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 130 R Part D Opt- Out Rejected, Opt-Out Flag Not Valid 131 A Part D Opt- Out Accepted BAD OPT OUT CD OPT OUT OK An opt-out from CMS, disenrollment, PBP enrollment change, or plan submitted Opt-Out transaction (Transaction Types 41, 51, 54, 61, 79) was rejected because the Part D Opt-Out Flag field was not correctly populated. The valid values for Part D Opt-Out Flag are: Transaction Types 41 or 79 transactions - ‘Y’ or ‘N’ All other Transaction Types - ‘Y,’ ‘N,’ or blank Plan Action: If submitted by the Plan (Transaction Types 51, 61, 79), correct the Part D Opt-Out Flag value and resubmit the transaction if appropriate. If submitted by CMS (Transaction Types 41, 54), no Plan action is required. A transaction (Transaction Types 51, 79) was received that specified a Part D opt-out flag value or a change to the Part D opt-out flag value. The Part D opt-out flag has been accepted. The new Part D Opt-Out Flag value is reported in TRR data record field 38. 133 R Part D Enroll Rejected; Invalid Secndry Insur Flag Plan Action: No action necessary. BAD 2 INS FLAG An enrollment, PBP change transaction or 4Rx record update transaction (Transaction Types 61, 72) was rejected because the TRR data file’s Secondary Drug Coverage Flag field was not correctly populated. The valid values for Secondary Drug Coverage Flag are Y, N or blank. Plan Action: Correct the Secondary Drug Coverage Flag and resubmit the transaction if appropriate. December 28, 2012 I-35 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 134 I Missing Secondary Insurance Information 135 M Beneficiary Has Started Dialysis Treatments 136 M Beneficiary Has Ended Dialysis Treatments NO 2 INS INFO DIALYSIS START DIALYSIS END An Enrollment, PBP Change, or 4Rx Record Update transaction (Transaction Types 61, 72) was submitted with the Secondary Insurance Flag set to Y, but the associated secondary insurance fields (Secondary RxID and Secondary RxGroup) were not populated. No changes to the beneficiary’s secondary insurance information were made. This is not a transaction rejection. The submitted transaction was accepted and a reply was provided in the TRR with an appropriate acceptance TRC. This reply provides additional information about the transaction. The Effective Date of the transaction for which this information is pertinent is reported in TRR data record field 18. The Transaction Type will reflect the Transaction Type of the submitted transaction. (Transaction Types 61 or 72). Plan Action: If appropriate, submit a 4Rx Record Update transaction (Transaction Type 72) with the correct Secondary Insurance RxID and Secondary Insurance RxGroup values. This TRC is returned on a reply with Transaction Type 01. It is not a reply to a submitted transaction but is intended to supply the Plan with additional information about the beneficiary. CMS has been notified that the beneficiary has ESRD and has begun dialysis treatments. The effective date of the change is reported in TRR data file field 18. Plan Action: Update the Plan’s beneficiary records with the information in the TRR. Take the appropriate actions as per CMS enrollment guidance. This TRC is returned on a reply with Transaction Type 01. It is not a reply to a submitted transaction but is intended to supply the Plan with additional information about the beneficiary. CMS has been notified that the beneficiary has ESRD and is no longer receiving dialysis treatments. The effective date of the change is reported in DTRR data file field 18. Plan Action: Update the Plan’s beneficiary records with the information in the DTRR. Process the TRC 136 to remove the prior period , if the effective date of the TRC 136 (field 18) is equal to the “start” date of an ESRD period reported to the Plan previously. Alternatively, process the TRC 136 to update the prior period, if the effective date of the TRC 136 (field 18) is not equal to the “start” date of an ESRD period reported to the Plan in a prior DTRR. Then process the TRC 135 to add the new corrected period as of the start date in field 18. The end date of the new, corrected period, if there is one, is not included.. Take the appropriate actions as per CMS enrollment guidance. December 28, 2012 I-36 Transaction Reply Codes (TRCs)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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