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 225 I Exceeds SSA Benefit & Safety Net Amount INSUF FUND&SNET CMS has changed the PPO specified on the transaction to “D – Direct Bill” because the transaction would result in the SSA benefit being insufficient to cover the withholding and the withholding would exceed the Safety Net amount. 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. 235 I SSA Accepted Part B Reduction Transaction 236 I SSA Rejected Part B Reduction Transaction SSA PT B ACCEPT SSA PT B REJECT 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. CMS submitted Part B Reduction information on a beneficiary to SSA (See TRC 237). TRC 235 is sent to the Plan when SSA acknowledges that they have accepted and processed the beneficiary data. If the submittal to SSA was the result of a requested Part B Reduction change, TRC 235 informs the Plan that SSA has accepted and processed the change. Plans will not see the results of any requested Part B Reduction changes until TRC 235 is received. Plan Action: No action required. CMS submitted Part B Reduction information on a beneficiary to SSA (See TRC 237). This data transmittal was rejected by SSA. This is exclusive to the communication between CMS and SSA. CMS will continue to interface with SSA to resolve the rejection. Plan Action: No action required. December 28, 2012 I-57 Transaction Reply Codes (TRCs)
Plan Communications User Guide Appendices, Version 6.3 Code Type Title Short Definition Definition 237 I Part B Premium Reduction Sent to SSA PT B RED UPDATE As a result of an accepted Plan-submitted transaction (Transaction Types 51, 61, 72, 73, 75, 78) or UI update to a beneficiary’s records, information has been forwarded to SSA to update SSA records and implement any requested Part B premium reduction changes. Any requested change will not take effect until an SSA acceptance is received. Plans are notified of the SSA acceptance with a TRC 235 on a future TRR. Plan Action: None required. Take the appropriate actions as per CMS enrollment guidance. 240 A Transaction Received, Withholding Pending 241 I No Change in Part D Opt Out Flag WHOLD UPDATE DUP PTD OPT OUT Note: The Plan will not see the result of any Part B Reduction change until they have received a TRC 235 on a future TRR. As a result of an accepted Plan-submitted transaction to update a beneficiary’s PPO (Transaction Type 75) or a UI update of same, a request will soon be forwarded to SSA. Plans will receive TRC 120 when this request is forwarded to SSA. Plans are notified of the subsequent SSA acceptance or rejection of the PPO change with a TRC 185 or 186, respectively, on a future TRR. All data provided for change other than the PPO field was ignored. Plan Action: Take the appropriate actions as per CMS enrollment guidance. Note: The Plan will not see the result of any PPO change until they have received a TRC 185 on a future TRR. A Part D Opt-Out Record Update transaction (Transaction Type 79) was submitted, however, no data change was made to the beneficiary’s record. The submitted transaction contained a Part D Opt Out Flag value that matched the Part D Opt Out Flag already on record with CMS. This transaction had no effect on the beneficiary’s records. Plan Action: None required. December 28, 2012 I-58 Transaction Reply Codes (TRCs)
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Medicare Advantage and Prescription Drug Plans December 28 ...

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