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 109 R Rejected, 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 the appropriate actions as per CMS enrollment guidance. 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. December 28, 2012 I-27 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 116 R 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)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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