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 144 M PPO changed to Direct Bill 150 I Enrollment accepted, Exceeds Capacity Limit PREM WH OPT CHG OVER CAP LIMIT CMS has changed the Premium Payment Option (PPO) specified on the transaction to “D – Direct Bill” for one of the following reasons: Retroactive premium withholding was requested. The beneficiary’s retirement system [Social Security Administration (SSA), RRB or Office of Personnel Management (OPM)] was unable to withhold the entire premium amount from the beneficiary’s monthly check. The beneficiary has a BIC of M or T and chose “SSA” as the withhold option. SSA cannot withhold premiums for these beneficiaries as there is no benefits check from which to withhold. The beneficiary chose “OPM” as the withhold option. OPM is not withholding premiums at this time. The Plan has submitted a Part C premium amount that exceeds the maximum Part C premium value provided by HPMS. RRB Withholding was requested for an effective date prior to 06/01/2011. The beneficiary is Out-of-Area for a segmented Contract/PBP. Retroactive premium withhold was requested and during one of the periods the beneficiary was Out-of-Area for a segmented Contract/PBP. This TRC may generate in response to an accepted Enrollment, PBP change, or PPO Change transaction (Transaction Types 61, 75) or CMS may initiate it. Plan Action: Update the Plan’s beneficiary records to reflect the direct bill payment method. Take the appropriate actions as per CMS enrollment guidance. Although a submitted enrollment or PBP change transaction (Transaction Type 61) was accepted, the resulting enrollment count exceeds the capacity limit for the contract or PBP. This TRC provides additional information about a new enrollment or PBP change (Transaction Type 61) for which an acceptance was sent in a separate TRR data record with an enrollment acceptance TRC. The effective date of the new enrollment for which this information is pertinent is reported in field 18. Plan Action: Follow the procedures in CMS enrollment guidance and contact your CMS Central Office Health Insurance Specialist. December 28, 2012 I-39 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 152 M Race Code Change 154 M Out of Area Status 155 M Incarceration Notification Received 156 F Transaction Rejected, User Not Authrzed for Cntrct NEW RACE CODE OUT OF AREA INCARCERATED BAD USR FOR PLN 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’s race code has changed. The effective date of the change is reported in TRR data file field 18. The new race code will be reported in the next Monthly Membership Detail Report (MMR). Plan Action: Update the Plan’s records accordingly, ensuring that the beneficiary’s information matches the data included in the TRR record. This TRC is returned either on a reply with Transaction Type 01 in response to a state and county code change or ZIP Code change. It is intended to supply the Plan with additional information about the beneficiary. In the case of the 01 transaction, CMS has information that the beneficiary is no longer in the Plan’s service area. This can be the result of: A change in the Plan’s service area and the beneficiary’s address is outside the new area A change in the beneficiary’s address which places them Out of area 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 is incarcerated. The effective date of the change is reported in TRR data file field 18. Plan Action: Contact the beneficiary to confirm the incarceration. Review full CMS guidance on enrollment of incarcerated beneficiaries in the MMCMor PDP Enrollment Guidance and take appropriate actions. This transaction (Transaction Types 01, 51, 61, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81) was failed because it was submitted by a user who is not authorized to submit transactions for the contract. This TRC will not be returned in the TRR. Plan Action: Resubmit using the correct submitter if appropriate. December 28, 2012 I-40 Transaction Reply Codes (TRCs)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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