUMBER CHANGE 

ENROLLMENT CANCELLED, CLAIM NUMBER CHANGE (BENEFICIARY MERGE) 

CMS-ONLINE UPDATES TRC GROUPING 

NEW UI ENROLLMENT (OPEN ENDED) 

UI FILL-IN ENROLLMENT 

UI ENROLLMENT CANCEL (DELETE) 

UI ENROLLMENT CANCEL-PBP CORRECTION 

UI ENROLLMENT PBP CORRECTION 

UI ENROLLMENT CANCEL SEGMENT CORRECTION 

UI ENROLLMENT SEGMENT CORRECTION 

UI ASSIGNS END DATE 

UI MOVED START DATE EARLIER 

UI MOVED START DATE LATER 

UI MOVED END DATE EARLIER 

UI MOVED END DATE LATER 

UI REMOVED ENROLLMENT END DATE 

UI PART D OPT OUT CHANGE ACCEPTED 

MEDICAID CHANGE ACCEPTED 

UI CHANGED THE NUMBER OF UNCOVERED MONTHS 

UI CHANGED ONLY THE APPLICATION DATE 

DEMONSTRATION TRC GROUPING 

056R 

169R 

307A 

308R 

309I 

310R 

311A 

312A 

313R 

314R 

DEMONSTRATION ENROLLMENT REJECTED 

REINSURANCE DEMONSTRATION ENROLLMENT REJECTED 

MMP PASSIVE ENROLLMENT ACCEPTED 

MMP PASSIVE ENROLLMENT REJECTED 

NO CHANGE IN MMP OPT-OUT FLAG 

MMP OPT-OUT REJECTED; INVALID OPT-OUT CODE 

MMP OPT-OUT ACCEPTED 

MMP ENROLLMENT CANCELLATION ACCEPTED 

MMP ENROLLMENT CANCELLATION REJECTED 

INVALID CANCELLATION TRANSACTION 



013 A DISENROLLMENT ACCEPTED AS SUBMITTED 

DISENROLLMENT TRC GROUPING 

014 A DISENROLLMENT DUE TO ENROLLMENT IN ANOTHER PLAN 

018 A AUTOMATIC DISENROLLMENT 

025 A DISENROLLMENT ACCEPTED, CLAIM NUMBER CHANGE 

026 A DISENROLLMENT ACCEPTED, NAME CHANGE 

050 R DISENROLLMENT REJECTED, NOT ENROLLED 

051 R DISENROLLMENT REJECTED, INCORRECT EFFECTIVE DATE 

052 R DISENROLLMENT REJECTED, DUPLICATE TRANSACTION 

054 R DISENROLLMENT REJECTED, RETROACTIVE EFFECTIVE DATE 

090M 

104R 

105R 

108R 

114R 

120A 

DATE OF DEATH ESTABLISHED 

REJECTED; INVALID OR MISSING ELECTION TYPE 

REJECTED; INVALID EFFECTIVE DATE FOR ELECTION TYPE 

REJECTED; ELECTION LIMITS EXCEEDED 

DRUG COVERAGE CHANGE REJECTED; NOT AEP 

PREMIUM PAYMENT OPTION CHANGE SENT TO W/H AGENCY 

151 I DISENROLLMENT ACCEPTED, INVALID DISENR REASON CODE 

205 I INVALID DISENROLLMENT REASON CODE 

036R 

042R 

044R 

116R 

284R 

288A 


291I 

296R 

292R 

110R 

127R 

128R 

129I 

139A 

162R 

164R 

189A 

DISENROLLMENT CANCELLATION TRC GROUPING 

TRANSACTION REJECTED BENEFICIARY IS DECEASED 

TRANSACTION REJECTED, BLOCKED 

TRANSACTION REJECTED, OUTSIDE CONTRACT PERIOD 

ENROLLMENT OR CHANGE REJECTED; INVALID SEGMT NUM 

CANCELLATION REJECTED, ENROLL/DISENROLL CANCELLATION 

DISENROLLMENT CANCELLATION ACCEPTED 

DISENROLLMENT CANCELLATION REJECTED 

ENROLLMENT REINSTATED, DISENROLLMENT CANCELLATION 

DISENROLL CANCEL REJECTED, REINSTATEMENT CONFLICT (CONFLICTS WITH AN EXISTING 

ENROLLMENT) 

DISENROLLMENT TRANSACTION (TC 51) 

Rejected when used to attempt an enrollment Cancellation 

DISENROLLMENT REJECTED, WAS CANCELLATION ATTEMPT 

EGHP TRC GROUPING 

REJECTED; NO PART A AND NO EGHP ENROLLMENT WAIVER 

PART D ENROLLMENT REJECTED, EMPLOYER SUBSIDY 

PART D ENROLL REJECT, EMPLYR SBSDY SET: NO PRIOR TRN 

PART D ENROLL ACCEPT, EMP SBSDY SET: PRIOR TURN REJECT 

EGHP FLAG CHANGE ACCEPTED 

INVALID EGHP FLAG VALUE 

EGHP FLAG VALUE NOT 'Y' 

NO CHANGE IN EGHP FLAG 



ENROLLMENT RECON TRC GROUPING 

600R UI TRANSACTION OVERRIDE 

601R CASEWORK BENEFICIARY 

602R NO DISCREPANCY 

603R 2007 DATE IS NOT VALID 

604A DISENROLLMENT 

605R RECON TRANSACTION DENIED 

606I DIRECT BILL 

607A ENROLLMENT ACCEPTED AS SUBMITTED 

608A ENROLLMENT ACCEPTED WITH CMS ESTABLISHED EFFECTIVE AND CMS END DATE 

609A ENROLLMENT ACCEPTED WITH CMS ESTABLISHED EFFECTIVE 

610A ENROLLMENT ACCEPTED WITH CMS ESTABLISHED END DATE 

611R NO DISCREPANCY IN 2006 

ENROLLMENT TRC GROUPING 

011 A ENROLLMENT ACCEPTED AS SUBMITTED 

015 A ENROLLMENT CANCELED 

016 I ENROLLMENT ACCEPTED, OUT OF AREA 

017 I ENROLLMENT ACCEPTED, PAYMENT DEFAULT RATE 

019 R ENROLLMENT REJECTED- NO PART- A & PART-B ENTITLEMENT 

020 R ENROLLMENT REJECTED-PACE UNDER 55 

032 R ENROLLMENT REJECTED, BENEFICIARY NOT ENTIT PART B 

033 R ENROLLMENT REJECTED, BENEFICIARY NOT ENTIT PART A 

034 R ENROLLMENT REJECTED, BENEFICIARY IS NOT AGE 65 

035 R ENROLLMENT REJECTED, BENEFICIARY IS IN HOSPICE 

036 R TRANSACTION REJECTED, BENEFICIARY IS DECEASED 

038 R ENROLLMENT REJECTED, DUPLICATE TRANSACTION 

039 R ENROLLMENT REJECTED, CURRENTLY ENOLL IN SAME PLAN 

042 R TRANSACTION REJECTED, BLOCKED 

044 R TRANSACTION REJECTED, OUTSIDE CONTRACT PERIOD 

045 R ENROLLMENT REJECTED, BENEFICIARY IS IN ESRD 

056R DEMONSTRATION ENROLLMENT REJECTED 

100 A PBP CHANGE ACCEPTED AS SUBMITTED 

102 R REJECTED; INCORRECT OR MISSING APPLICATION DATE 

103 R ICEP/IEP ELECTION, MISSING A/B ENTITLEMENT DATE 

104R REJECTED; INVALID OR MISSING ELECTION TYPE 

105R REJECTED; INVAILD EFFECTIVE DATE FOR ELECTION TYPE 

106R REJECTED; ANOTHER TRANSACTION RECEIVED WITH LATER APPLICATION DATE 

108R REJECTED; ELECTION LIMITS EXCEEDED 

114R DRUG COVERAGE CHANGE REJECTED; NOT AEP 

116R ENROLLMENT OR CHANGE REJECTED; INVALID SEGMT NUM 

120A PREMIUM PAYMENT OPTION CHANGE SENT TO W/H AGENCY 

124R ENROLLMENT/CHANGE REJECTED; INVALID UNCOVERED MONTHS 

126R ENROLLMENT/CHANGE REJECTED; INVALID CRED CVRG FLAG 



127R 

128R 

129I 

133R 

134I 

150I 

176R 

184R 

196R 

211R 

212A 

246A 

247A 

248R 

249R 

250R 

251R 

268I 

269I 

307A 

308R 

312A 

313R 

PART D ENROLLMENT REJECTED; EMPLOYER SUBSIDY STATUS 

PART D ENROLLMENT REJECT, EMPLYR SBSDY SET; NO PRIOR TRN 

PART D ENROLL ACCEPT; EMP SBSDY SET; PRIOR TRN REJECT 

PART D ENROLL REJECTED; INVALID SECNDRY INSUR FLAG 

MISSING SECONDARY INSURANCE INFORMATION 

ENROLLMENT ACCEPTED, EXCEEDS CAPACITY LIMIT 

TRANSACTION REJECTED, ANOTHER TRANSACTION ACCEPTED 

ENROLLMENT REJECTED, BENEFICIARY IS Medicaid 

TRANSACTION REJECTED, BENE NOT ELIGIBLE FOR PART D 

RE-ASSIGNMENT ENROLLMENT REJECTED 

RE-ASSIGNMENT ENROLLMENT ACCEPTED 

GAP ENROLLMENT ACCEPTED; NO CHANGE TO DATES 

GAP ENROLLMENT ACCEPTED; NEW END DATE 

GAP ENROLLMENT REJECTED; INVALID END DATE 

GAP ENROLLMENT OVERLAP AE, FE OR POS/LI NET PERIOD 

GAP ENROLLMENT DATES FALL WITHIN ANOTHER ENROLLMENT 

GAP ENROLLMENT NOT IN RETRO FILE 

BENEFICIARY HAS DIALYSIS PERIOD 

BENEFICIARY HAS TRANSPLANT 

MMP PASSIVE ENROLLMENT ACCEPTED 

MMP PASSIVE ENROLLMENT REJECTED 



060R 




292R 

312A 

313R 

ENROLLMENT CANCELLATION TRC GROUPING 

TRANSACTION REJECTED, NOT ENROLLED 

ENROLLMENT CANCELLATION ACCEPTED 

ENROLLMENT CANCELLATION REJECTED 

ENROLLMENT REINSTATED 

DISENROLLMENT REJECTED, WAS CANCELLATION ATTEMPT 



314R 

INVALID CANCELLATION TRANSACTION 

ESRD TRC GROUPING 

055 M ESRD CANCELLATION 

073 M ESRD STATUS SET 

074 M ESRD STATUS TERMINIATED 

135 M BENEFICIARY HAS STARTED DIALYSIS TREATMENTS 

136 M BENEFICIARY HAS ENDED DIALYSIS TREATMENTS 

137 M BENEFICIARY HAS RECEIVED A KIDNEY TRANSPLANT 

268I 

269I 

BENEFICIARY HAS DIALYSIS PERIOD 

BENEFICIARY HAS TRANSPLANT 



000I 

264I 

299I 

257F 

258F 

259F 

263F 

071M 

072M 

177M 

178M 

218M 

219M 

117A 

118A 

121M 

166R 

194M 

223I 

077M 

078M 

097R 

098R 

099M 

184R 

227R 

245M 

280I 

120A 

124R 

126R 

141A 

187A 

215R 

216I 

217R 

NO DATA TO REPORT 

PAYMENT NOT YET COMPLETED 

CORRECTION TO PREVIOUSLY FAILED PAYMENT 

FAILED PAYMENT 

FAILED TRCs GROUPING 

FAILED; BIRTH DATE INVALID FOR DATABASE INSERTION 

FAILED; EFFECTIVE DATE INVALID FOR DATABASE INSERTION 

FAILED; END DATE INVALID FOR DATABASE INSERTION 

APPLICATION DATE INVALID FOR DATABASE INSERTION 

HOSPICE TRC GROUPING 

HOSPICE STATUS SET 

HOSPICE STATUS TERMINATED 

CHANGE IN LATE ENROLLMENT PENALTY 

LATE ENROLLMENT PENALTY RESCINDED 

LEP RESET UNDONE 

LEP RESET ACCEPTED 

FBD AUTO ENROLLMENT ACCEPTED 

LIS FACILITATED ENROLLMENT ACCEPTED 

LOW INCOME PERIOD STATUS 

LATE ENROLLMENT PENALTY/LEP TRC GROUPING 

LIS/AUTO/FACI TRC GROUPING 

PART D FBD AUTO ENROLLMENT OR FACILITATED ENROLLMENT REJECTED 

DEEMED CORRECTION 

LOW INCOME PERIOD CLOSED 

MEDICAID STATUS SET 

MEDICAID STATUS TERMINATED 

MEDICAID PREVIOUSLY TURNED ON 

MEDICAID PREVIOUSLY TURNED OFF 

MEDICAID PERIOD CHANGE/CANCELLATION 

MEDICAID TRC GROUPING 

ENROLLMENT REJECTED, BENEFICIARY IS IN MEDICAID 

MEDICARE SECONDARY PAYER/MSP TRC GROUPING 

AGED/DISABLED TRANSACTION REJECTED-INVALID TRANSACTION TYPE 

MEMBER HAS MSP PERIOD 

MEMBER MSP PERIOD HAS ENDED 

NUMBER OF UNCOVERED MONTHS/NUNCMO TRC GROUPING 


ENROLLMENT/CHANGE REJECTED, INVALID UNCOV MONTHS 

ENROLLMENT/CHANGE REJECTED, INVALID CRED CVRG FLAG 

UNCOVERED MONTHS CHANGE ACCEPTED 

NO CHANGE IN NUMBER OF UNCOVERED MONTHS INFORMATION 

UNCOVERED MONTHS CHANGE REJECTED, INCORRECT EFF DATE 

UNCOVERED MONTHS EXCEEDS MAX POSSIBLE VALUE 

CAN'T CHANGE NUMBER OF UNCOVERED MONTHS 



290I 

295M 

300R 

060R 

116R 

134I 

140A 

171R 

172R 

188A 

130R 

131A 

241I 

210A 

220R 

119A 

120A 

122R 

123R 

144M 

170I 

173R 

179A 

182I 

191A 

206I 

213I 

222I 

237I 

240A 

243R 

252I 

253M 

267M 

IEP NUNCMO RESET 

LOW INCOME NUNCMO RESET 

NUNCMO CHANGE REJECTED, EXCEEDS MAX POSSIBLE VALUE 

PLAN CHANGES TRC GROUPING 

TRANSACTION REJECTED, NOT ENROLLED IN PLAN 

ENROLLMENT OR CHANGE REJECTED; INVALID SEGMT NUM 

MISSING SECONDARY INSURANCE INFORMATION 

SEGMENT ID CHANGE ACCEPTED 

RECORD UPDATE REJECTED, INVALID CHG EFFECTIVE DATE 

CHANGE REJECTED; CREDITABLE COVERAGE//2 DRUG INFO NOT APPLICABLE 

NO CHANGE IN SEGMENT ID 

PART D OPT OUT TRC GROUPING 

PART D OPT-OUT REJECTED, OPT-OUT FLAG NOT VALID 

PART D OPT-OUT ACCEPTED 

NO CHANGE IN PART D OPT OUT FLAG 

POINT OF SALE (POS) TRC GROUPING 

POS ENROLLMENT ACCEPTED 

TRANSACTION REJECTED; INVALID POS ENROLL SOURCE CODE 

PREMIUM PAYMENT TRC GROUPING 

PREMIUM AMOUNT CHANGE ACCEPTED 


ENROLLMENT/CHANGE REJECTED, INVALID PREM AMT 

ENROLLMENT/CHANGE REJECTED, INVALID PREM PAY OPT CD 

PREMIUM PAYMENT OPTION CHANGED TO DIRECT BILL 

PREMIUM WITHHOLD OPTION CHANGE TO DIRECT BILL 

CHANGE REJECTED; PREMIUM NOT PREVIOUSLY SET 

TRANSACTION ACCEPTED- NO CHANGE TO PREMIUM RECORD 

INVALID PTC PREMIUM SUBMITTED, CORRECTED 

NO CHANGE IN PREMIUM WITHHOLD OPTION 

PART C PREMIUM HAS BEEN CORRECTED TO ZERO 

PREMIUM WITHHOLD OPTION CHANGE TO DIRECT BILL 

BENE EXCLUDED FROM TRANSMISSION TO SSA/RRB 

PART B PREMIUM REDUCTION SENT TO SSA 

TRANSACTION RECEIVED, WITHHOLDING PENDING 

CHANGE TO SSA WITHHOLDING REJECTED DUE TO NO SSN 

PREM PAYMENT OPTION CHANGED TO DIRECT BILL, NO SSN 

CHANGED TO DIRECT BILL; NO FUNDS WITHHELD 

PREMIUM PAYMENT OPTION SET TO "N" DUE TO NO PREMIUM 



154M 

260R 

261R 

265A 

266R 



RESIDENCE ADDRESS CHANGE TRC GROUPING 

OUT OF AREA STATUS 

REJECTED; BAD END DATE, REJECT RESIDENCE ADDRESS CHANGE 

REJECTED; INCOMPLETE RESIDENCE ADDRESS INFORMATION 

RESIDENCE ADDRESS CHANGE ACCEPTED, NEW SCC 

UNABLE TO RESOLVE SSA STATE COUNTY CODES 

RESIDENCE ADDRESS DELETED 

RESIDENCE ADDRESS DELETE REJECTED 

120A 

PPO CHANGE SENT TO W/H AGENCY 

RRB TRC GROUPING 

123R 

144M 

185M 

186I 

191A 

222I 

252I 

254I 

255I 

256I 

ENROLLMENT/CHANGE REJECTED, INVALID PRE PAY OPT CD 

PREMIUM PAYMENT OPTION CHANGED TO DIRECT BILL 

WITHHOLDING AGENCY ACCEPTED TRANSACTION 

WITHHOLDING AGENCY REJECTED TRANSACTION 

NO CHANGE IN PREMIUM WITHHOLD OPTION 

BENE EXCLUDED FROM TRANSMISSION TO SSA/RRB 

PRE PAYMENT OPTION CHANGED TO DIRECT BILL; NO SSN 

BENE SET TO DIRECT BILL, SPANS JURISDICTION 

PLAN SUBMITTED RRB W/H FOR SSA BENE 

PLAN SUBMITTED SSA W/H FOR RRB BENE 

262R 

085M 

138M 

154M 

305M 

BAD RRB PREMIUM WITHHOLD EFFECTIVE DATE 

SCC ADDRESS TRC GROUPING 

STATE AND COUNTY CODE CHANGE 

BENEFICIARY ADDRESS CHANGE TO OUTSIDE THE U.S. 

OUT OF AREA STATUS 

ZIP CODE CHANGE 

SPECIAL REPLY TRC GROUPING 

990-995 APPEAR ON SPECIAL TRR GENERATED FOR SPECIFIC PURPOSE. WHEN A SPECIAL TRR PRODUCES ONE 

OF THESE CODES, CMS WILL PROVIDE COMMUNICATIONS TO EXPLAIN THE TRC 

996 EOY LOSS OR LOW INCOME SUBSIDY STATUS 

997-999 APPEAR ON SPECIAL TRR GENERATED FOR SPECIFIC PURPOSE. WHEN A SPECIAL TRR PRODUCES ONE 

OF THESE CODES, CMS WILL PROVIDE COMMUNICATIONS TO EXPLAIN THE TRC 

185M 

186I 

195M 

235I 

236I 

243R 

WITHHOLDING AGENCY ACCEPTED TRANSACTION 

WITHHOLDING AGENCY REJECTED TRANSACTION 

SSA TRC GROUPING 

SSA UNSOLICITED RESPONSE (SSA WITHHOLD UPDATE) 

SSA ACCEPTED PART B REDUCTION TRANSACTION 

SSA REJECTED PART B REDUCTION TRANSACTION 

CHANGE TO SSA WITHHOLDING REJECTED DUE TO NO SSN 

048 R NURSEING HOME CERTIFIABLE STATUS SET 

SYSTEM NOTIFICATION TRC GROUPING 



062 R CORRECTION REJECTED, OVERLAPS OTHER PERIOD 

075 A INSTITUTIONAL STATUS SET 

079 M PART A TERMINATION 

080 M PART A REINSTATEMENT 

081 M PART B TERMINIATION 

082 M PART B REINSTATEMENT 

086 M CLAIM NUMBER CHANGE 

087 M NAME CHANGE 

088 M SEX CODE CHANGE 

089 M DATE OF BIRTH CHANGE 

090 M DATE OF DEATH ESTABLISHED 

091 M DATE OF DEATH REMOVED 

092 M DATE OF DEATH CORRECTED 

121M LOW INCOME PERIOD STATUS 

152 M RACE CODE CHANGE 

154M OUT OF AREA STATUS 

155 M INCARCERATION NOTIFICATION RECEIVED 

158 M INSTITUTIONAL PERIOD CHANGE/CANCELLATION 

159 M NURSING HOME CERT PERIOD CHANGE/CANCELLATION 

165 R PROCESSING DELAYED DUE TO MARX SYSTEM PROBLEMS 

194M DEEMED CORRECTION 

197M PART D ELIGIBILITY TERMINATION 

198M PART D ELIGIBILITY REINSTATEMENT 

267M PREMIUM PAYMENT OPTION SET TO "N" DUE TO NO PREMIUM 

270M BENEFICIARY TRANSPLANT HAS ENDED 



I.5 Payment Reply Codes 

Table I-4 lists the reply codes returned for transactions found in Table I-1. 

PRC Types: 

A - Accepted - A transaction is accepted and the requested action is applied 

(Example: enrollment or disenrollment) 

R - Rejected - A transaction is rejected due to an error or other condition. The 

requested action is not applied to the CMS System. The TRC code 

indicates the reason for the transaction rejection. The Plan should 

analyze the rejection to validate the submitted transaction and to 

determine whether to resubmit the transaction with corrections. 

I - 

Informational - These replies accompany Accepted TRC replies and provide 

additional information about the transaction or Beneficiary. For 

example: If an enrollment transaction for a Beneficiary who is “out of 

area” is accepted, the Plan receives an accepted TRC (TRC 011) and 

an additional reply is included in the TRR that gives the Plan the 

additional information that the Beneficiary is “Out of Area” (TRC 

016). 

M - Maintenance - These replies provide information to Plans about their Beneficiaries 

enrolled in their Plan. They are sent in response to information 

received by CMS. For example: If CMS is informed of a change in a 

Beneficiary’s claim number, a reply is included in the Plan’s TRR 

with TRC 086, giving the Plan the new claim number. 

F - Failed - A transaction failed due to an error or other condition and the 

requested action did not occur. The TRC code indicates the reason for 

the transaction’s failure. The Plan should analyze the failed 

transaction and determine whether to resubmit with corrections. 

Table I-4: Payment Reply Codes 

Code/Type* Title Short 

Definition 

Definition 

000 

I 

264 

I 

299 

I 

No Data to 

Report 

Payment Not 

Yet Completed 

Correction to 

Previously 

Failed Payment 

NO REPORT 

Monthly Payment Exception Report: 

On the MPER it indicates the presence of all prospective 

payments for the plan (contract/PBP), none are missing. 


NO PAYMENT A transaction was accepted requiring a payment calculation. The 

calculation has not been completed. 


RESTORED 

PYMT 

A previously incomplete payment calculation is now completed. 


December 28 , 2012 I-100 Payment Reply Codes


I.6 MMR Adjustment Reason Codes 

Table I-5 lists the adjustment reasons and their associated codes. 

Table I-5: Adjustment Reason Codes 

Code 

Description 

01 Notification of Death of Beneficiary 

02 Retroactive Enrollment 

03 Retroactive Disenrollment 

04 Correction to Enrollment Date 

05 Correction to Disenrollment Date 

06 Correction to Part A Entitlement 

07 Retroactive Hospice Status 

08 Retroactive ESRD Status 

09 Retroactive Institutional Status 

10 Retroactive Medicaid Status 

11 Retroactive Change to State County Code 

12 Date of Death Correction 

13 Date of Birth Correction 

14 Correction to Sex Code 

15 Obsolete 

16 Obsolete 

17 For APPS use only 

18 Part C Rate Change 

19 Correction to Part B Entitlement 

20 Retroactive Working Aged Status 

21 Retroactive NHC Status 

22 Disenrolled Due to Prior ESRD 

23 Demo Factor Adjustment 

24 Retroactive Change to Bonus Payment 

25 Part C Risk Adj Factor Change/Recon 

26 Mid-year Part C Risk Adj Factor Change 

27 Retroactive Change to Congestive Heart Failure (CHF) Payment 

28 Retroactive Change to BIPA Part B Premium Reduction Amount 

29 Retroactive Change to Hospice Rate 

30 Retroactive Change to Basic Part D Premium 

31 Retroactive Change to Part D Low Income Premium Subsidy Change 

32 Retroactive Change to Estimated Cost-Sharing Amount 

33 Retroactive Change to Estimated Reinsurance Amount 

34 Retroactive Change Basic Part C Premium 

December 28, 2012 I-101 MMR Adjustment 

Reason Codes


Code 

Description 

35 Retroactive Change to Rebate Amount 

36 Part D Rate Change 

37 Part D Risk Adjustment Factor Change 

38 Part C Segment ID Change 

41 Part D Risk Adjustment Factor Change (ongoing) 

42 Retroactive MSP Status 

43 Retroactive Plan Premium Waiver Update 

44 Retroactive correction of previously failed Payment (affects Part C and D) 

45 Disenroll for Failure to Pay Part D IRMAA Premium – Reported for Pt C and Pt D 

46 Correction of Part D Eligibility – Reported for Pt D 

50 Payment adjustment due to Beneficiary Merge 

90 System of Record History Alignment 

94 Special Payment Adjustment Due to Clean-Up 

December 28, 2012 I-102 MMR Adjustment 

Reason Codes


I.7 State Codes 

Table I-6 lists the numeric and character code for all states. 

Table I-6: State Code Table 

State / Territory Numeric Code Character Code 

Alabama 01 AL 

Alaska 02 AK 

Arizona 03 AZ 

Arkansas 04 AR 

California 05 CA 

Colorado 06 CO 

Connecticut 07 CT 

Delaware 08 DE 

District of Columbia (Washington DC) 09 DC 

Florida 10 FL 

Georgia 11 GA 

Hawaii 12 HI 

Idaho 13 ID 

Illinois 14 IL 

Indiana 15 IN 

Iowa 16 IA 

Kansas 17 KS 

Kentucky 18 KY 

Louisiana 19 LA 

Maine 20 ME 

Maryland 21 MD 

Massachusetts 22 MA 

Michigan 23 MI 

Minnesota 24 MN 

Mississippi 25 MS 

Missouri 26 MO 

Montana 27 MT 

Nebraska 28 NE 

Nevada 29 NV 

New Hampshire 30 NH 

New Jersey 31 NJ 

New Mexico 32 NM 

New York 33 NY 

North Carolina 34 NC 

North Dakota 35 ND 

Ohio 36 OH 

Oklahoma 37 OK 

Oregon 38 OR 

Pennsylvania 39 PA 

Puerto Rico 40 PR 

December 28, 2012 I-103 State Codes


State / Territory Numeric Code Character Code 

Rhode Island 41 RI 

South Carolina 42 SC 

South Dakota 43 SD 

Tennessee 44 TN 

Texas 45 TX 

Utah 46 UT 

Vermont 47 VT 

Virgin Islands 48 VI 

Virginia 49 VA 

Washington 50 WA 

West Virginia 51 WV 

Wisconsin 52 WI 

Wyoming 53 WY 

Africa 54 

Asia 55 

Canada 56 

Ctrl America/West Indies/Alvarado (Honduras) 57 

Himariotis (Greece) (Europe) 58 

Ibarra (Mexico) 59 

Oceania (Australia & Islands in the Pacific) 60 

Bush (Philippine Islands) 61 

South America 62 

U.S. Possessions 63 

American Samoa 64 

Gogue (Guam) 65 

Dirksz (Aruba) 78 

Lynch (APO NE) 94 

Correa (APO) 95 

St. Peter (Plaisted) 99 

December 28, 2012 I-104 State Codes


I.8 Entitlement Status and Enrollment Reason Codes 

The tables below list the codes for Part A and Part B Enrollment, Entitlement and Non-Entitlement 

1.8.1 Entitlement Status Code Tables 

Part A – Entitlement Status Codes 

The following codes occur when the Part A Entitlement Date is present and the Part A 

Termination Date is blank: 

Code 

E 

G 

Y 

Definition 

Free Part A Entitlement 

Entitled due to good cause 

Currently entitled, premium is payable 

The following codes occur when the Part A Entitlement Date is present and the Part A 

Termination Date is also present: 

Code 

C 

S 

T 

W 

X 

Definition 

No longer entitled due to disability cessation 

Terminated, no longer entitled under ESRD provision 

Terminated for non-payment of premiums 

Voluntary withdrawal from premium Part A coverage 

Free Part A terminated because of Title II termination 

Part A – Non Entitlement Status Codes 

The following codes occur when there is no Part A Entitlement 

Date and no Part A Termination Date: 

Code 

D 

F 

H 

N 

R 

Definition 

Coverage denied 

Terminated due to invalid enrollment or enrollment voided 

Ineligible for free Part A, or did not enroll for premium Part A 

Not valid SSA HIC, used by CMS 3 rd party sys for potential PTA entitled date 

Refused benefits 

December 28, 2012 I-105 Entitlement Status and 

Enrollment Reason Codes


Part A - Enrollment Reason Codes 

Code Definition 

A Attainment of age 65 

B 

Equitable relief 

Code Definition 

D Disability – Under age 65 entitlement 

G General Enrollment Period 

I 

Initial Enrollment Period 

J 

MQGE entitlement 

K Renal disease not reason for entitled prior to 65 or 25 th month of disability 

L 

Late filing 

M Termination based on renal entitlement but disability based on entitlement continues 

N Age 65 and uninsured 

P 

Potentially insured beneficiary is enrolled for Medicare coverage only 

Q Quarters of coverage requirements are involved 

R 

Residency requirements are involved 

T 

Disabled working individual 

U Unknown blank = not applicable; e.g. Part A data is generated at age 64 years, 8 months 

Part B - Entitlement Status Codes 

The following codes occur when the Part B Entitlement Date is present and the Part B 

Termination Date is blank: 

Code 

G 

Y 

Entitled due to good cause 

Currently entitled, premium is payable 

Definition 

The following codes occur when the Part B Entitlement Date is present and the Part B 

Termination Date is also present: 

Code 

C 

F 

S 

T 

W 

Definition 

No longer entitled due to cessation of disability 

Terminated due to invalid enrollment or enrollment voided 

Terminated, no longer entitled under ESRD provision 

Terminated for non-payment of premiums 

Voluntary withdrawal from coverage 




Part B – Non Entitlement Reason Codes 

The following codes occur when there is no Part B Entitlement Date and no Part B 

Termination Date: 

Code 

D 

N 

R 

Definition 

Coverage denied 

No Foreign/Puerto Rican Beneficiary is not entitled to SMI or dually/Technically entitled 

Beneficiary ID not entitled to SMI. 

Refused benefits 

Part B - Enrollment Reason Codes 

Code 

B 

C 

D 

F 

G 

I 

K 

M 

R 

S 

T 

U 

Definition 

Equitable Relief 

Good Cause 

Deemed date of birth 

Working aged 

General enrollment period 

Initial enrollment period 

Renal disease was a reason for entitlement prior to age 65 or prior to the 25 th month of disability 

Renal entitlement terminated, but disability based entitlement continues 

Residency requirements are involved 

State buy-in 

Disabled working Individual * 

* = future – current CMS program edits do not create this code 

Unknown 




I.9 Disenrollment Reason Codes 

Table I-7 lists the reason codes for Disenrollment. 

Table I-7: Disenrollment Reason Code Table 

Disenrollment 

Reason Number 

Disenrollment Reason Description 

MARx 

UI 

AUTO- 

DIS 

PLAN 

SUB’D 

1 FAILURE TO PAY PREMIUMS N/A N/A N/A 

2 

3 

RELOCATION OUT OF PLAN SERVICE AREA 

(NO SPECIAL PROVISIONS) 

FAILURE TO CONVERT TO RISK 

PROVISIONS 

N/A N/A N/A 

N/A N/A N/A 

4 FRAUD N/A N/A N/A 

5 LOSS OF PART B ENTITLEMENT N/A Y N/A 

6 

LOSS OF PART A ENTITLEMENT (PLAN- 

SPECIFIC) 

N/A Y N/A 

7 FOR CAUSE Y N/A N/A 

8 REPORT OF DEATH N/A Y N/A 

9 

10 

11 

12 

13 

TERMINATION OF CONTRACT (CMS- 

INITIATED) 

TERMINATION OF 

CONTRACT/PBP/SEGMENT (PLAN 

WITHDRAWAL) 

VOLUNTARY DISENROLLMENT THROUGH 

PLAN 

VOLUNTARY DISENROLLMENT THROUGH 

DISTRICT OFFICE 

DISENROLLMENT BECAUSE OF 

ENROLLMENT IN ANOTHER PLAN 

N/A Y N/A 

N/A Y N/A 

Y N/A Y 

N/A N/A N/A 

N/A Y N/A 

14 RETROACTIVE N/A N/A N/A 

15 TERMINATED IN ERROR BY CMS SYSTEM N/A N/A N/A 

16 

17 

END OF SCC CONDITIONAL ENROLLMENT 

PERIOD 

BENE DOES NOT MEET AGE CRITERION 

(PLAN-SPECIFIC) 

N/A N/A N/A 

N/A N/A N/A 

18 ROLLOVER N/A Y N/A 

19 TERMINATED BY SSA DISTRICT OFFICE N/A N/A N/A 

20 INVALID ENROLLMENT WITH ESRD N/A Y N/A 

21 

22 

23 

CANNOT TRAVEL/POOR HEALTH/TO 

HMO/PLAN DOCTORS 

SPOUSE IS NO LONGER MEMBER OF 

HMO/PLAN 

COULDN'T USE MEDICARE CARD TO SEE 

OTHER PLAN 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

December 28, 2012 I-108 Disenrollment Reason Codes


Disenrollment 

Reason Number 


MARx 

UI 

AUTO- 

DIS 

PLAN 

SUB’D 

24 DID NOT KNOW I JOINED THIS HMO N/A N/A N/A 

25 

26 

27 


DIFFICULTY REACHING HMO/PLAN 

DOCTOR BY PHONE PROBLEM 

CALLED HMO/PLAN COULD NOT GET HELP 

WITH PROBLEM 

DISSATISFIED WITH MEDICAL CARE/DOCS 

OR HOSPITAL 

TOLD BY PLAN DOCTORS OR STAFF I 

SHOULD DISENROLL 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

29 PREFER TRADITIONAL MEDICARE N/A N/A N/A 

30 

HAVE OTHER HEALTH INSURANCE 

BENEFITS AVAILABLE 

N/A N/A N/A 

31 FOUND HMO/PLAN TOO CONFUSING N/A N/A N/A 

32 MY CLAIMS/BILLS WERE NOT PAID N/A N/A N/A 

33 HAD LITTLE OR NO CHOICE OF SPECIALIST N/A N/A N/A 

34 

35 

36 

37 

41 

42 

43 

44 

TREATED DISCOURTEOUSLY BY 

DOCTOR/NURSE/STAFF 

DOCTOR COULDN'T IMPROVE MY 

CONDITION 

HMO/PLAN MEDICAL GROUP WAS 

LOCATED TOO FAR AWAY 

HAD LIMITED OR NO CHOICE OF MY 

PRIMARY DOCTOR 

YOU MOVED PERMANENTLY OUT OF 

AREA WHERE PLAN PROVIDES SERVIC 

YOUR DOCTOR OR THE PLAN TOLD YOU 

TO DISENROLL 

YOUR DOCTOR DIDN'T GIVE YOU GOOD 

QUALITY CARE 

YOU USED UP THE PRESCRIPTION 

ALLOWANCE 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

N/A N/A N/A 

45 THE PLAN COST YOU TOO MUCH N/A N/A N/A 

46 

YOU COULDN'T GET CARE WHEN YOU 

NEEDED IT 

N/A N/A N/A 

47 YOUR DOCTOR ISN'T IN THE PLAN N/A N/A N/A 

48 

49 

YOU DIDN'T KNOW YOU SIGNED UP FOR 

THIS PLAN 

YOU DIDN'T LIKE HOW THE PLAN 

WORKED 

N/A N/A N/A 

N/A N/A N/A 

54 PART A OR B START DATE CHANGE N/A Y N/A 

56 

BENEFICIARY MEDICAID PERIOD 

RECEIVED 

N/A N/A N/A 



Disenrollment 

Reason Number 


MARx 

UI 

AUTO- 

DIS 

PLAN 

SUB’D 

57 BENEFICIARY HOSPICE PERIOD RECEIVED N/A Y N/A 

59 INVALID ENROLLMENT WITH HOSPICE N/A Y N/A 

60 

BENEFICIARY LIVES IN USA LESS THAN 

183 DAYS A YEAR 

N/A N/A N/A 

61 LOSS OF PART D ELIGIBILITY N/A Y N/A 

62 

PART D DISENROLLMENT DUE TO FAILURE 

TO PAY IRMAA 

N/A Y N/A 

63** MMP OPT-OUT AFTER ENROLLED Y Y Y 

64** LOSS OF DEMONSTRATION ELIGIBILITY Y Y Y 

88 CONVERSION N/A N/A N/A 

90 

ENROLLMENT CANCELLED DUE TO 

BENEFICIARY MERGE 

N/A Y N/A 

91 FAILURE TO PAY PREMIUMS Y N/A Y 

92 RELOCATION OUT OF PLAN SERVICE AREA Y N/A Y 

93 

LOST SPECIFIC PLAN ELIGIBILITY (SNP 

ONLY) 

Y N/A Y 

99 OTHER (NOT SUPPLIED BY BENE) N/A N/A Y* 

*Plan cannot submit 99; it is assigned as a default value by the system only. 

**Only valid for MMP Disenrollments, Disenrollment Cancellations or Enrollment Cancellations. 



I.10 BEQ Response File Error Condition Table 

I.10.1 Request File Error Conditions 

The following table contains File Level Error information. File Level Errors represent conditions 

in which a BEQ Request File is rejected and not processed. 

Table I-8: File Level Error information 

SOURCE OF 

ERROR 

Header Record 

Header Record 



File Content 

ERROR MESSAGE 

The Header Record is 

missing. 

The Header Record is 

Invalid. 

The Trailer Record is 

missing. 

The Trailer Record is 

invalid. 

The File has no 

Transactions. 

ERROR CONDITION 

● The Header Record is not provided on the file. 

● The Header Record is unreadable. 

● More than one Header Record is provided on the file. 

● The Header Record is incorrectly formatted. 

● The Header Record contains invalid values. 

● The Header Record contains Critical Fields that are not 

provided. 

● The Trailer Record is not provided on the file. 

● The Trailer Record is unreadable. 

● More than one Trailer Record is provided on the file. 

● The Trailer Record is incorrectly formatted. 

● The Trailer Record contains invalid values. 

● The Trailer Record contains Critical Fields that are not 

populated. 

● The Record Count in the Trailer Record is more than 2 

different from the actual number of Detail Records 

(Transactions) in the file. 

● There are no Transactions (Detail Records) found in the file. 

December 28, 2012 I-111 BEQ Response File Error Condition 

Table


I.10.2 Request Transaction Detail Record Error Conditions 

The following Flag fields are provided in the Response File Detail Record. Flag fields represent 

the successful or unsuccessful result of processing data within a Transaction Detail Record of the 

input file. 

Table I-9: Error Conditions 

FLAG FLAG CODE FLAG CODE RESULT FLAG RESULT CONDITION 

Processed Flag Y The Transaction is 

accepted for processing. 

All critical fields on the Transaction are populated 

with valid values. 

Processed Flag N The Transaction is not 

accepted for processing. 

At least one critical field on the Transaction is 

populated with a value other than the prescribed 

valid values. 

Beneficiary 

Match Flag 

Y 

The beneficiary on the 

Transaction is 

successfully located in 

the MBD. 

The beneficiary is successfully located by the 

combination of the HICN or RRB, SSN; date of 

birth, and gender. 

Beneficiary 

Match Flag 

N 

The beneficiary on the 

Transaction is not 

successfully located in 

the MBD. 

The beneficiary is not successfully located by the 

combination of the HICN or RRB, SSN; date of 

birth, and gender. 

Beneficiary 

Match Flag 

SPACE 

No attempt made to 

locate the beneficiary on 

the MBD. 

An invalid condition exists in the Transaction Detail 

Record such as an unexpected, absent, or invalid 

value in a Critical Field. 

December 28, 2012 I-112 BEQ Response File Error Condition 

Table


J: Report Files 

This appendix provides a description and sample snapshot of each report file. Table J-1 lists the 

names of all the accessible reports to Plans and on which page of this appendix J they are 

located. Note that the examples provided for the reports do not identify any person living or 

dead; all Beneficiary, contract, and user information is fictional. Appendix J identifies the 

naming conventions for all reports sent to Plans. The user needs dataset names to request a report 

through the mainframe. 

Table J-1: Reports Lookup Table 


J.1 BIPA 606 Payment Reduction Report J-2 

J.2 Bonus Payment Report J-6 

J.3 HMO Bill Itemization Report J-11 

J.4 Monthly Membership Detail Report – Drug Report (Part D) J-12 

J.5 Monthly Membership Detail Report – Non Drug Report (Part C) J-13 

J.6 Monthly Membership Summary Report J-15 

J.7 Monthly Summary of Bills Report J-19 

J.8 Part C Risk Adjustment Model Output Report J-21 

J.9 RAS RxHCC Model Output Report 

J-22 

AKA - Part D Risk Adjustment Model Output Report 

J.10 Payment Records Report J-23 

J.11 Plan Payment Report (PPR) (APPS Payment Letter) J-24 

J.12 Interim Plan Payment Report (IPPR) J-29 

J.13 No Premium Due Report Format J-30 

J.14 Sample BEQ Request File Pass and Fail Acknowledgement J-36 

Note: See Appendix K for complete information on Dataset Names. 

December 28, 2012 J-1 Report Files


J.1 BIPA 606 Payment Reduction Report 

Description 

This report lists members for whom the MCO is paying a portion of the Part B premium. This report only reflects data for periods prior to 2006. 

Example 

1 RUN DATE: 2003/12/10 

PAY MONTH: 2004/01 BIPA606 PAYMENT REDUCTION REPORT PAGE: 1 

CONTRACT#: H3333 REPORT DATE: 2003/12/10 

0 PBP ID: 026 

0 CLAIM SURNAME F S BIRTH ADJ PAY/ADJ BIPA BLEND TOT BIPA BLEND BLEND PT-B BLEND TOT 

NUMBER I E DATE RC DATES RATE W/O BIPA AMOUNT PT-A PLUS BIPA PLUS BIPA 

X 

123456789A PARR H F 19121128 200401-200401 31.25 609.52 -31.25 362.64 215.63 578.27 

123456789A MONET M F 19170402 200401-200401 31.25 677.32 -31.25 400.05 246.02 646.07 

123456789D GARRISO M F 19130812 200401-200401 31.25 744.55 -31.25 437.15 276.15 713.30 

123456789A GEISEL A M 19190407 200401-200401 31.25 687.28 -31.25 387.95 268.08 656.03 

123456789A BLAZE H M 19170901 200401-200401 31.25 688.39 -31.25 406.45 250.69 657.14 

123456789D AMES E F 19061027 200401-200401 31.25 607.62 -31.25 361.59 214.78 576.37 

123456789D KLEIN P F 19270531 200401-200401 31.25 459.05 -31.25 243.34 184.46 427.80 

123456789A DAVIDS J M 19200513 200401-200401 31.25 787.43 -31.25 444.78 311.40 756.18 

123456789B DAVIDS E F 19180521 200401-200401 31.25 744.30 -31.25 443.28 269.77 713.05 

123456789A MURRAY E F 19190614 200401-200401 31.25 724.95 -31.25 418.69 275.01 693.70 

123456789A MURDOCK P M 19161126 200401-200401 31.25 734.80 -31.25 433.85 269.70 703.55 

123456789D TROTTER S F 19230411 200401-200401 31.25 905.11 -31.25 518.10 355.76 873.86 

123456789A RUSS D M 19220119 200401-200401 31.25 860.56 -31.25 486.14 343.17 829.31 

123456789A PRINCE A F 19041104 200401-200401 31.25 646.97 -31.25 384.27 231.45 615.72 

123456789A LONG I M 19190101 200401-200401 31.25 723.08 -31.25 427.31 264.52 691.83 

123456789A SHAPIRO S M 19100313 200401-200401 31.25 858.29 -31.25 506.54 320.50 827.04 

December 28, 2012 J-2 BIPA 606 Payment Reduction Report


123456789A WEISMAN W M 19160511 200401-200401 31.25 900.15 -31.25 528.34 340.56 868.90 

123456789A BERGER B F 19190910 200401-200401 31.25 641.60 -31.25 370.61 239.74 610.35 

123456789A KELLER H F 19190906 200401-200401 31.25 580.79 -31.25 335.44 214.10 549.54 

123456789A RYAN J M 19181027 200401-200401 31.25 857.21 -31.25 505.94 320.02 825.96 

123456789A FALK S M 19080704 200401-200401 31.25 749.63 -31.25 442.25 276.13 718.38 

123456789A DUFFY S F 19120426 200401-200401 31.25 640.90 -31.25 381.26 228.39 609.65 

123456789D ADAMS E F 19101114 200401-200401 31.25 657.82 -31.25 391.28 235.29 626.57 

123456789A TATE V F 19160825 200401-200401 31.25 643.82 -31.25 382.53 230.04 612.57 

123456789A SCOTT P F 19140929 200401-200401 31.25 709.80 -31.25 422.54 256.01 678.55 

123456789D SMALL T F 19110616 200401-200401 31.25 633.83 -31.25 377.02 225.56 602.58 

123456789A WILEY R F 19100427 200401-200401 31.25 573.46 -31.25 341.11 201.10 542.21 

123456789D DENNIS D F 19020517 200401-200401 31.25 641.90 -31.25 381.47 229.18 610.65 

123456789A HAMMIL J M 19090425 200401-200401 31.25 822.26 -31.25 483.25 307.76 791.01 

123456789A VOSS E F 19060220 200401-200401 31.25 664.03 -31.25 394.51 238.27 632.78 

123456789A TUTTLE A M 19140320 200401-200401 31.25 948.38 -31.25 559.93 357.20 917.13 

123456789A BARTLET A M 19190119 200401-200401 31.25 939.40 -31.25 530.59 377.56 908.15 

123456789D GREEN H F 19220628 200401-200401 31.25 641.60 -31.25 370.61 239.74 610.35 

123456789A RUSK M M 19171115 200401-200401 31.25 859.79 -31.25 507.03 321.51 828.54 

123456789A POWELL W M 19061121 200401-200401 31.25 850.31 -31.25 501.80 317.26 819.06 

123456789D MCDONAL H F 19191007 200401-200401 31.25 565.59 -31.25 326.62 207.72 534.34 

123456789D KING L F 19130321 200401-200401 31.25 839.02 -31.25 498.73 309.04 807.77 

123456789D LEWIS M F 19150407 200401-200401 31.25 781.74 -31.25 464.48 286.01 750.49 

PBP ID: 026 TOTALS: 38 $ 27,602.25 $ -1,187.50 $ 26,414.75 

AGED REDUCTION: $ -1,187.50 

DIB REDUCTION: $ 0.00 

1 RUN DATE: 2003/12/10 

PAY MONTH: 2004/01 BIPA606 PAYMENT REDUCTION REPORT PAGE: 2 




0 PBP ID: 027 

0 CLAIM SURNAME F S BIRTH ADJ PAY/ADJ BIPA BLEND TOT BIPA BLEND BLEND PT-B BLEND TOT 

NUMBER I E DATE RC DATES RATE W/O BIPA AMOUNT PT-A PLUS BIPA PLUS BIPA 

X 

123456789B MARKS E F 19220112 200401-200401 73.38 685.30 -73.38 395.50 216.42 611.92 

123456789A MONTGOM M F 19111113 200401-200401 73.38 723.40 -73.38 430.47 219.55 650.02 

123456789D SCHREIB A F 19190814 200401-200401 73.38 520.09 -73.38 300.46 146.25 446.71 

123456789A BECKER V F 19191224 200401-200401 73.38 520.09 -73.38 300.46 146.25 446.71 

123456789A BRIDGE H M 19171219 200401-200401 73.38 715.74 -73.38 422.51 219.85 642.36 

123456789A EDELMAN S M 19160825 200401-200401 73.38 765.94 -73.38 452.29 240.27 692.56 

123456789A ZEMLACK A F 19090715 200401-200401 73.38 640.90 -73.38 381.26 186.26 567.52 

123456789A ROSENST L M 19180629 200401-200401 73.38 712.25 -73.38 420.62 218.25 638.87 

123456789B ROSENST L F 19231014 200401-200401 73.38 558.72 -73.38 322.85 162.49 485.34 

123456789D ROLNICK I F 19090215 200401-200401 73.38 633.83 -73.38 377.02 183.43 560.45 

123456789D KAIN M F 19150907 200401-200401 73.38 831.80 -73.38 494.02 264.40 758.42 

123456789A SHANK W M 19200707 200401-200401 73.38 756.68 -73.38 427.40 255.90 683.30 

123456789A KAY T M 19121119 200401-200401 73.38 926.09 -73.38 546.43 306.28 852.71 

123456789A GOLDMAN S M 19160221 200401-200401 73.38 734.80 -73.38 433.85 227.57 661.42 

123456789D MILLMAN E F 19110709 200401-200401 73.38 692.33 -73.38 411.35 207.60 618.95 

123456789A JARRETT J M 19110519 200401-200401 73.38 722.82 -73.38 426.42 223.02 649.44 

123456789B JARRETT E F 19170417 200401-200401 73.38 643.79 -73.38 382.51 187.90 570.41 

123456789C1 MENG A M 19500301 200401-200401 73.38 347.11 -73.38 189.69 84.04 273.73 

123456789A BLACK M F 19151205 200401-200401 73.38 665.44 -73.38 395.27 196.79 592.06 

123456789A TAUBMAN E F 19420723 200401-200401 73.38 689.25 -73.38 376.64 239.23 615.87 

123456789D DRUSKIN M F 19290303 200401-200401 73.38 424.51 -73.38 216.96 134.17 351.13 

123456789A SMITH V F 19130908 200401-200401 73.38 631.21 -73.38 375.57 182.26 557.83 

123456789D JEFFRIE C F 19000201 200401-200401 73.38 646.99 -73.38 384.28 189.33 573.61 

123456789A PRITZKE S M 19120929 200401-200401 73.38 722.86 -73.38 426.44 223.04 649.48 

123456789A SAMUELS S M 19180331 200401-200401 73.38 713.94 -73.38 421.52 219.04 640.56 

123456789A KANTER D F 19150103 200401-200401 73.38 653.71 -73.38 389.01 191.32 580.33 

123456789D NORMAN F F 19230914 200401-200401 73.38 559.86 -73.38 323.49 162.99 486.48 



123456789A MARTIN L F 19150709 200401-200401 73.38 653.71 -73.38 389.01 191.32 580.33 

123456789A COHEN R M 19171019 200401-200401 73.38 811.54 -73.38 479.27 258.89 738.16 

123456789D RUBIN J F 19121124 200401-200401 73.38 857.74 -73.38 509.52 274.84 784.36 

123456789A TROUTMA J M 19110502 200401-200401 73.38 980.15 -73.38 577.46 329.31 906.77 

123456789A ROUND P F 19170127 200401-200401 73.38 569.89 -73.38 339.14 157.37 496.51 

123456789A AZMAN F F 19180203 200401-200401 73.38 734.82 -73.38 436.59 224.85 661.44 

123456789D PRATT F F 19080919 200401-200401 73.38 746.11 -73.38 443.95 228.78 672.73 

123456789A LOMBARD F F 19160926 200401-200401 73.38 834.62 -73.38 496.76 264.48 761.24 

123456789D BALTIMO M F 19080301 200401-200401 73.38 837.34 -73.38 498.26 265.70 763.96 

123456789D HOWARD J F 19070402 200401-200401 73.38 580.51 -73.38 345.61 161.52 507.13 

123456789A COLUMBU F M 19180904 200401-200401 73.38 1,004.55 -73.38 593.51 337.66 931.17 

123456789C2 CARROLL K M 19580202 200401-200401 73.38 333.27 -73.38 182.23 77.66 259.89 

PBP ID: 027 TOTALS: 39 $ 26,783.70 $ -2,861.82 $ 23,921.88 


DIB REDUCTION: $ -293.52 

0 CONTRACT: H3333 TOTALS: 77 $ 54,385.95 $ -4,049.32 $ 50,336.63 


DIB REDUCTION: $ -293.52 



J.2 Bonus Payment Report 

Description 

This report lists members for whom the MCO receives a bonus. (MCOs are paid a bonus for extending services to beneficiaries in some underserved areas.) This 

report only reflects data for periods prior to 2004. 

Example 

1 RUN DATE: 2003/10/03 

PAY MONTH: 2003/03 BONUS PAYMENT REPORT PAGE: 2 


0 STATE/COUNTY CODE: 27030 

0 CLAIM SURNAME F S BIRTH ADJ PAY/ADJ BONUS BLENDED BONUS BONUS BONUS ----- BLENDED PLUS BONUS ---- 

NUMBER I E DATE RC DATES PCT W/O BONUS PART A PART B TOTAL PART A PART B TOTAL 

X 

123456789A JONES J M 19280611 200303-200303 3.00 480.44 7.66 6.75 14.41 263.03 231.82 $ 494.85 

123456789A CHANG A M 19140222 200303-200303 3.00 647.58 11.47 7.96 19.43 393.75 273.26 $ 667.01 

123456789B CHANG F F 19151105 200303-200303 3.00 569.89 10.17 6.92 17.09 349.31 237.67 $ 586.98 

123456789A COHEN A M 19250714 200303-200303 3.00 650.30 10.65 8.86 19.51 365.74 304.07 $ 669.81 

123456789A PULASKI W M 19290909 200303-200303 3.00 449.12 7.14 6.33 13.47 245.23 217.36 $ 462.59 

* STATE/COUNTY 27030 TOTALS: 5 $ 2,797.33 $ 83.91 $ 2,881.24 




X 

123456789A KIRBY C M 19220222 200303-200303 3.00 599.47 10.16 7.83 17.99 348.73 268.73 $ 617.46 

December 28, 2012 J-6 Bonus Payment Report


* STATE/COUNTY 27040 TOTALS: 1 $ 599.47 $ 17.99 $ 617.46 




X 

123456789C1 TAPLEY P F 19500322 200303-200303 3.00 398.14 5.60 6.34 11.94 192.42 217.66 $ 410.08 

123456789A WALT A F 19350710 200303-200303 3.00 340.68 5.16 5.06 10.22 177.24 173.66 $ 350.90 

123456789A ZIMMER J M 19351008 200303-200303 3.00 358.55 5.46 5.29 10.75 187.58 181.72 $ 369.30 

123456789B6 ZIMMER R F 19350717 200303-200303 3.00 307.84 4.62 4.62 9.24 158.58 158.50 $ 317.08 





X 

123456789A DUNN W M 19460531 200303-200303 3.00 375.60 6.28 4.99 11.27 215.51 171.36 $ 386.87 


1 RUN DATE: 2003/10/03 






X 



123456789A UNGER W M 19280219 200303-200303 3.00 540.82 8.84 7.38 16.22 303.52 253.52 $ 557.04 





X 

123456789A LABER E F 19290807 200303-200303 3.00 384.07 5.89 5.63 11.52 202.18 193.41 $ 395.59 

123456789A SESLER S F 19371109 200303-200303 3.00 307.79 4.62 4.62 9.24 158.55 158.48 $ 317.03 

123456789B TAPLEY M F 19250503 200303-200303 3.00 476.04 7.59 6.69 14.28 260.53 229.79 $ 490.32 

123456789A EVERETT S F 19551018 200303-200303 3.00 398.14 5.60 6.34 11.94 192.42 217.66 $ 410.08 

123456789A ROY R M 19240904 200303-200303 3.00 541.75 8.86 7.40 16.26 304.05 253.96 $ 558.01 

123456789A LEGAUL E F 19490514 200303-200303 3.00 398.14 5.60 6.34 11.94 192.42 217.66 $ 410.08 

123456789A NOYES J M 19350402 200303-200303 3.00 358.55 5.46 5.29 10.75 187.58 181.72 $ 369.30 

123456789A SAVAGE L F 19370220 200303-200303 3.00 309.36 4.64 4.64 9.28 159.44 159.20 $ 318.64 

123456789A BRUCAT P M 19210502 200303-200303 3.00 599.47 10.16 7.83 17.99 348.73 268.73 $ 617.46 

123456789A CAPOZZI I F 19220115 200303-200303 3.00 511.73 8.87 6.49 15.36 304.39 222.70 $ 527.09 

123456789A DYER D M 19301227 200303-200303 3.00 449.12 7.14 6.33 13.47 245.23 217.36 $ 462.59 

123456789D NAETHEL L F 19340427 200303-200303 3.00 307.84 4.62 4.62 9.24 158.58 158.50 $ 317.08 

123456789A DUFFY R M 19260410 200303-200303 3.00 541.75 8.86 7.40 16.26 304.05 253.96 $ 558.01 

123456789A RIVARD J M 19280509 200303-200303 3.00 481.36 7.68 6.76 14.44 263.56 232.24 $ 495.80 

123456789A BROWN M F 19350908 200303-200303 3.00 307.84 4.62 4.62 9.24 158.58 158.50 $ 317.08 

123456789A TEEPLE A F 19450506 200303-200303 3.00 465.37 7.01 6.95 13.96 240.58 238.75 $ 479.33 

123456789A VICARY C M 19361021 200303-200303 3.00 360.94 5.50 5.32 10.82 188.94 182.82 $ 371.76 

123456789A HEATON G M 19170306 200303-200303 3.00 647.58 11.47 7.96 19.43 393.75 273.26 $ 667.01 

123456789A NOLLEY J M 19460216 200303-200303 3.00 407.91 6.81 5.43 12.24 233.87 186.28 $ 420.15 

123456789A JAMIESO W M 19210627 200303-200303 3.00 599.47 10.16 7.83 17.99 348.73 268.73 $ 617.46 

123456789A HORNE J M 19171211 200303-200303 3.00 647.58 11.47 7.96 19.43 393.75 273.26 $ 667.01 

123456789A BROWN J M 19280428 200303-200303 3.00 457.37 7.28 6.44 13.72 249.92 221.17 $ 471.09 

123456789A ARMSTRO V F 19360130 200303-200303 3.00 307.84 4.62 4.62 9.24 158.58 158.50 $ 317.08 



123456789A REESE T M 19280415 200303-200303 3.00 457.37 7.28 6.44 13.72 249.92 221.17 $ 471.09 

123456789A BESSLER N F 19170530 200303-200303 3.00 569.89 10.17 6.92 17.09 349.31 237.67 $ 586.98 

123456789A WAMBEKE B F 19360803 200303-200303 3.00 310.39 4.66 4.65 9.31 160.03 159.67 $ 319.70 

123456789A STEINBE H F 19251012 200303-200303 3.00 451.39 7.18 6.36 13.54 246.52 218.41 $ 464.93 


1 RUN DATE: 2003/10/03 






X 

123456789A COFFIN A M 19290424 200303-200303 3.00 449.12 7.14 6.33 13.47 245.23 217.36 $ 462.59 

123456789C1 CARACCA S M 19620723 200303-200303 3.00 296.38 5.20 3.69 8.89 178.49 126.78 $ 305.27 

123456789A ALTMAN R M 19251111 200303-200303 3.00 541.75 8.86 7.40 16.26 304.05 253.96 $ 558.01 

123456789A ROBICH R F 19241116 200303-200303 3.00 451.39 7.18 6.36 13.54 246.52 218.41 $ 464.93 

123456789A RACHES C M 19340308 200303-200303 3.00 358.55 5.46 5.29 10.75 187.58 181.72 $ 369.30 

123456789A WELLS A M 19340809 200303-200303 3.00 358.55 5.46 5.29 10.75 187.58 181.72 $ 369.30 

123456789A WASHBU H F 19140313 200303-200303 3.00 569.89 10.17 6.92 17.09 349.31 237.67 $ 586.98 

123456789A ROSE C M 19160131 200303-200303 3.00 647.58 11.47 7.96 19.43 393.75 273.26 $ 667.01 

123456789D BEARDS J F 19330729 200303-200303 3.00 318.53 4.80 4.76 9.56 164.66 163.43 $ 328.09 

123456789A BENNETT E M 19370325 200303-200303 3.00 359.85 5.49 5.31 10.80 188.33 182.32 $ 370.65 

123456789D LOESER S F 19320223 200303-200303 3.00 384.07 5.89 5.63 11.52 202.18 193.41 $ 395.59 

123456789A ACKLEY P F 19190304 200303-200303 3.00 580.72 10.01 7.41 17.42 343.60 254.54 $ 598.14 

123456789A NEWMAN R F 19290129 200303-200303 3.00 384.07 5.89 5.63 11.52 202.18 193.41 $ 395.59 

123456789A LUZAR B F 19361016 200303-200303 3.00 342.80 5.20 5.09 10.29 178.45 174.64 $ 353.09 

123456789A CRAIG R F 19330708 200303-200303 3.00 311.53 4.68 4.67 9.35 160.68 160.20 $ 320.88 

123456789A ZUSSBLE N M 19310707 200303-200303 3.00 449.12 7.14 6.33 13.47 245.23 217.36 $ 462.59 



123456789A TEMPLE K M 19180322 200303-200303 3.00 645.95 11.44 7.94 19.38 392.82 272.51 $ 665.33 

123456789A COFFIN J F 19321201 200303-200303 3.00 384.07 5.89 5.63 11.52 202.18 193.41 $ 395.59 





X 


0 ** CONTRACT H5555 TOTALS: 57 $ 25,608.40 $ 768.25 $ 26,376.65 



J.3 HMO Bill Itemization Report 

Description 

This report lists the Part A bills processed under Medicare fee-for-service for beneficiaries enrolled in the contract. 

Example 

1 PART A BILLS POSTED IN OCT 2002 PAGE 1 

BILL TYPE: INPATIENT 

* * * * * HMO H4444 * * * * * 

HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP 

CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE 

DAYS AMT CD CR 

123456789A BAKER 010084 00010 20020630 7821 0 812 0 0 0 0 812 20020630 20020703 0 0 

123456789C2 MILLER 014007 00010 20020819 8320 8320 0 0 0 0 0 0 20020819 20020920 0 0 N 

1 PART A BILLS POSTED IN OCT 2002 PAGE 2 

* * * * * HMO H4444 * * * * * 

BILL TYPE: HOSPICE 

HMO ADM TOTAL NON-COV INP NC BLD COINSURANCE TOTAL FROM THRU COV REIM NP 

CLAIM NUM NAME PROV INTER PD DATE CHARGES CHARGES DED DEDUCT DAYS CHGS AMOUNT DEDUCT DATE DATE 

DAYS AMT CD CR 

1234567891 CANDLE 011570 00380 20020826 3084 0 0 0 0 0 0 0 20020901 20020930 0 3084 

12345678946 FLICKE 011570 00380 20020912 1953 0 0 0 0 0 0 0 20020912 20020930 0 1953 

December 28, 2012 J-11 HMO Bill Itemization Report


J.4 Monthly Membership Detail Report – Drug Report (Part D) 

Description 

This report lists every Medicare member of the contract and provides details about the payments and adjustments made for each Beneficiary. The two Monthly 

Membership Detail Reports are for drugs and for non-drugs. 

Example 

The example below is part of a Monthly Membership Detail Report containing drug information. The full report includes all members in the contract. 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

RUN DATE:20050115 MONTHLY MEMBERSHIP REPORT-DRUG PAGE: 1 

PAYMENT MONTH:200502 PLAN(Hzzzz) PBP(nnn) SEGMENT(mmm) PLAN NAME HERE 

BASIC PREMIUM | ESTIMATED REINSURANCE 

PART D $SS9.99 | $SS9.99 

S --- FLAGS ----- ------------------ PAYMENTS/ADJUSTMENTS --------------------------- 

CLAIM E AGE STATE P P S L L D C ADJ RA FCTR DATES LOW-INCOME COST LOW-INCOME COST 

NUMBER X GRP CNTY A A E 0 O I E M RES START END SHARING PERCENTAGE SHARING SUBSIDY 

------------ - ---- ----- O R R G U I N M C ---- ------------------------------------------------------------------- 

SURNAME F DMG BIRTH O T T H R N S I A MTHS DIRECT SUBSIDY COVERAGE GAP 

I RA DATE A A B P C C T N I D PAYMENT AMT DISCOUNT TOTAL PAYMENT 

------------ - ---- ----- - - - - - - - - - ---- ------------------------------------------------------------------- 

1234567890AB F 33800 XXXXXXXXXXXX 99 20.0405 200504 200505 ZZ $SSSSSS9.99 

FIRST G 8084 19200206 Y Y N N Y Z9 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

0987654321AB M 8084 33800 Z9 20.0405 200504 200505 ZZ $SSSSSS9.99 

SECOND H 8084 19251008 Y Y Y Y N Z9 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

December 28, 2012 J-12 Monthly Membership Detail Report – Drug Report (Part D)


J.5 Monthly Membership Detail Report – Non-Drug Report (Part C) 

Description 

This report lists every Medicare member of the contract and provides details about the payments and adjustments made for each beneficiary. 

Example 

The example below is one page of a Monthly Membership Detail Report containing non-drug information. The full report includes all members in the contract. 

(above benchmark bid) 

1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

RUN DATE:20090124 MONTHLY MEMBERSHIP REPORT - NON DRUG PAGE: 1 


------------------------------------------------- REBATES -------------------------------------------- 

BASIC PREMIUM | COST SHR REDUC MAND SUPP BENEFIT PART D SUPP BENEFIT PART B BAS PRM REDUC PART D BAS PRM REDUC 

PART A $SSS9.99 | N/A N/A N/A N/A N/A 

PART B $SSS9.99 | N/A N/A N/A N/A N/A 

S ----------- FLAGS --------------- ------------------ PAYMENTS/ADJUSTMENTS -------------------- 

CLAIM E AGE STATE P P M F A D S C MTHS PAYMENT DATE LAG FTYPE----FACTORS-------- AMOUNT 

NUMBER X GRP CNTY A A H E I C R O D E E O M A B START END FRAILTY-SCORE MSP MSP 

------------ - ---- ----- O R R O S N N A A R D F G U M C ---- --- ------------------------------------------------------------ 

SURNAME F DMG BIRTH O T T S R S H I I E O A H R S A PIP ADJ 

I RA DATE A A B P D T C D L C N U P C P I DCG REA FCTR-A FCTR-B PART A PART B TOTAL PAYMENT 

------------ - ---- ----- - - - - - - - - - - - - - - - - --- ----------------------------------------------------------------- 

123456789A F 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 

FIRST G 8084 19200206 Y Y 1 A Y Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

987654321B M 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 

SECOND H 8084 19251008 Y Y Y Y 4 T N Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

December 28, 2012 J-13 Monthly Membership Detail Report – 

Non-Drug Report (Part C)


(below benchmark bid) 

1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

RUN DATE: 20090124 MONTHLY MEMBERSHIP REPORT – NON DRUG PAGE: 1 


------------------------------------------------- REBATES -------------------------------------------- 

BASIC PREMIUM | COST SHR REDUC MAND SUPP BENEFIT PART D SUPP BENEFIT PART B BAS PRM REDUC PART D BAS PRM REDUC 

PART A N/A | $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 

PART B N/A | $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 $SSS9.99 

S ----------- FLAGS --------------- ------------------ PAYMENTS/ADJUSTMENTS --------------------CLAIM E AGE STATE P P M F A D S C MTHS PAYMENT DATE 

LAG FTYPE----FACTORS-------- AMOUNT 

NUMBER X GRP CNTY A A H E I C R O D E E O M A B START END FRAILTY-SCORE MSP MSP 

------------ - ---- ----- O R R O S N N A A R D F G U M C ---- --- ------------------------------------------------------------ 

SURNAME F DMG BIRTH O T T S R S H I I E O A H R S A PIP ADJ 

I RA DATE A A B P D T C D L C N U P C P I DCG REA FCTR-A FCTR-B PART A PART B TOTAL PAYMENT 

------------ - ---- ----- - - - - - - - - - - - - - - - - --- ----------------------------------------------------------------- 

1234567890AB F 8084 33800 200405 200405 Y C 99.9999 $SSSS9.99 

FIRST G 8084 19200206 Y Y N 1 Y Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

0987654321AB M 8084 33800 200405 200405 Y C 99.9999 99.9999 $SSSS9.99 

SECOND H 8084 19251008 Y Y Y Y 4 P N Z9Z9 ZZ 1.0650 1.0650 $SSSSSS9.99 $SSSSSS9.99 $SSSSSSS9.99 

December 28, 2012 J-14 Monthly Membership Detail Report – 

Non-Drug Report (Part C)


J.6 Monthly Membership Summary Report (MMSR) 

Description 

This report summarizes payments to an MCO for the month, in several categories, and adjustments, by all adjustment categories. When the report automatically 

generates as part of month-end processing, it covers one contract in one payment month. When the report generates on user request, it is based on the transactions 

received to-date for the current payment month and may generate for one contract or for all contracts in a region. 

Example 

1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

RUN DATE:yyyymmdd MONTHLY MEMBERSHIP SUMMARY REPORT (PAGE 1 OF 2) 

PAYMENT MONTH:yyyymm 

PLAN: H9999 PBP(mmm) SEG(nnn) Name-of-Provider-Here 

CURRENT PAYMENTS 

PART A ---------- COUNTS ----- TOTAL MONEY PART B -------- COUNTS ----- TOTAL MONEY PART D ---------- COUNTS ----- TOTAL MONEY 

HOSPICE z,zzz,zz9 $$,$$$,$$$,$$9.99 HOSPICE z,zzz,zz9 $$,$$$,$$$,$$9.99 

ESRD z,zzz,zz9 $$,$$$,$$$,$$9.99 ESRD z,zzz,zz9 $$,$$$,$$$,$$9.99 

WA z,zzz,zz9 $$,$$$,$$$,$$9.99 WA z,zzz,zz9 $$,$$$,$$$,$$9.99 

INST z,zzz,zz9 $$,$$$,$$$,$$9.99 INST z,zzz,zz9 $$,$$$,$$$,$$9.99 

NHC z,zzz,zz9 $$,$$$,$$$,$$9.99 NHC z,zzz,zz9 $$,$$$,$$$,$$9.99 

MCAID z,zzz,zz9 $$,$$$,$$$,$$9.99 MCAID z,zzz,zz9 $$,$$$,$$$,$$9.99 

PART C PREMIUM z,zzz,zz9 $$,$$$,$$$,$$9.99 PART C PREMIUM z,zzz,zz9 $$,$$$,$$$,$$9.99 DIR SUBSDY z,zzz,zz9 $$,$$$,$$$,$$9.99 

A/B COST SHR z,zzz,zz9 $$,$$$,$$$,$$9.99 A/B COST SHR z,zzz,zz9 $$,$$$,$$$,$$9.99 LIS COST SHR z,zzz,zz9 $$,$$$,$$$,$$9.99 

A/B MAN SUP BN z,zzz,zz9 $$,$$$,$$$,$$9.99 A/B MAN SUP BN z,zzz,zz9 $$,$$$,$$$,$$9.99 ESTIMATD REINS z,zzz,zz9 $$,$$$,$$$,$$9.99 

D BAS PRM REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 D BAS PRM REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 PACE PRM ADDON z,zzz,zz9 $$,$$$,$$$,$$9.99 

D SUPP BENFITS z,zzz,zz9 $$,$$$,$$$,$$9.99 D SUPP BENFITS z,zzz,zz9 $$,$$$,$$$,$$9.99 PACE CSR ADDON z,zzz,zz9 $$,$$$,$$$,$$9.99 

B BAS PRM REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 B BAS PRM REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 COV GAP DISC z,zzz,zz9 $$,$$$,$$$,$$9.99 

A/D MSP REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 A/D MSP REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 LIPS z,zzz,zz9 $$,$$$,$$$,SS9.99 

ESRD MSP REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 ESRD MSP REDU z,zzz,zz9 $$,$$$,$$$,$$9.99 

MEMBERS z,zzz,zz9 $$,$$$,$$$,$$9.99 MEMBERS z,zzz,zz9 $$,$$$,$$$,$$9.99 MEMBERS z,zzz,zz9 $$,$$$,$$$,$$9.99 

MONTHS z,zzz,zz9 MONTHS z,zzz,zz9 MONTHS z,zzz,zz9 

AVERAGE $$$$,$$$,$$9.99 AVERAGE $$$$,$$$,$$9.99 AVERAGE $$$$,$$$,$$9.99 

OUT OF AREA z,zzz,zz9 

B PRM REDU - A $$,$$$,$$$,$$9.99 B PRM REDU - A $$,$$$,$$$,$$9.99 

B PRM REDU - D $$,$$$,$$$,$$$.99 B PRM REDU - D $$,$$$,$$$,$$$.99 

1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 


December 28, 2012 J-15 MMSR




ADJUSTMENT PAYMENTS 

ADJ 

REA ADJUSTMENT NUMBER MONTHS MONTHS MONTHS ----------------------- ADJUSTMENT AMOUNT ------------------------ 

CDE DESCRIPTION OF ADJS A B D PART A PART B PART D TOTAL 

--- ------------------- ------- ------- ------- ------- ------------------ ------------------ ------------------ ------------------- 

01 DEATH zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

02 RETRO ENROLL zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

03 RETRO DISENR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

04 CORR ENROLL zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

05 CORRT DISENR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

06 CORR PARTA E zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

07 HOSPC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

08 ESRD zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

09 INSTNHC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

10 MCAID zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

11 RETRO SCC CH zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

12 CORR DT. OF zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 


14 CORR SEX zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

18 AAPCC RT FAC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

19 CORR PARTB E zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

20 WKAGE zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 


22 DISENROLL PR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 



1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 




ADJUSTMENT PAYMENTS 

ADJ 

REA ADJUSTMENT NUMBER MONTHS MONTHS MONTHS ----------------------- ADJUSTMENT AMOUNT ------------------------ 

CDE DESCRIPTION OF ADJS A B D PART A PART B PART D TOTAL 

--- ------------------- ------- ------- ------- ------- ------------------ ------------------ ------------------ ------------------- 

01 DEATH zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

02 RETRO ENROLL zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

03 RETRO DISENR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

04 CORR ENROLL zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

05 CORRT DISENR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

06 CORR PARTA E zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

07 HOSPC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

08 ESRD zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 


10 MCAID zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

11 RETRO SCC CH zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 



14 CORR SEX zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

18 AAPCC RT FAC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

19 CORR PARTB E zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

20 WKAGE zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 


22 DISENROLL PR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 



1 1 1 1 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

23 DEMO FACTOR zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

25 PTC RSK ADJF zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

26 RISK ADJ FAC zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

27 RETRO CHF zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

29 HOSPICE RATE zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

30 RTRO PTD PM zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

31 RTRO PTD LIP zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

32 RTRO CST SHR zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

33 RTRO EST REI zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

34 RTRO PTC PM zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

35 RTRO REBATE zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

36 PTD RATE CHG zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

37 PTD RAF CHG zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

38 SEG ID CHG zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

41 PTD RAF ONGO zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

42 RETRO MSP zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

43 PLN WVD PRM zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

44 PYMT CORR zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

50 XRF MRG zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

94 CLNUP ADJ zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

TOTAL ADJUSTMENT zzzzzz9 zzzzzz9 zzzzzz9 zzzzzz9 $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$,$$$,$$$,$$9.99- $$$,$$$,$$$,$$9.99- 

TOTAL ADJUSTMENTS 

Months A : zzzzzzz9 Part A Amount : $$$,$$$,$$$,$$9.99- 

Months B : zzzzzzz9 Part B Amount : $$$,$$$,$$$,$$9.99- 

Months D : zzzzzzz9 Part D Amount : $$$,$$$,$$$,$$9.99- 

Number of Adjustments : zzzzzzz9 Total Amount : $$$,$$$,$$$,$$9.99- 

TOTAL PYMT AMT A $$$,$$$,$$$,$$9.99- 

TOTAL PYMT AMT B $$$,$$$,$$$,$$9.99- 

TOTAL PYMT AMT D $$$,$$$,$$$,$$9.99- 

SUM TOTAL AMOUNT $$$$,$$$,$$$,$$9.99- 



J.7 Monthly Summary of Bills Report 

Description 

This report summarizes all Medicare fee-for-service activity, both Part A and Part B, for Beneficiaries enrolled in the contract. 

Example 

1 MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 

0 HMO NO H123A HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2004 CURRENT MONTH 01/2009 

0 TOTALS FOR THIS MONTH 

0 CARRIER MEDICAL REIMB TOTAL 

NUMBER CHARGES AMOUNT BILLS 

NO ACTIVITY FOR THIS HMO FOR THIS PERIOD 

FY TOTAL $198,903- $151,602- 4,266 

1 MONTHLY SUMMARY OF BILLS PAID BY INTERMEDIARIES FOR HMO ENROLLEES 

0 HMO NO H123B HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2005 CURRENT MONTH 01/2009 

BILLS THROUGH 01/30/2009 

0 ------------------ INPATIENT BILLS -------------- ------ OUTPATIENT BILLS -------- -------------- HHA BILLS ------------ 

NON 

TOTAL COVERED REIMB COVERED TOTAL COVERED REIMB TOTAL TOTAL REIMB TOTAL TOTAL 

CHARGES CHARGES AMOUNT DAYS BILLS CHARGES AMOUNT BILLS CHARGES AMOUNT VISITS BILLS 


FY TOTAL $123,526,251 $113,627,247 42,572 $570,708- $245,326 9 

$1,315,398 16,614 $3,309,867- 1,606 $229,640 617 

1 MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 

0 HMO NO H123C HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2005 CURRENT MONTH 01/2009 





FY TOTAL $548,050- $428,202- 8,315 

1 MONTHLY SUMMARY OF BILLS PAID BY INTERMEDIARIES FOR HMO ENROLLEES 

0 HMO NO H123D HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2006 CURRENT MONTH 01/2009 

BILLS THROUGH 01/30/2009 

0 ------------------ INPATIENT BILLS -------------- ------ OUTPATIENT BILLS -------- -------------- HHA BILLS ------------ 

NON 

TOTAL COVERED REIMB COVERED TOTAL COVERED REIMB TOTAL TOTAL REIMB TOTAL TOTAL 

December 28, 2012 J-19 Monthly Summary of Bills Report


CHARGES CHARGES AMOUNT DAYS BILLS CHARGES AMOUNT BILLS CHARGES AMOUNT VISITS BILLS 

0INTER NO 0000A 

PROV NO 

00000A 1,147 0 1,147 0 1 0 0 0 0 0 0 0 

------------------------------------------------------------------------------------------------------------------------------------ 

INT TOTAL 1,147 0 1,147 0 1 0 0 0 0 0 0 0 

0INTER NO 0000B 

PROV NO 

00000B 4,488 0 0 0 2 0 0 0 0 0 0 0 

00000C 0 0 0 0 0 78- 90- 1 0 0 0 0 

00000D 0 0 0 0 0 102- 90- 1 0 0 0 0 

------------------------------------------------------------------------------------------------------------------------------------ 

INT TOTAL 4,488 0 0 0 2 180- 180- 2 0 0 0 0 

0INTER NO 0000C 

PROV NO 

00000E 182,012 0 0 23 2 0 0 0 0 0 0 0 

------------------------------------------------------------------------------------------------------------------------------------ 

INT TOTAL 182,012 0 0 23 2 0 0 0 0 0 0 0 

-HMO TOTAL 187,647 0 1,147 23 5 180- 180- 2 0 0 0 0 

FY TOTAL $116,001,944 $85,570,972 34,354 $937,010- $159,078 102 

$2,835,588 14,675 $6,493,082- 2,876 $162,661 485 

1 

MONTHLY SUMMARY OF CLAIMS PAID BY CARRIERS FOR HMO ENROLLEES 

0 HMO NO H123E HMO NAME ABC FOUNDATION, INC. HMO FY ENDING 12/2006 CURRENT MONTH 01/2009 




0 01192 224 161 1 

0 HMO TOTAL 224 161 1 

FY TOTAL $750,298- $574,946- 8,412 

December 28, 2012 J-20 Monthly Summary of Bills Report


J.8 Part C Risk Adjustment Model Output Report 

Description 

This report shows the Hierarchical Condition Codes (HCCs) used by RAS to calculate risk adjustment factors for each beneficiary. 

Example 

Below is part of a Risk Adjustment Model Output report. The full report shows all of the Beneficiaries in the contract. 

1***GROUP=H8888,CONTRACT=H8888, 

1RUN DATE: 20031219 RISK ADJUSTMENT MODEL OUTPUT REPORT PAGE: 1 

PAYMENT MONTH: 200401 PLAN: H8888 CHAMPION INSURANCE RAPMORP1 

0 LAST FIRST DATE OF 

HIC NAME NAME I BIRTH SEX & AGE GROUP 

------------ --------------- --------------- - -------- --------------- 

123456789A WOOD CHARLES W 19250225 Male75-79 

123456789B TREE LILLIAN L 19270418 Female75-79 

123456789A GRASS ALBERT A 19421213 Male60-64 

HCC DISEASE GROUPS: HCC019 Diabetes without Complication 

HCC080 Congestive Heart Failure 

HCC092 Specified Heart Arrhythmias 

INTERACTIONS: INTI01 DM_CHF 

December 28, 2012 J-21 Part C Risk Adjustment Model Output Report


J.9 RAS RxHCC Model Output Report - aka - Part D RA Model Output Report 

Description 

This report shows the Hierarchical Condition Codes (HCCs) used by RAS to calculate risk adjustment factors for each beneficiary. 

Example 

Below are the first few lines of a RA Model Output report. The full report shows all of the Beneficiaries in the contract. 

1RUN DATE: 20060124 RISK ADJUSTMENT MODEL OUTPUT REPORT PAGE: 1 

PAYMENT MONTH: 200602 PLAN: H9999 ACME INSURANCE COMPANY RAPMORP2 

0 LAST FIRST DATE OF 

HIC NAME NAME I BIRTH SEX & AGE GROUP 

------------ ---------------------------------------- ---------------------------------- - -------- --------------- 

123456789A TWO RUTH M 19181122 Female85-89 

RXHCC DISEASE GROUPS: RXHCC019 Disorders of Lipoid Metabolism 

RXHCC048 Other Musculoskeletal and Connective Tissue Disorders 

RXHCC092 Acute Myocardial Infarction and Unstable Angina 

RXHCC098 Hypertensive Heart Disease or Hypertension 

RXHCC159 Cellulitis, Local Skin Infection 

123456789A BREEZE WINDY T 19620730 Female35-44 

RXHCC DISEASE GROUPS: RXHCC045 Disorders of the Vertebrae and Spinal Discs 

RXHCC085 Migraine Headaches 

RXHCC098 Hypertensive Heart Disease or Hypertension 

RXHCC113 Acute Bronchitis and Congenital Lung/Respiratory Anomaly 

RXHCC129 Other Diseases of Upper Respiratory System 

RXHCC144 Vaginal and Cervical Diseases 

December 28, 2012 J-22 RAS RxHCC Model Output Report aka Part D Risk 

Adjustment Model Output Report


J.10 Payment Records Report 

Description 

This report lists the Part B physician and supplier claims that were processed under Medicare fee-for-service for 

Beneficiaries enrolled in the contract. 

Example 

1 PART B CLAIMS RECORDS POSTED IN OCT 2002 PAGE 

1 

0 * * * * *HMO H2222 * * * * * 

0 CLAIM NAME EXPENSE DATES ALLOWED REIMB COINSURANCE DED PHYS 

PAY CARRIER CARRIER INFORMATION 

NUMBER FIRST LAST TOTAL AMT AMT APP SUPP ID IND NUMBER 

PAID CONTROL NUMBER 

CHARGES 

123456789A JONES 20020917 20020917 9.72 7.78 1.94 .00 L99999 1 11111 20021014 

620902283027160 

123456789A JONES 20020920 20020920 12.00 9.60 2.40 .00 L88888 1 11111 20021014 

620902283027550 

123456789A JONES 20020830 20020830 12.65 10.12 2.53 .00 P77777 1 11111 20021017 

620902283028810 

123456789A JONES 20020831 20020831 12.00 9.60 2.40 .00 P77777 1 11111 20021014 


123456789A JONES 20020915 20020915 12.00 9.60 2.40 .00 P77777 1 11111 20021014 


123456789A HOWARD 20020708 20020708 5.43 5.43 .00 .00 0000000000 1 22222 

20021023 02262828553000 

123456789A WILLS 20020908 20020908 87.97 70.38 17.59 .00 666666666 1 22222 

20021018 02254815230000 

123456789A LEE 20020920 20020920 27.21 21.77 5.44 .00 555555555 1 22222 20021016 

02270301676000 

123456789A BRILL 20011019 20011119 26.46 21.17 5.29 .00 4444444444 1 33333 

20021013 02266171165000 

123456789D SOMMER 20020916 20020916 134.47 107.58 26.89 .00 333333333 1 22222 

20021023 02262834339000 

123456789A JONES 20020917 20020919 115.79 92.63 23.16 .00 222222 1 11111 20021005 

620202275864060 

123456789A JONES 20020925 20020925 11.16 11.16 .00 .00 111111 1 11111 20021024 

620202294476660 

123456789A JONES 20021010 20021010 28.97 28.97 .00 .00 111111 1 11111 20021024 

620202294476670 

123456789A JONES 20021011 20021011 28.97 28.97 .00 .00 111111 1 11111 20021024 

620202294476680 

December 28, 2012 J-23 Payment Records Report


J.11 Plan Payment Report (APPS Payment Letter) 

Description 

Also known as the APPS Payment Letter, this report itemizes the final monthly payment to the MCO. This report is 

produced by APPS when final payments are calculated. CMS makes this report available to MCOs as part of monthend 

processing. 

Plan Payment Report (PPR) - Final 

The PPR includes Part D payments and adjustments, the National Medicare Education Campaign (NMEC) and COB 

User Fees and premium settlement information. There is one version of the PPR applicable to all Plans and it is 

provided monthly. 

Following is an updated example of a PPR or APPS Payment Letter: 

December 28, 2012 24 Plan Payment Report


December 28, 2012 J-25 Plan Payment Report






December 28, 2012 J-28 Plan Payment Report


J.12 Interim Plan Payment Report (IPPR) 

Description 

Also known as the Interim Payment Letter, this report itemizes interim payments to the MCO. It is produced by APPS when interim payments are calculated. 

CMS computes interim payments on an as-needed basis. When this occurs, the interim payment letter is pushed to the involved Plan(s). 

IPPR 

The APPS IPPR is provided when a Plan is approved for an interim payment outside of the normal monthly process. The report contains the amount and reason 

for the interim payment to the Plan. 

Plans may request the IPPR via the MARx User Interface under the weekly reports section of the menu. 

12 Plan Payment Report 

Note: For a sample of this report, refer to I- (PPR) for the file format. 

December 28, 2012 J-29 IPPR


J.13 No Premium Due Report Format 

No Premium Due Reports are no longer generated. Only a data file is produced. The report is here for reference 

1 2 3 4 5 6 7 8 9 0 1 2 3 

1234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123456789012345678901234567890123 

RUN DATE: 01/15/2005 TRANSACTION REPLIES/MONTHLY ACTIVITY REPORT ID: 10 

REPORTING MONTH: 12/2004 PLAN (Hzzzz) PBP (nnn) SGMT (mmm) Health Plan Name Here PAGE: 1 

* * * PLAN-SUBMITTED TRANSACTIONS: ACCEPTED * * * 

--------------------------- T R A N S A C T I O N ---------------------------------------------- R E P L Y ----------------- 

S O E L CO-PAY 

F E DATE OF EFF O L SRCE SPECIAL I EFF --PREMIUMS-- RPLY 

TC CLAIM NUMBER SURNAME I X BIRTH DATE SCC A T ID STATUS S DATE PT C PT D CODE REMARKS 

------------------------------------------------------------------------------------------------------------------------------------ 

61 1234567890AB DAVIDSO F M 09/10/26 01/01/05 45850 Y A SYSGN HEWIN 1 01/01/05 100.00 200.00 011 ENROLL ACCEPTED 

51 1234567890AB BELMORE M F 03/27/33 01/01/05 22000 N E TV6K N 2 04/01/05 .00 85.30 014 DISNROL-NEW MCO 

51 123456789A DUGAN D F 07/14/17 01/01/05 45180 Y I TOE8 E 3 05/01/05 .00 113.56 014 AUTO DISENROLL 

December 28, 2012 J-30 No Premium Due Report Format


J.13.1 Error Condition 

The six following STATUS file messages generate when an error condition prevents the transaction from processing. 

1. Invalid User Id 

********************************* Top of Data ***************************** 

TRANSACTIONS RECEIVED ON 2006-01-27 AT 16.59.49 

PROCESSING STOPPED ON 2006-01-27 AT 17.00.39 

USER ID (aaaa ) NOT AUTHENTICATED: 2-USER ID NOT FOUND 

HEADER CODE= AAAAAAHEADER 

HEADER DATE= 

BATCH ID = 

USER ID = 

TRAN CNTS1 = nnnnnnnn T01 nnnnnnnn T51 nnnnnnnn T60 nnnnnnnn T61 nnnnnnnn 

TRAN CNTS2 = T71 nnnnnnnn T72 nnnnnnnn TXX nnnnnnnn T62 nnnnnnnn 

TRAN CNTS3 = T73 nnnnnnnn T74 nnnnnnnn T75 nnnnnnnn T85 nnnnnnnn 

TRAN CNTS4 = T63 nnnnnnnn 

******************************** Bottom of Data *************************** 

2. Invalid Header Date 

********************************* Top of Data***************************** 



HEADER RECORD IS MISSING OR INVALID 


HEADER DATE= 

BATCH ID = 

USER ID = 





******************************** Bottom of Data *************************** 

December 28, 2012 J-31 Error Condition


3. Missing Header Record 

********************************* Top of Data ***************************** 

TRANSACTIONS RECEIVED ON AT 


HEADER RECORD IS MISSING OR INVALID 

HEADER CODE= XXXHEADERZZZ 

HEADER DATE= 

BATCH ID = 

USER ID = 

TRAN CNTS1 = 

TRAN CNTS2 = 

TRAN CNTS3 = 

******************************** Bottom of Data *************************** 

4. Future Header Date 

********************************* Top of Data ***************************** 



HEADER RECORD DATE IS A FUTURE PROCESSING MONTH 

RESUBMIT DURING THE CORRECT PROCESSING MONTH 

PROCESSING MONTH= 


HEADER DATE= 

BATCH ID = 

USER ID = 





******************************** Bottom of Data *************************** 

5. Header Date earlier than CCM 

********************************* Top of Data ***************************** 





HEADER RECORD DATE IS NOT EQUAL TO THE CURRENT PAYMENT MONTH 

PROCESSING MONTH= 


HEADER DATE= 

BATCH ID = 

USER ID = 





******************************** Bottom of Data *************************** 

6. Transaction File Rejection Reason 

After a Specialty file is reviewed by CMS, the following STATUS messages are generated upon rejection: 

********************************* Top of Data ***************************** 


THIS FILE WAS REJECTED BY 

REJECTION REASONS: 

TRANSACTIONS REJECTED ON 24 Mar 2010 AT 14:39:33 

HEADER CODE= AAAAAAHEADER RETRO 

HEADER DATE= 

BATCH ID = 

USER ID = 





TOTAL TRANSACTIONS REJECTED= nnnnnnnn 

******************************** Bottom of Data *************************** 



J.13.2 Specialty Files 

If the file is a Specialty file, the following STATUS messages generate upon initial receipt: 

Retro File Detected 

********************************* Top of Data ***************************** 



HEADER DATE= 

BATCH ID = 

USER ID = 





PROCESSING STOPPED ON 2006-01-27 AT 14:23:39 

RETRO FILE DETECTED FOR USERID 


HEADER DATE= 012006 

******************************** Bottom of Data *************************** 

Rollover File Detected 

********************************* Top of Data ***************************** 


HEADER CODE= AAAAAAHEADER POVER 

HEADER DATE= 

BATCH ID = 

USER ID = 





December 28, 2012 J-34 Specialty Files



ROLLOVER FILE DETECTED FOR USERID 

HEADER CODE= AAAAAAHEADER POVER 


******************************** Bottom of Data *************************** 

Review File Detected 

********************************* Top of Data ***************************** 


HEADER CODE= AAAAAAHEADER SVIEW 

HEADER DATE= 

BATCH ID = 

USER ID = 






REVIEW FILE DETECTED FOR USERID 

HEADER CODE= AAAAAAHEADER SVIEW 


******************************** Bottom of Data *************************** 

December 28, 2012 J-35 Specialty Files


J.14 Sample BEQ Request File Pass and Fail Acknowledgments 

Description 

The Enrollment Processing System issues an e-mail acknowledgment of receipt and status to the Sending Entity. If the status is accepted, the file is processed. If 

the status is rejected, the e-mail informs the Sending Entity of the first File Error Condition that caused the BEQ Request File’s rejection. A rejected file is not 

returned. 

Example 

Sample e-mail notifications showing a Pass Acknowledgement and a Fail Acknowledgement appear below: 

TO: Jim.Doe@xxs.net 

TO: Chris.Doe@dxxx.org 

TO: Falcon.Doe@xxxx.org 

TO: eevs.helpdesk@ngc.com 

FROM: 

Subject: 

MBD#BQ94.HCFJES@cms.hhs.gov 

CMS MMA DATA EXCHANGE FOR MMABTCH 

Example of BEQ Request File “Pass” Acknowledgment 

MMABTCH file has been received and passed surface edits by CMS. 

QUESTIONS? Contact 1-800-927-8069 or E-mail mapdhelp@cms.hhs.gov 

INPUT HEADER RECORD 

MMABEQRHS0094 20070306F20070306 

INPUT TRAILER RECORD 

MMABEQRTS0094 20070306F200703060000074 

December 28, 2012 J-36 Sample BEQ Request File Pass and Fail Acknowledgments


Example of BEQ Request File “Fail” Acknowledgment 

TO: Jim.Doe@xxs.net 

TO: Chris.Doe@dxxx.org 

TO: Falcon.Doe@xxxx.org 

TO: eevs.helpdesk@ngc.com 

FROM: MBD#BQ30.HCFJES@cms.hhs.gov 

Subject: CMS MMA DATA EXCHANGE FOR MMABTCH 

MMABTCH file has been received and failed surface edits by CMS. 

QUESTIONS? Contact 1-800-927-8069 or E-mail mapdhelp@cms.hhs.gov 

INPUT HEADER RECORD 

MMABEQRHH0030 20070228 84433346 

INPUT TRAILER RECORD 

MMABEQRTH0030 20070221 844333460074065 

THE TRAILER RECORD IS INVALID 

December 28, 2012 J-37 Sample BEQ Request File Pass and Fail Acknowledgments


K: All Transmissions Overview 

Table K-1: All Transmissions Overview 

ID# Transmittal 

Dataset naming conventions key: 

[GUID] = 7 character IACS User ID 

P = Production Data 

[.ZIP] = Appended if the file is compressed 

[directory] = optional directory specification 

from non-mainframe C:D clients (if present, 

may consist of up to 60 characters). If none 

exists, directory defaults to the constant 

“EFTO.” for Production files and "EFTT." for 

Test files. 

Plan Submittals to CMS 

1 

MARx Batch Input Transaction 

Data File 

Header Record 

Enrollment Transaction (Employer 

& Plan - 61 Detail Record 

Disenrollment Transaction (51/54) 

Detail Record 

Plan Elections (PBP Change) 

Transaction (71) Detail Record 

4Rx Data Update (72) 

NUNCMO Update (73) 

Other Enrollment record Update 

(74) 

Premium Withhold Option Update 

(75) 

Description 

pn = Processing number of varying length assigned to the 

file by Gentran 

ccccc = Contract number 

Pccccc = Plan Contract Number for C:D 

Uuuu-uuuuuuu = 4-7 character transmitter RACF ID 

xxxxx = 5 character Contract ID 

yyyymmdd = Calendar year, month & day 

yymmdd = two digit year, month, day 

zzzzzzzz = Plan-provided high level qualifier 

eeee = Year for which final yearly RAS file was produced 

vvvvv = Sequence counter for final yearly RAS files 

Enrollment Transaction 

file to CMS MARx 

system requesting new 

enrollment, disenrollment, 

changes, etc. 

Only the 1-800-Medicare 

group submits a Part D 

Opt-Out (41) transaction. 

Responsible 

System Type Freq. Dataset Naming Conventions 

MARx 

Data 

File 

Annnnn & Bnnnnn = MARx batch transaction ID, 

nnnnnnnnnn split into two nodes A…and B …with 

leading zeroes as necessary to complete tencharacter 

batch ID 

hhmm = hour and minute 

ssssss= Sequentially assigned number 

mmyyyy = Calendar month & year 

hlq = High Level Qualifier or Directory per VSAM File 

freq = Frequency code of file 

Batch - 

Daily 

PRN 

Gentran Mailbox/TIBCO MFT 

Internet Server: 

[GUID].[RACFID].MARX.D.xxxx 

x.FUTURE.[P/T][.ZIP] 

Note: FUTURE is part of the 

filename and does not change. 

Connect:Direct: 

P#EFT.IN.uuuuuuu.MARXTR.DY 

YMMDD.THHMMSST 

Note: DYYMMDD.THHMMSST 

must be coded as shown, as it is a 

literal 

PCUG Record Layout – F.6 

2 

Batch Eligibility Query (BEQ) 

Request File 

Header Record 

Detail Record 



File of transactions 

submitted by Plans to 

request eligibility 

information for 

prospective Plan 

enrollees. 

Used to do initial 

eligibility checks against 

CMS MBD system to 

verify member is Part 

A./B eligible 

MBD 

Data 

File 

PRN 

(Plans can 

send 

multiple 

files in a 

day) 



[GUID].[RACFID].MBD.D.xxxxx. 

BEQ.[P/T][.ZIP] 


P#EFT.IN.PLxxxxx.BEQ4RX.DY 




literal 

3 

Electronic Correspondence 

Referral System (ECRS) Batch 

Submittal File 

File used by Plans to 

submit other healthcare 

information (OHI) to 

CMS (rather than 

submittal through the 

ECRS online system) 

ECRS 

Data 

File 

Daily 



[GUID].[RACFID].ECRS.D.ccccc. 

FUTURE.[P/T] [.ZIP] 

Connect:Direct: TRANSMITTED 

TO GHI 

4 Prescription Drug Event (PDE) 



submitted by the Plans 

with Prescription Drug 

Events. 

PDE 

Data 

File 

Can be 

Daily 



[GUID].[RACFID].PDE.D.ccccc.F 

UTURE.[P/T] [.ZIP] 


TRANSMITTED TO PALMETTO 

December 28, 2012 K-1 All Transmissions Overview



Plan Submittals to CMS 

Description 

Responsible 


5 

MARx Batch Input Transaction 

Data File 

Header Record 

Enrollment Transaction (Employer 

& Plan - 61 Detail Record 

Disenrollment Transaction (51/54) 

Detail Record 

Plan Elections (PBP Change) 

Transaction (71) Detail Record 

4Rx Data Update (72) 

NUNCMO Update (73) 

Other Enrollment record Update 

(74) 

Premium Withhold Option Update 

(75) 

Enrollment Transaction 

file to CMS MARx 

system requesting new 

enrollment, disenrollment, 

changes, etc. 

Only the 1-800-Medicare 

group submits a Part D 

Opt-Out (41) transaction. 

MARx 

Data 

File 

Batch - 

Daily 

PRN 


Internet Server: ** 

[GUID].[RACFID].MARX.D.xxxx 

x.FUTURE.[P/T][.ZIP] 

Note: FUTURE is part of the 

filename and does not change. 


P#EFT.IN.uuuuuuu.MARXTR.DY 




literal 


6 


Request File 

Header Record 

Detail Record 




submitted by Plans to 

request eligibility 

information for 

prospective Plan 

enrollees. 

Used to do initial 

eligibility checks against 

CMS MBD system to 

verify member is Part 

A./B eligible 

MBD 

Data 

File 

PRN 

(Plans can 

send 

multiple 

files in a 

day) 


Internet Server: ** 

[GUID].[RACFID].MBD.D.xxxxx. 

BEQ.[P/T][.ZIP] 


P#EFT.IN.PLxxxxx.BEQ4RX.DY 




literal 

7 

Electronic Correspondence 

Referral System (ECRS) Batch 


File used by Plans to 

submit other healthcare 

information (OHI) to 

CMS (rather than 

submittal through the 

ECRS online system) 

ECRS 

Data 

File 

Daily 



[GUID].[RACFID].ECRS.D.ccccc. 


Connect:Direct: TRANSMITTED 

TO GHI 

8 Prescription Drug Event (PDE) 




with Prescription Drug 

Events. 

PDE 

Data 

File 

Can be 

Daily 



[GUID].[RACFID].PDE.D.ccccc.F 

UTURE.[P/T] [.ZIP] 



9 RAPS Submittal File 



with diagnoses for FFS 

Beneficiaries 

RAPS 

Data 

File 

Daily 



[GUID].[RACFID].RAPS.D.ccccc. 




10 

Electronic Data Services (EDS) 




with EDS. 

EDS 

Data 

File 

Daily 



[GUID].[RACF].EDS.D.xxxxx.FU 

TURE.[P/T][.ZIP] 






CMS Transmittals to the Users 

(Submitters) 

Description 

Responsible 


11 

Failed Transaction Data File 

Header Record 

Failed Record 

This report is no longer 

generated as a result of 

the November 2009 

software release. Failed 

Records are now reported 

on the BCSS data file. 

MARx 

Data File Response to 

transaction 

batch file 

Obsolete 

12 

Batch Completion Status 

Summary Data File 

Summary Record 

Failed Records 


Data file sent to the 

submitter once a batch of 

submitted transactions has 

been processed. Provides a 

count of all transactions 

within the batch and 

details the number of 

rejected and accepted 

transactions. It provides an 

image of the rejected and 

accepted transactions. 

MARx 

Data File Once batch 

is processed 



P.uuuuuuu.BCSSD.Annnnn.Bnnnnn. 

Thhmmss.pn 

Connect:Direct [Mainframe]: 

zzzzzzzz.uuuuuuu.BCSSD.Annnnn.B 

nnnnn.Thhmmss 

Connect:Direct [Non-mainframe]: 

[directory]uuuuuuu.BCSSD.Annnnn. 

Bnnnnn.Thhmmss 

13 

Enrollment Transmission 

Message File (STATUS) 

This message is no longer 

generated as a result of the 

April 2011 software 

release. This information 

is now incorporated into 

the Batch Completion 

Status Summary (BCSS) 

data file. 

MARx 

Report Response to 

transaction 

batch file 

Obsolete 

CMS Transmittals to the Plans 

14 

Coordination of Benefits 

(Validated Other Insurer 

Information) Data File 

Detail Record 




File containing members' 

primary and secondary 

coverage that has been 

validated through COB 

processing. MARx 

forwards this report 

whenever a Plan's 

enrollees are affected. It 

may be as often as 

daily.The enrollees 

included on the report are 

those newly enrolled who 

have known Other Health 

Insurance (OHI) and those 

Plan enrollees with 

changes to their OHI. 

MBD 

(MARx) 

Data File 

As Needed 

(can be 

daily) 



P.Rxxxxx.MARXCOB.Dyymmdd.Th 

hmmsst.pn 

Connect:Direct (Mainframe): 

zzzzzzzz.Rxxxxx.MARXCOB.Dyym 

mdd.Thhmmsst 

Connect:Direct (Non-Mainframe): 

[directory]Rxxxxx.MARXCOB.Dyy 

mmdd.Thhmmsst 

15 

MA Full Dual Auto Assignment 

Notification File 

Header Record 

Detail Record (Transaction) 



Monthly file of Full Dual 

Beneficiaries in an 

existing Plan. 

MBD 

Data File Monthly 



P.Rxxxxx.#ADUA4.Dyymmdd.Thh 

mmsst.pn 


zzzzzzzz.Rxxxxx.#ADUA4.Dyymmd 

d.Thhmmsst 


[directory]Rxxxxx.#ADUA4.Dyymm 

dd.Thhmmsst 

ID# Transmittal Description Responsible Type Freq. Dataset Naming Conventions 




System 

16 

Auto Assignment (PDP) Address 

Notification File 

Header Record 

Detail Record(s) 



Monthly file of addresses 

of Beneficiaries who have 

been either Auto Assigned 

or Facilitated Assigned to 

PDPs 

MBD 




P.Rxxxxx.#APDP4.Dyymmdd.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx.#APDP4.Dyymmd 

d.Thhmmsst 


[directory]Rxxxxx.#APDP4.Dyymm 

dd.Thhmmsst 

17 

NoRx File 

Header Record 

Detail Record 



File containing records 

identifying those enrollees 

that do not currently have 

4Rx information stored in 

CMS files. A Detail 

Record Type containing a 

value of “NRX” in 

positions 1 – 3 of the file 

layout will indicate that 

this record is a request for 

your organization to send 

CMS 4Rx information for 

the beneficiary. 

MBD 




P.Rxxxxx.#NORX.Dyymmdd.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx.#NORX.Dyymmdd 

.Thhmmsst 


[directory]Rxxxxx.#NORX.Dyymmd 

d.Thhmmsst 

18 

19 


Request File Acknowledgment 

(Accept/Reject) 

PCUG Sample Report – J.14 


Response File 

Header Record 

Detail Record (Transaction) 



MBD will determine if a 

BEQ Request File is 

Accepted or Rejected. 

MBD will issue an e-mail 

acknowledgment of 

receipt and status to the 

Sending Entity. If 

Accepted the file will be 

processed. If Rejected, the 

e-mail shall inform the 

Sending Entity of the first 

File Error Condition that 

caused the BEQ Request 

File to be Rejected. A 

rejected file will not be 

returned. 

File containing records 

produced as a result of 

processing the 

transactions of accepted 

BEQ Request files. Detail 

records for all submitted 

records that were 

successfully processed 

will contain Processed 

Flag = Y. Detail records 

for all submitted records 

that were not successfully 

processed contain 

Processed Flag = N. 

MBD E-mail Response 

to BEQ 

MBD 

Data File Response 

to BEQ 

N/A 



P.Rxxxxx.#BQN4.Dyymmdd.Thhm 

msst.pn 

Connect:Direct [Mainframe]: 

zzzzzzzz.Rxxxxx.#BQN4.Dyymmdd. 

Thhmmsst 

Connect:Direct [Non-mainframe]: 

[directory]Rxxxxx.#BQN4.Dyymmd 

d.Thhmmsst 





Description 

Responsible 


20 ECRS Data File 

File containing errors and 

statuses of ECRS 

submissions. 

ECRS Data File Daily 



PCOB.BA.ECRS.ccccc.RESPONSE. 

ssssss 


TRANSMITTED FROM GHI 

21 

Prescription Drug Event (PDE) 

PDFS Response Data File 

File containing responses 

if files are accepted or 

rejected. 

PDE Data File Daily 



RSP.PDFS_RESP_ssssss 


TRANSMITTED FROM 

PALMETTO 

22 

23 


Drug Data Processing System 

(DDPS Return Data File 


DDPS Transaction Error 

Summary Data File 

File provides feedback on 

every record processed in 

a batch. Up to 10 specific 

errors are reported for 

each PDE in the file. 

File provides frequency of 

occurrence for each error 

code encountered during 

the processing of a PDE 

file. The percentage to the 

total errors is also 

computed and displayed 

for each error code. 





RPT.DDPS_TRANS_VALIDATION 

_ssssss 



PALMETTO 



RPT.DDPS_ERROR_SUMMARY_s 

sssss 



PALMETTO 

24 

Front-End Risk Adjustment 

System (FERAS) Response 

Reports 

Report indicates that the 

file was accepted or 

rejected by the Front-End 

Risk Adjustment System. 

FERAS Report Daily 



RSP.FERAS_RESP_ssssss 



PALMETTO 

25 


System 

(FERAS) Response Data Files 

File contains all of the 

submitted transactions 

whether or not the file 

contains errors. 

FERAS Data File Daily 



RPT.RAPS_RETURN_FLAT_ssssss 



PALMETTO 

26 



Reports Transaction Error 

Report 

Report lists the 

transactions that 

contained errors and 

identifies the errors 

found. 




RPT.RAPS_ERRORRPT_ssssss 



PALMETTO 





Description 

Responsible 


27 



Reports Transaction Summary 

Report 

Report contains all of 

the transactions 

submitted, whether 

accepted or rejected. 




RPT.RAPS_SUMMARY_ssssss 



PALMETTO 




Reports Duplicate Diagnosis 

Cluster Report 

Report identifies 

diagnosis clusters with 

502 error message, 

clusters accepted, but not 

stored. 




RPT.RAPS_DUPDX_RPT_ssssss 



PALMETTO 



29 

Transaction Reply Daily 

Activity Data File 


Data file version of the 

Transaction Reply Daily 

Activity Report. MARx Data File Daily 

P.Rxxxxx.DTRRD.Dyymmdd.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx.DTRRD.Dyymmdd 

.Thhmmsst 


[directory]Rxxxxx.DTRRD.Dyymmd 

d.Thhmmsst 

30 


Response Data File 



rejected. 

EDS Data File Daily 



P.xxxxx.EDS_RESPONSE.pn 



PALMETTO 

31 


Reject IC ISAIEA Data File 



rejected. 




P.xxxxx.EDS_REJT_IC_ISAIEA.pn 



PALMETTO 



32 


Reject Function Transaction 

Data File 



rejected. 


P.xxxxx.EDS_REJT_FUNCT_TRAN 

S.pn 



PALMETTO 



33 


Accept Function Transaction 

Data File 



rejected. 


P.xxxxx.EDS_ACCPT_FUNCT_TR 

ANS.pn 



PALMETTO 

ID# Transmittal Description Responsible Type Freq. Dataset Naming Conventions 




System 



34 


Response Claim Number Data 

File 



rejected. 


P.xxxxx.EDS_RESP_CLAIM_NUM. 

pn 



PALMETTO 

Weekly Transmittals (Data & Reports) 

35 

LIS/Part D Premium Data File 


The data in the report 

reflects LIS info, premium 

subsidy levels, Low-income 

co-pay levels, etc. for all 

Beneficiaries who have a 

low-income designation 

enrolled in a Plan. 

This data file is produced 

bi-weekly. It is not 

automatically transmitted to 

the Plans. Through the 

MARx UI plans can request 

or reorder this data file. 

MARx 

Data File Biweekly 



P.Rxxxxx.LISPRMD.Dyymmdd.Thh 

mmsst.pn 


zzzzzzzz.Rxxxxx.LISPRMD.Dyymm 

dd.Thhmmsst 


[directory]Rxxxxx.LISPRMD.Dyym 

mdd.Thhmmsst 

Monthly Transmittals (Data & 

Reports) 



36 

Part C Monthly Membership 

Detail Report (Non Drug 

Report) 

aka: Monthly Membership Report 

(MMR) 


Report listing every Part 

C Medicare member of 

the contract and providing 

details about the payments 

and adjustments made for 

each. 

Note: 

The date in the file name 

defaults to “01” denoting 

the first day of the current 

payment month 

MARx Report Monthly 

P.Fxxxxx.MONMEMR.Dyymm01.T 

hhmmsst.pn 

P.Rxxxxx.MONMEMR.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Fxxxxx.MONMEMR.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMR.Dyy 

mm01.Thhmmsst 


[directory]Fxxxxx.MONMEMR.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMR.Dyy 

mm01.Thhmmsst 





Reports) 

Description 

Responsible 


37 

Part D Monthly Membership 

Detail Report (Drug Report) 

aka: Monthly Membership Report 

(MMR) 


Report listing every Part 

D Medicare member of 

the contract and provides 

details about the payments 

and adjustments made for 

each. 

Note: 




payment month 




P.Fxxxxx.MONMEMDR.Dyymm01. 

Thhmmsst.pn 

P.Rxxxxx.MONMEMDR.Dyymm01. 

Thhmmsst.pn 


zzzzzzzz.Fxxxxx.MONMEMDR.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMDR.Dy 

ymm01.Thhmmsst 


[directory]Fxxxxx.MONMEDR.Dyy 

mm01.Thhmmsst 

[directory]Rxxxxx.MONMEDR.Dyy 

mm01.Thhmmsst 

38 

Monthly Membership Detail 

Data File 



Monthly Membership 

Detail Reports. This file 

contains the data for both 

Part C and Part D 

members. 

Note: 




payment month 

MARx 




P.Fxxxxx.MONMEMD.Dyymm01.T 

hhmmsst.pn 

P.Rxxxxx.MONMEMD.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Fxxxxx.MONMEMD.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMD.Dyy 

mm01.Thhmmsst 


[directory]Fxxxxx.MONMEMD.Dyy 

mm01.Thhmmsst 

[directory]Rxxxxx.MONMEMD.Dyy 

mm01.Thhmmsst 

39 

Monthly Membership Summary 

Report 


Report summarizing 

payments to a Plan for the 

month, in several 

categories, and 

adjustments, by all 

adjustment categories. 

This report contains data 

for both Part C and Part D 

members. 

Note: 




payment month 




P.Fxxxxx.MONMEMSR.Dyymm01. 

Thhmmsst.pn 

P.Rxxxxx.MONMEMSR.Dyymm01. 

Thhmmsst.pn 


zzzzzzzz.Fxxxxx.MONMEMSR.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMSR.Dyy 

mm01.Thhmmsst 


[directory]Fxxxxx.MONMEMSR.Dy 


[directory]Rxxxxx.MONMEMSR.Dy 






Reports) 

40 

41 

42 

43 

Monthly Membership Summary 

Data File 


RAS RxHCC Model Output 

Report 

AKA: Part D Risk Adjustment 

Model Output Report 


RAS RxHCC Model Output Data 

File 

AKA: Part D Risk Adjustment 

Model Output Data File 

Header Record 

Detail / Beneficiary Record Format 



Part C Risk Adjustment Model 

Output Report 


Description 


Monthly Membership 

Summary Report for both 

Part C and Part D members. 

Note: 




payment month 

Report showing the Part D 

risk adjustment factors for 

each beneficiary. MARx 

forwards this report that is 

produced by RAS to plans 

as part of the month-end 

processing. 

Note: 




payment month 


RAS RxHCC Model Output 

Report. MARx forwards 

this report that is produced 

by RAS to Plans as part of 

the month-end processing. 

Note: 




payment month 

Report showing the 

Hierarchical Condition 

Codes (HCCs) used by the 

Risk Adjustment System 

(RAS) to calculate Part C 

risk adjustment factors for 


forwards this report that is 

produced by RAS to plans 


processing. 

Responsible 


MARx 

RAS 

(MARx) 

RAS 

(MARx) 

RAS 

(MARx) 


Report 

(.pdf) 

Monthly 


Report 

Monthly 



P.Fxxxxx.MONMEMSD.Dyymm01. 

Thhmmsst.pn 

P.Rxxxxx.MONMEMSD.Dyymm01. 

Thhmmsst.pn 


zzzzzzzz.Fxxxxx.MONMEMSD.Dyy 

mm01.Thhmmsst 

zzzzzzzz.Rxxxxx.MONMEMSD.Dyy 

mm01.Thhmmsst 


[directory]Fxxxxx.MONMEMSD.Dy 


[directory]Rxxxxx.MONMEMSD.Dy 




P.Rxxxxx.PTDMODR.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.PTDMODR.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.PTDMODR.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.PTDMODD.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.PTDMODD.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.PTDMODD.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.HCCMODR.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.HCCMODR.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.HCCMODR.Dyy 

mm01.Thhmmsst 

Note: 




payment month 





Reports) 

44 

45 

46 

Part C Risk Adjustment Model 

Output Data File 

Header Record 

Detail Record 



BIPA 606 Payment Reduction 

Report 


BIPA 606 Payment Reduction 

Data File 


Description 

Data file version of the Risk 

Adjustment Model Output 

Report 

Note: 




payment month 

Report listing members for 

whom the plan is paying a 

portion of the Part B 

premium. Generated only if 

there are pre-2006 

adjustments that involve 

BIPA 606 premium 

reductions. 

Note: 




payment month 


BIPA 606 Reduction 

Report. 

Note: 




payment month 

Responsible 


RAS 

(MARx) 

MARx 

MARx 


Report 

Data File 

Monthly, 

if 

applicable 

Monthly, 

if 

applicable 



P.Rxxxxx.HCCMODD.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.HCCMODD.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.HCCMODD.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.BIPA606R.Dyymm01.Thh 

mmsst.pn 


zzzzzzzz.Rxxxxx.BIPA606R.Dyymm 

01.Thhmmsst 


[directory]Rxxxxx.BIPA606R.Dyym 

m01.Thhmmsst 



P.Rxxxxx.BIPA606D.Dyymm01.Thh 

mmsst.pn 


zzzzzzzz.Rxxxxx.BIPA606D.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.BIPA606D.Dyym 

m01.Thhmmsst 

47 

Bonus Payment Report 


Report listing members for 

whom the plan is to be paid 

a bonus. (Plans are paid a 

bonus for extending 

services to Beneficiaries in 

some underserved areas.) 

Generated only if there are 

pre-2006 adjustments that 

involve bonus payments. 

Note: 




payment month 

MARx 

Report 

Monthly, 

if 

applicable 



P.Rxxxxx.BONUSRPT.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Rxxxxx.BONUSRPT.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.BONUSRPT.Dyy 

mm01.Thhmmsst 




Reports) 

48 

49 

Bonus Payment Data File 


Monthly Summary of Bills Report 


50 HMO Bill Itemization Report 



Description 


Bonus Payment Report 

Note: 


will default to The date in 

the file name defaults to 

“01” denoting the first day 

of the current payment 

month 

Report summarizing all 

Medicare fee-for-service 

activity, both Part A and 

Part B, for Beneficiaries 

enrolled in the contract 

Note: 




payment month 

Report listing the Part A 

bills that were processed 

under Medicare fee-forservice 

for Beneficiaries 

enrolled in the contract. 

Note: 




payment month 

Responsible 


MARx 

Data File 

Monthly, 

if 

applicable 





P.Rxxxxx.BONUSDAT.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Rxxxxx.BONUSDAT.Dyy 

mm01.Thhmmsst 


[directory]Rxxxxx.BONUSDAT.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.SUMBILLS.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.SUMBILLS.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.SUMBILLS.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.BILLITEM.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.BILLITEM.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.BILLITEM.Dyym 

m01.Thhmmsst 

51 

Part B Claims Data File 

Record Type 1 

Record Type 2 


52 Payment Records Report 


Data file listing the Part B 

physician and supplier 

claims and Part B home 

health claims that were 

processed under Medicare 

fee-for-service for 

Beneficiaries enrolled in the 

contract. 

Note: 




payment month 

Report listing the Part B 

physician and supplier 

claims that were processed 

under Medicare fee-forservice 

for Beneficiaries 

enrolled in the contract. 

Note: 




payment month 

MARx 





P.Rxxxxx.CLAIMDAT.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Rxxxxx.CLAIMDAT.Dyy 

mm01.Thhmmsst 


[directory]Rxxxxx.CLAIMDAT.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.PAYRECDS.Dyymm01.T 

hhmmsst.pn 


zzzzzzzz.Rxxxxx.PAYRECDS.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.PAYRECDS.Dyy 

mm01.Thhmmsst 





Reports) 

53 

54 

55 

56 

Monthly Premium Withholding 

Report Data File (MPWR) 

Header Record 

Detail Record 

Trailer - T1 - Total at segment 

level 

Trailer - T2 - Total at PBP level 

Trailer - T3 - Total at contract 

level 


Failed Payment Reply Report 

Detail Record 


Plan Payment Report (APPS 

Payment Letter) 


Plan Payment Report (APPS 

Payment Letter) Data File 


Description 

Monthly reconciliation file 

of premiums withheld from 

SSA, RRB, or OPM checks. 

Includes Part C and Part D 

premiums and any Part D 

Late Enrollment Penalties. 

This file is produced by the 

Premium Withhold System 

(PWS). MARx makes this 

report available to plans as 

part of the month-end 

processing. 

Note: 




payment month 

Data file reporting payment 

actions which failed to 

complete. 

Report itemizing the final 

monthly payment to the 

plan. This report is 

produced by the APPS 

when final payments are 

calculated. MARx makes 

this report available to plans 


processing. 

Note: 




payment month 

This data file itemizes the 

final monthly payment to 

the MCO. This data file and 

subsequent report is 

produced by the APPS 

when final payments are 

calculated. CMS makes this 

report available to MCO’s 

as part of month-end 

processing. 

Note: 




payment month 

Responsible 


PWS 

(MARx) 

MARx 


Data File 

Monthly 

Payment 

Cycle 

APPS Report Monthly 

APPS 




P.Rxxxxx.MPWRD.Dyymm01.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx.MPWRD.Dyymm0 

1.Thhmmsst 


[directory]Rxxxxx.MPWRD.Dyymm 

01.Thhmmsst 



P.Rxxxxx.FPRRD.Dyymm01.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx 

FPRRD.Dyymm01.Thhmmsst 


[directory]Rxxxxx. 

FPRRD.Dyymm01.Thhmmsst 



P.Fxxxxx.PLANPAY.Dyymm01.Thh 

mmsst.pn 

P.Rxxxxx.PLANPAY.Dyymm01.Thh 

mmsst.pn 


zzzzzzzz.Fxxxxx.PLANPAY.Dyym 

m01.Thhmmsst 

zzzzzzzz.Rxxxxx.PLANPAY.Dyym 

m01.Thhmmsst 


[directory]Fxxxxx.PLANPAY.Dyym 

m01.Thhmmsst 

[directory]Rxxxxx.PLANPAY.Dyym 

m01.Thhmmsst 



P.Rxxxxx.PPRD.Dyymm01.Thhmms 

st.pn 


zzzzzzzz.Rxxxxx.PPRD.Dyymm01.T 

hhmmsst 


[directory].Rxxxxx.PPRD.Dyymm01. 

Thhmmsst 




Reports) 

57 

58 

59 

60 

61 

Interim APPS Plan Payment 

Report 


Interim APPS Plan Payment 

Report Data File 

PCUG Sample Layout – F.25 

820 Format Payment Advice Data 

File 


Monthly Full Enrollment Data 

File 



DBC Cumulative Beneficiary 

Summary Report 


Description 

When a Plan is approved 

for an interim payment 

outside of the normal 

monthly process, an interim 

Plan Payment Report is 

distributed to that Plan. The 

report contains the amount 

and reason for the interim 

payment. Plans can also 

request these reports via the 

MARx user interface under 

the weekly report section of 

the menu. 

The Interim APPS Plan 

Payment Data File and 

Report is provided when a 

Plan is approved for an 

interim payment outside of 

the normal monthly 

process. The data file / 

report contains the amount 

and reason for the interim 

payment to the Plan. 

HIPAA-Compliant version 

of the Plan Payment Report. 

This data file itemizes the 

final monthly payment to the 

plan. This data file is not 

available through MARx. 

Note: 



the first day of the CCM 

File includes all active Plan 

membership on the date the 

file is run. This file is 

considered a definitive 

statement of current plan 

enrollment. This file uses 

the same format as the 

weekly TRR. The file is 

distributed on or about the 

first of the month. 

File includes summary for 

the beneficiary of 

accumulated overall totals 

in PDE amount fields with 

accumulated totals for 

covered drugs. 

Responsible 


APPS Report As needed 

APPS 

APPS 

MARx 

PDE 

Data File As needed 






P.Rxxxxx.PLNPAYI.Dyymm01.Thh 

mmsst.pn 


zzzzzzzz.Rxxxxx.PLNPAYI.Dyymm 

01.Thhmmsst 


[directory]Rxxxxx.PLNPAYI.Dyym 

m01.Thhmmsst 



P.Rxxxxx.PPRID.Dyymmdd.Thhmm 

sst.pn 


zzzzzzzz.Rxxxxx.PPRID.Dyymmdd. 

Thhmmsst 


[directory].Rxxxxx.PPRID.Dyymmd 

d.Thhmmsst 



P.Rxxxxx.PLAN820D.Dyymm01.Th 

hmmsst.pn 


zzzzzzzz.Rxxxxx.PLAN820D.Dyym 

m01.Thhmmsst 


[directory]Rxxxxx.PLAN820D.Dyy 

mm01.Thhmmsst 



P.Rxxxxx.FEFD.Dyymm01.Thhmms 

st.pn 


zzzzzzzz.Rxxxxx.FEFD.Dyymm01.T 

hhmmsst 


[directory]Rxxxxx.FEFD.Dyymm01. 

Thhmmsst 



RPT.DDPS.CUM_BENE_ACT_CO 

V_ssssss 



PALMETTO 





Reports) 

62 

63 

64 

65 

66 









Reports 

Monthly Plan Activity Report 



Reports 

Cumulative Plan Activity Report 



Reports 

Frequency Report Monthly 

Report 

Description 





accumulated totals for 

enhanced drugs. 





accumulated totals for overthe-counter 

drugs. 

Report provides monthly 

summary of the status of 

submissions by submitter 

and plan number. 

Report provides cumulative 

summary of the status of 

submissions by Submitter 

ID and plan number. 

Report provides monthly 

summary of all errors on all 

file submissions within the 

month. 

Responsible 


PDE 

PDE 



FERAS Report Monthly 





RPT.DDPS_CUM_BENE_ACT_EN 

H_ssssss 



PALMETTO 



RPT.DDPS_CUM_BENE_ACT_OT 

C_ssssss 



PALMETTO 



RPT.RAPS_MONTHLY_ssssss 



PALMETTO 



RPT.RAPS_CUMULATIVE_ssssss 



PALMETTO 



RAPS_ERRORFREQ_MNTH_ssssss 



PALMETTO 



67 

LIS/LEP Data File 

Header Record 

Detail Record 



This report provides 

information on low-income 

subsidized Beneficiaries 

and on direct-billed 

Beneficiaries with late 

enrollment penalties. 

Note: 




payment month. 

MARx 


P.Fxxxxx.LISLEPD.Dyymm01.Thh 

mmsst.pn 

P.Rxxxxx.LISLEPD.Dyymm01.Thh 

mmsst.pn 


zzzzzzzz.Fxxxxx.LISLEPD.Dyymm0 

1.Thhmmsst 

zzzzzzzz.Rxxxxx.LISLEPD.Dyymm 

01.Thhmmsst 


[directory]Fxxxxx.LISLEPD.Dyymm 

01.Thhmmsst 

[directory]Rxxxxx.LISLEPD.Dyymm 

01.Thhmmsst 





Reports) 

68 

LIS History Data File (LISHIST) 


Description 

This file supplements 

existing files that provide 

LIS notifications. It 

provides a complete picture 

of a beneficiary’s LIS 

eligibility over a period of 

time not to exceed 36 

months. 

Note: 


defaults to “dd” denoting 

the day of the calendar 

month 

Responsible 


MARx 




P.Rxxxxx.LISHIST.Dyymmdd.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx.LISHIST.Dyymmd 

d.Thhmmsst 


[directory]Rxxxxx.LISHIST.Dyymm 

dd.Thhmmsst 

69 

Agent Broker Compensation Data 

File 


This data file provides sixyear 

broker compensation 

cycle-year counts. Data is 

sent to Plans 1) when a 

beneficiary enrolls, 2) each 

January when the cycleyear 

count increments and 

3) as necessary when 

retroactive change affects 

the compensation cycle. 

Plans may re-order the 6- 

year Broker Compensation 

Report Data File” via the 

UI. 

MARx 

Data File 

Monthly, 

generally 

with the 

first weekly 

TRR of the 

month 



P.Rnnnnn.COMPRPT.Dyymmdd.Th 

hmmsst.pn 


zzzzzzzz.Rnnnnn.COMPRPT.Dyym 

mdd.Thhmmsst 


[directory]Rnnnnn.COMPRPT.Dyym 

mdd.Thhmmsst 

70 

Monthly MSP Information Data 

File 

PCUG Record Layout – F.28 

This data file is sent 

directly to Plans on the first 

Monday after the MARx 

month-end processing 

completes. This file 

contains a subset of 

information to allow Plans 

to reconcile payment; the 

full monthly MSP COB file 

distributed at the beginning 

of each month contains 

more detail. 

MDB 




P.Rxxxxx.MSPCOBAD.Dyymmdd.T 

hhmmsst.pn 


zzzzzzzz.Rxxxxx.MSPCOBAD.Dyy 

mmdd.Thhmmsst 


[directory].Rxxxxx.MSPCOBAD.Dy 

ymmdd.Thhmmsst 

71 

Other Health Coverage 

Information Data File 


CMS provides Plans with a 

file listing the Beneficiaries 

who are enrolled in their 

plan(s) where Medicare is 

listed secondary. As a 

monthly report, this vehicle 

provides Plans with regular 

updates to the MSP data. 

MDB 


Gentran: 

P.Rxxxxx.MSPCOBMA.Dyymmdd. 

Thhmmsst.pn 


zzzzzzzz.Rxxxxx.MSPCOBMA.Dyy 

mmdd.Thhmmsst 


[directory].Rxxxxx.MSPCOBMA.Dy 




Quarterly Report 

72 



Reports 

Frequency Report Quarterly 

Report 

Missing Payment Exception 

Report Data Record Layout 


Description 

Report provides quarterly 

summary of all errors on all 

file submissions within the 

three-month quarter. 

Data file reporting payment 

actions which failed to 

complete. 

Responsible 


FERAS Report Quarterly 

MARx 

Data 

File 

Monthly 

Payment 

Cycle 



RAPS_ERRORFREQ_QTR_ssssss 



PALMETTO 



73 

Yearly Report 

P.Rxxxxx.MPERD.Dyymmdd.Thhm 

msst.pn 


zzzzzzzz.Rxxxxx. 

MPERD.Dyymmdd.Thhmmsst 


[directory]Rxxxxx. 

MPERD.Dyymmdd.Thhmmsst 



74 

RAS Final Yearly Model 

Output Report, Part D 

Report indicates the year-end 

Part D risk adjustment factors for 


forwards this report, produced by 

RAS, to Plans as part of the 


RAS 

(MARx) 

Report 

(.pdf) 

Yearly 

P.Rxxxxx.PTDMOFR.Yeeee.Cvvvvv 

.Thhmmss.pn 


zzzzzzzz.Rxxxxx.PTDMOFR.Yeeee. 

Cvvvvv.Thhmmss 


[directory]Rxxxxx.PTDMOFR. 

Yeeee.Cvvvvv.Thhmmss 



75 


Output Data File, Part D 

Data file version of the year end 

Part D RAS Model Output 

Report. MARx forwards this 

report, produced by RAS, to 

Plans as part of the month-end 

processing. 

RAS 

(MARx) 

Data File 

Yearly 

P.Rxxxxx.PTDMOFD.Yeeee.Cvvvvv 

.Thhmmss.pn 


zzzzzzzz.Rxxxxx.PTDMOFD.Yeeee. 



[directory]Rxxxxx.PTDMOFD.Yeeee 

.Cvvvvv.Thhmmss 



76 


Output Report, Part C 

Report indicates the year end 

Part C risk adjustment factors for 


forwards this report, produced by 

RAS, to Plans as part of the 


RAS 

(MARx) 

Report 

(.pdf) 

Yearly 

P.Rxxxxx.HCCMOFR.Yeeee.Cvvvv 

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[directory]Rxxxxx.HCCMOFR.Yeee 

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Yearly Report 

Description 

Responsible 




77 


Output Data File, Part C 

Data file version of the year end 

Part C RAS Model Output 

Report. MARx forwards this 

report, produced by RAS, to 

Plans as part of the month-end 

processing. 

RAS 

(MARx) 

Data File 

Yearly 

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78 

Loss of Subsidy Data File 


79 PDP Loss Data File 

80 PDP Gain Data File 

The first file is sent in September 

and identifies members receiving 

a joint CMS and SSA letter 

informing them they will not 

have Deemed status for the 

following year. The second file is 

sent in December and is an 

updated version of the September 

file, indicating those 

Beneficiaries who still do not 

have Deemed status for the 

following year. 

The data file has a record length 

of 500 bytes. The TRC used for 

this special file type is 996. TRC 

996 indicates the loss of Deeming 

which means the Beneficiary will 

not be redeemed for the 

upcoming period. 

Once a year notification file sent 

by CMS providing a preliminary 

listing of LIS-eligible 

Beneficiaries whom CMS 

reassigns to a new PDP or to a 

new PBP within the same plan 

sponsor effective January 1, 

2008. 

The LOSS file notifies PDPs of 

the members they will lose as a 

result of reassignment to other 

Plans. These members are 

classified as losing members. 

Once a year notification file, sent 

by CMS, provides a preliminary 

listing of LIS-eligible 

Beneficiaries whom CMS 

reassigns to a new PDP or to a 

new PBP within the same Plan 

sponsor effective January 1, 

2008. 

The GAIN file notifies PDPs of 

members they will gain as a 

result of the yearly reassignment. 

These members are classified as 

gaining members. 

MARx Data File Twice 

Yearly 

MBD Data File Yearly 

MBD Data File Yearly 



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Yearly Report 

81 

82 

Long-Term Institutionalized 

Resident Report 


No Premium Due Data File 



Description 

The Long-Term Institutionalized 

(LTI) Resident Report provides 

Part D sponsors a list of their 

Beneficiaries who are LTI 

residents during July and January 

of each year. This report contains 

basic information on the 

Beneficiaries and their 

institutions (Skilled Nursing 

Home or Nursing Home). 

The no premium due data file 

reports members that had a Part 

C premium, but will no longer 

have the Part C premium in the 

upcoming year. This data file is 

produced during MARx end of 

year processing. 

Responsible 


MDS 

Report 

Twice 

Yearly 

MARx Data File Yearly 



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dd.Thhmmsst 



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L: MA Plan Connectivity Checklist 

Getting Started 

or N/A # Task Checkpoint Notes 

or N/A 

or N/A 

Security and Access 

1. Obtain a Contract Number from CMS/HPMS Once completed, Task #4 

may be initiated. 

2. Enter Connectivity Data into HPMS Plan Connectivity 

Data Module 

(Plans are required to mail/fax completed forms to 

MAPD Help Desk) 

3. Complete T1/Connect:Direct information in the PCD 

module 

1. CMS Connect:Direct data entry into HPMS 

2. CMS SPOE ID Request form 

Must be started at least 6 

weeks prior to target 

connectivity testing date. 

Contract #: 

or N/A # Task Checkpoint Notes 

or N/A 

or N/A 

4. Submit EPOC Designation Letter to CMS After completion of Task 

#1. 

5. EPOC registered in IACS 

(Allow 5 business days once EPOC letter is submitted 

before registering in IACS) 

6. EPOC approval received from CMS 

7. User/Submitter(s) registered in IACS for Enrollment, 

BEQ and ECRS 

8. User/Representative(s) registered in IACS for 

Enrollment, BEQ and ECRS 

After completion of Task 

#4. 

After EPOC registration is 

complete. 

After EPOC registration is 

complete. 

9. User/Submitter(s) registered in IACS for PDE/RAPS Gentran/TIBCO MFT 

Submitters only. May be 

completed the same time as 

Task #7 or at a later date. 

Connectivity – Setup 

Note: Plans perform either Task #10 or Task #11. 

or N/A 

or N/A 

or N/A 

or N/A 

or N/A 

# Task Checkpoint Notes 

10. Each item listed in this Task is required by Plans 

submitting data via Connect:Direct. 

Set up T1/Connect:Direct to CMS: 

1. Contact AT&T or an AT&T reseller to establish 

connectivity to CMS via AGNS. 

2. Verify access to CMS via AGNS 

3. High-level qualifier and/or security designations 

verified as accessible to CMS. 

4. Obtain Connect:Direct Software from Sterling 

Commerce. 

Must be started at least 6 

weeks prior to target 

connectivity testing date. 

December 28, 2012 L-1 MA Plan Connectivity Checklist


or N/A 

or N/A 

or N/A 

5. Complete installation and configuration of 

Connect:Direct Software. 

6. Submitter successfully registered in IACS (see 

Task #8). 

7. Obtain SPOE ID from CMS (see Task #3.2). 


submitting data via Gentran/TIBCO MFT. 

or N/A 

or N/A 

or N/A 

Set up Gentran/TIBCO MFT access: 

1. Submitter successfully registered in IACS (see 

Task #7). 

2. Obtain and install SFTP Software (if not using 

HTTPS) 

3. Open required firewalls/ports: 

SFTP Port: 10022 

HTTPS Port: 3443 

Connectivity – Testing 

Note: Plans perform either Task #12 or Task #13. Plans submitting PDE/RAPS data must also perform Task #14. 

or N/A 

# Task Checkpoint Notes 


submitting data via Connect:Direct. 

or N/A 

or N/A 

or N/A 

or N/A 

or N/A 

or N/A 

or N/A 

Test T1/Connect:Direct to CMS: 

1. Appropriate telecommunications and technical 

resources participate in conference call with 

appropriate CMS Resources (initiated by MAPD Help 

Desk). 

2. Successfully transfer data to CMS 

3. Successfully receive data from CMS 


submitting data via Gentran/TIBCO MFT. 

Test Gentran/TIBCO MFT: 

1. Mailbox(s) established at CMS is accessible 

2. Screenshot of successful access to 1 Gentran 

mailbox e-mailed to the MAPD Help Desk. 

3. Send test file to Gentran mailbox/TIBCO MFT 

server 

14. Contact CSSC Help Desk for assistance with 

Connectivity Testing of PDE/RAPS data submission. 

Task # 7 must be 

completed successfully 

before this task can be 

completed. 

December 28, 2012 L-2 MA Plan Connectivity Checklist


M: Valid Election Types for Plan-Submitted Transactions 

Table M-1 shows the valid election types for Plan-submitted enrollment and disenrollment 

transactions. Plans must ensure the requirements in the CMS Enrollment and Disenrollment 

guidance applicable to the Plan type are followed to properly determine and report the election 

type. 

Table M-1:Valid Election Types for Plans 

Election Types 

PLANS 

AEP (A) OEPI (T) SEP (Note 2) IEP (E/F) MADP ICEP (I) 

MA Y Y Y N Y Y 

MA-PD Y Y Y Y Y Y 

PDP 

Y 

N 

(Use coordinating 

SEP where 

appropriate per 

CMS guidance) 

Y Y N 

(Use 

coordinating 

SEP where 

appropriate 

per CMS 

guidance) 

N 

SHMO I Y Y Y Y 

SHMO II Y Y Y Y 

Cost with Part D 

Y 

N 

(Use coordinating 

SEP where 

appropriate per 

CMS guidance) 

Y 

Y 

Use 

coordinating 

SEP where 

appropriate 

per CMS 

guidance) 

Cost without 

Part D 

None required; however, if the beneficiary is currently enrolled in an MA Plan, a valid 

MA election period is required to leave that program and enroll in the cost Plan. 

WPP Y Y Y Y Y 

ESRD I 

ESRD II 

PACE National 

CCIP / FFS 

Demos 

MDHO Demo 

MSHO Demo 

Y 

Y 

None Required 

None Required 

None Required 

None Required 

December 28, 2012 M-1 Valid Election Types for 

Plan-Submitted


Election Types 

PLANS 

AEP (A) OEPI (T) SEP (Note 2) IEP (E/F) MADP ICEP (I) 

MSA Y N Y N N Y 

MSA Demo Y Y N Y 

Note 1: For code usage, refer to the previously released MMA Guidance and PDP Guidance. 

Note 2: For election type SEP, use the following values under these specific circumstances: 

 

 

 

 

 

U - for Duals and Individuals with LIS 

W - for EGHP 

V - for permanent moves 

Y - CMS Casework use only (not submitted by Plans) 

S - Any other SEP as provided in guidance that is not one of the above values. 

Note 3: In addition to these election period identifiers, CMS provides a valid value of ‘X’ for use 

in the election period identifier field. This value is an Administrative Action and Plans may use 

when a submitted transaction is not reflective of an actual Beneficiary election, as follows: 

 

 

 

 

Plan submitted “rollover”- Year-end processing occasionally requires that Plans submit 

transactions to accomplish the Plan crosswalk from one contract year to another. When 

required, as defined in the CMS Call Letter instructions, Plans should use the ‘X’ value 

in the election period field of the enrollment transaction submitted for this purpose. 

Involuntary Disenrollment - In limited circumstances, Plans may involuntarily disenroll 

individuals for specific reasons and when meeting all of the conditions provided in CMS 

enrollment guidance. Since these actions are not “elections,” Plans should use the value 

of ‘X’ in the election period field of the disenrollment transaction submitted for this 

purpose. 

Premium Option Change - Plans may submit changes to an individual’s premium 

withholding status via a 72 transaction. When doing so, Plans should use the ‘X’ value in 

the election period field of the 72 transaction submitted for this purpose. 

Plan-submitted “canceling” Transaction - Since beneficiaries may choose to cancel an 

enrollment or disenrollment request prior to the effective date of the request, 

occasionally Plans submit “canceling” transactions to CMS to cancel an already 

submitted action. Plans should use the value TC 80 to cancel an enrollment or TC 81 to 

cancel a disenrollment transaction. 

December 28, 2012 M-2 Valid Election Types for 

Plan-Submitted

Medicare Advantage and Prescription Drug Plans December 28 ...

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