Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 037 R Transaction Rejected, Incorrect Effective Date 038 R Enrollment Rejected, Duplicate Transaction 039 R Enrollment Rejected, Currently Enrolled in Same Plan 042 R Transaction 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. Plan Action: None required 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. December 28, 2012 I-11 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 044 R Transaction 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. TC61 – transaction was rejected because the submitted enrollment date is outside the Plan’s contracted period TC80 and TC81 – transaction was rejected because the enrollment reinstatement period is outside the Plan’s contracted period 045 R Enrollment Rejected, Beneficiary is 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. December 28, 2012 I-12 Transaction Reply Codes (TRCs)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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