Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 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. Field Size Position Description 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 ‘0’ = Unknown; ‘1’ = Male; ‘2’ = Female. 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
Plan Communications User Guide Appendices, Version 6.3 Field Size Position Description 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 Total Length = 500 December 28, 2012 F-151 No Premium Due Data File Layout
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Medicare Advantage and Prescription Drug Plans December 28 ...

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