Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 F.16 LIS/LEP Data File F.16.1 Header Record Item Field Size Position Description 1 Record Type 3 1-3 2 MCO Contract Number 5 4-8 3 Payment/Payment Adjustment Date 6 9-14 4 Data file Date 8 15-22 5 Filler 143 23-165 Spaces Total Length = 165 F.16.2 Detail Record H = Header Record PIC XXX MCO Contract Number 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 1 Record Type 3 1-3 AD = Adjustment Detail Record “Adjustment” means all Premium Periods other than Prospective *** PLAN IDENTIFICATION 2 MCO Contract Number 5 4-8 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 MCO Contract Number 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
Plan Communications User Guide Appendices, Version 6.3 Item Field Name Size Position Description 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 Premium Amount 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 December 28, 2012 F-93 LIS/LEP Data File
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Medicare Advantage and Prescription
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I.3 Obsolete Transaction Reply Code
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CMS Transmittals to the Plans Plan
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ID# Transmittal Monthly Transmittal
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Medicare Advantage and Prescription Drug Plans December 28 ...

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