Medicare Advantage and Prescription Drug Plans December 28 ...

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