Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences) Item Field Size Position Format Valid Values/Description 1 Record Type 3 1-3 CHAR "PRM" 2 HICN/RRB Number 12 4-15 CHAR Spaces if unknown 3 SSN 9 16-24 ZD 000000000 if unknown 4 Date of Birth (DOB) 8 25-32 CHAR YYYYMMDD 5 Gender Code 1 33 CHAR 0=unknown, 1 = male, 2 = female 6 RxID Number* 20 34-53 CHAR 7 RxGroup Number* 15 54-68 CHAR 8 RxBIN Number* 6 69-74 ZD 9 RxPCN Number* 10 75-84 CHAR 10 Rx Plan Toll Free Number* 18 85-102 CHAR 11 Sequence Number* 3 103-105 CHAR 12 COB Source Code* Note: There may be instances where an unknown COB Source Code will be provided. Plans should contact COBC for clarification on any unknown Source Codes. 5 106-110 CHAR 11100 Non Payment/Payment Denial 11101 IEQ 11102 Data Match 11103 HMO 11104 Litigation Settlement BCBS 11105 Employer Voluntary Reporting 11106 Insurer Voluntary Reporting 11107 First Claim Development 11108 Trauma Code Development 11109 Secondary Claims Investigation 11110 Self Report 11111 411.25 11112 BCBS Voluntary Agreements 11113 Office of Personnel Management (OPM) Data Match 11114 Workers' Compensation Data Match 11118 Pharmacy Benefit Manager (PBM) 11120 COBA 11125 Recovery Audit Contractor (RAC) 1 (April Release) 11126 RAC 2 (April Release) 11127 RAC 3 (April Release) P0000 PBM S0000 Assistance Program Note: Contractor numbers 11100 - 11199 are reserved for COB December 28, 2012 F-12 COB; Validated Other Health Insurance Data
Plan Communications User Guide Appendices, Version 6.3 Item Field Size Position Format Valid Values/Description 13 MSP Reason (Entitlement Reason from COB) 1 111 CHAR 14 Coverage Code* 1 112 CHAR 15 Insurer's Name* 32 113-144 CHAR 16 Insurer's Address-1* 32 145-176 CHAR 17 Insurer's Address-2* 32 177-208 CHAR 18 Insurer's City* 15 209-223 CHAR 19 Insurer's State* 2 224-225 CHAR 20 Insurer's Zip Code* 9 226-234 CHAR 21 Insurer TIN 10 235-244 CHAR 22 Individual Policy Number* 17 245-261 CHAR 23 Group Policy Number* 20 262-281 CHAR 24 Effective Date* 8 282-289 ZD CCYYMMDD A=Working Aged B=ESRD C=Conditional Payment D=Automobile Insurance, No fault E=Workers Compensation F=Federal (public) G=Disabled H=Black Lung I=Veterans L=Liability A=Hospital and Medical U=Drug (network benefit) V=Drug with Major Medical (nonnetwork benefit) W=Comprehensive, Hospital, Medical, Drug (network) X=Hospital and Drug (network) Y=Medical and Drug (network) Z=Health Reimbursement Account (hospital, medical, and drug) 25 Termination Date* 8 290-297 ZD CCYYMMDD 26 Relationship Code* 2 298-299 CHAR 01=Bene is Policy Holder 02=Spouse 03=Child 04=Other 27 Payer ID* 10 300-309 CHAR This is a future element. 28 Person Code* 3 310-312 CHAR 29 Payer Order* 3 313-315 ZD 30 Policy Holder's First Name 9 316-324 CHAR 31 Policy Holder's Last Name 16 325-340 CHAR 32 Policy Holder's SSN 12 341-352 CHAR 33 Employee Information Code 1 353 CHAR 34 Employer's Name 32 354-385 CHAR P=Patient S=Spouse M=Mother F=Father December 28, 2012 F-13 COB; Validated Other Health Insurance Data
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Item # Plan Communications User Gui
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I.3 Obsolete Transaction Reply Code
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ID# Transmittal Monthly Transmittal
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Medicare Advantage and Prescription Drug Plans December 28 ...

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