Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 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 December 28, 2012 B-3 CMS Central Office Contact Information
Plan Communications User Guide Appendices, Version 6.3 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. December 28, 2012 B-4 CMS Central Office Contact Information
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F.10.3 Trailer Record Plan Communic
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F.11.2 Record Type 2 Plan Communica
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Item # Plan Communications User Gui
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F.28.3 Trailer Record Plan Communic
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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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