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 209 R 4Rx Change Rejected, Invalid Change Effective Date 210 A POS Enrollment Accepted 211 R Re- Assignment Enrollment Rejected 212 A Re- Assignment Enrollment Accepted NO ENROLL MATCH POS ENROLLMENT RE-ASN ENRL REJ REASSIGN ACCEPT A 4Rx change transaction (Transaction Type 72) for 4Rx information for primary drug insurance was rejected because the beneficiary was not enrolled as of the submitted transaction effective date. Plans may only submit 4Rx data for periods when the beneficiary is enrolled in the Plan. Plan Action: Correct the dates and resubmit the transaction if appropriate. An enrollment into a POS designated Part D plan that was submitted by a Point Of Sale (POS/POS 10) contractor or CMS (MBD) has been successfully processed. The effective date of the new enrollment is shown in the Effective Date (field 18) of the TRR data record. The date in field 18 will always be the first day of the month. Plan Action: Ensure the Plan’s system matches the information included in the TRR record. Take the appropriate actions as per CMS enrollment guidance. A reassignment enrollment request transaction (Transaction Type 61) which would move the beneficiary into another Part D plan was rejected because CMS has record of an “Opt-Out” option on file for the beneficiary. The beneficiary has ‘opted out’ of auto or facilitated enrollment. Plan Action: Do not move the beneficiary’s enrollment to the new Plan. Keep the beneficiary in the Plan in which they are currently enrolled. Take the appropriate actions as per CMS enrollment guidance. A reassignment enrollment request transaction (Transaction Type 61) to move the beneficiary into a new Part D Plan has been successfully processed. The beneficiary has been moved from the original contract and PBP to the new contract and PBP. The effective date of enrollment in the new PBP is reported in fields 18 and 24 of the TRR data record. Other accompanying replies with different TRCs may give additional information about this accepted reassignment. Field 20 (Plan Benefit Package ID) contains the new PBP identifier and the old PBP is reported in field 29 (Prior Plan Benefit Package ID). Plan Action: Update the Plan’s records accordingly with the information in the TRR record, ensuring that the Plan’s beneficiary’s information reflects enrollment in the new contract and PBP. December 28, 2012 I-53 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 213 I Premium Withhold Exceeds Safety Net Amount 215 R Uncovered Months Chng Rejected, Incorrect Eff Date 216 I Uncovered months exceeds max possible value 217 R Cant Change number of uncovered months EXCEED SNET AMT BAD NUNCMO EFF NUNCMO EXDS MAX CANT CHG NUNCMO CMS has changed the PPO specified on the transaction to “D – Direct Bill” because the transaction would result in SSA withholding exceeding the Safety Net amount from the beneficiary’s check in one month. This TRC may be generated in response to an accepted enrollment or PBP change (Transaction Type 61), NUNCMO Record Update (Transaction Type 73), Part C Premium Update (Transaction Type 78), PPO Change (Transaction Type 75), or may be initiated by CMS. Plan Action: Change the beneficiary to Direct Bill and contact them to explain the consequences of the PPO change. Take the appropriate actions as per CMS enrollment guidance. A NUNCMO Change (Transaction Type 73) transaction was rejected because the submitted effective date is incorrect. The date may have been incorrect for one of the following reasons: The submitted effective date is prior to August 1, 2006; The submitted effective date is after the Current Calendar Month (CCM) plus 3; or The submitted effective date falls within a Part D plan enrollment but does not match the contract enrollment start date. Plan Action: Correct the effective date and resubmit the transaction if appropriate. If the Plan is trying to correct the uncovered months value for a beneficiary who is no longer enrolled in the Plan, contact their CMS Representative. The NUNCMO provided on an accepted enrollment transaction (Transaction Type 61) exceeds the maximum possible value. This will NOT cause the rejection of the enrollment transaction but zero uncovered months (000) is associated with the effective date of the enrollment. This informational TRC is generated in addition to the transaction’s acceptance TRC. Plan Action: Update the Plan’s beneficiary records to reflect the zero uncovered months. If the NUNCMO should be another value, review CMS enrollment guidance and correct the NUNCMO value using a new NUNCMO Record Update (Transaction Type 73) transaction. An uncovered months change transaction (Transaction Type 73) was rejected because the submitted transaction attempted to change the number of uncovered months for an effective date corresponding to a “LEP Reset” transaction in the CMS database. Plan Action: Review CMS enrollment guidance. If appropriate, submit a Number of Uncovered Months Record Update transaction (Transaction Type 73) to UNDO the LEP Reset. December 28, 2012 I-54 Transaction Reply Codes (TRCs)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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