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 194 M Deemed Correction DEEMD CORR 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 manually added or updated a co-pay period for this beneficiary. This added or updated co-pay period occurs within a period during which the beneficiary is DEEMED by CMS. This is a correction. Each TRC 194 returns start and end dates, premium subsidy percentage, and copayment category for one low income subsidy period affecting a beneficiary’s PBP enrollment. There may be more than one TRC 194 returned. The effective date for the added or updated deemed low-income subsidy period is shown in the Transaction Reply Report data record Low-Income Period Effective Date field (field 51). The new co-pay level is reported in the Low-Income Co-Pay Category field (field 50). The Effective Date field (field 18) contains the PBP enrollment period start date. Low income scenarios TRC 121 and/or TRC 223 may accompany TRC 194. These three TRCs convey the beneficiary’s low income subsidy profile at the time of report generation. They provide a full replacement set of low income subsidy data affecting the identified PBP enrollment period. This code is considered obsolete as of 1/1/2010. 195 M SSA Unsolicited Response SSA WHOLD UPDT Plan Action: Update the Plan’s records to reflect the given data for the beneficiary’s LIS period. Take the appropriate actions as per CMS enrollment guidance. An unsolicited response has been received from SSA. The PPO for this beneficiary is set to Direct Bill. This action is not in response to a Plan-initiated transaction. The effective date of the change is reported in TRR data record field 18. Plan Action: Change the beneficiary to direct bill as of the effective date in field 18. Take the appropriate actions as per CMS enrollment guidance. December 28, 2012 I-49 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 196 R Transaction Rejected, Bene not Eligible for Part D 197 M Part D Eligibility Termination NO PART D PART D OFF An enrollment transaction or PBP change transaction (Transaction Type 61) or disenrollment cancellation transaction (Transaction Type 81) [enrollment reinstatement] was rejected. Part D eligibility is required for Part D plan enrollment. TC61 – transaction was rejected because the submitted enrollment date is outside the beneficiary’s Part D eligibility period TC81 – transaction was rejected because the enrollment reinstatement period is outside the beneficiary’s Part D eligibility period Plan Action: Take the appropriate actions as per CMS enrollment guidance. This TRC is returned on a reply with Transaction Type 01 and occasionally with Transaction Type 51 and Transaction Type 61. When returned with Transaction Type 01, the TRC is in response to a change in beneficiary Part D Eligibility. It is not a reply to a submitted transaction but is intended to supply the Plan with additional information about the beneficiary. In the case of Transaction Type 01, this beneficiary’s Part D eligibility has been terminated. The effective date of the termination is reported in TRR data record fields 18 and 24. If applicable, CMS will automatically disenrolls the beneficiary from the plan. A Transaction Type 51 transaction will be sent in this or another TRR. When this TRC is returned with Transaction Type 61 the TRC is in response to a retroactive enrollment and is identifying the fact that an enrollment end date has been established due to the beneficiary’s termination of Part D. The enrollment start date is in TRR data record field 18 and the enrollment end date is in field 24. In this circumstance it is accompanied by TRC 018, Automatic Disenrollment, as well. Note: A TRR record with this reply code is only reported to the Plan in which the beneficiary is currently enrolled, even if it affects periods of enrollment in other Plans. Plan Action: Update the Plan’s beneficiary records with the information in the TRR. Take the appropriate actions as per CMS enrollment guidance. December 28, 2012 I-50 Transaction Reply Codes (TRCs)
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