Medicare Advantage and Prescription Drug Plans December 28 ...

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Plan Communications User Guide Appendices, Version 6.3 Item Field Size Position Format Valid Values/Description 35 Employer's Address 1 32 386-417 CHAR 36 Employer's Address 2 32 418-449 CHAR 37 Employer's City 15 450-464 CHAR 38 Employer's State 2 465-466 CHAR 39 Employer's Zip Code 9 467-475 CHAR 40 Filler 20 476-495 CHAR 41 Employer TIN 10 496-505 CHAR 42 Filler 20 506-525 CHAR 43 Claim Diagnosis Code 1 10 526-535 CHAR 44 Claim Diagnosis Code 2 10 536-545 CHAR 45 Claim Diagnosis Code 3 10 546-555 CHAR 46 Claim Diagnosis Code 4 10 556-565 CHAR 47 Claim Diagnosis Code 5 10 566-575 CHAR 48 Attorney's Name 32 576-607 CHAR 49 Attorney's Address 1 32 608-639 CHAR 50 Attorney's Address 2 32 640-671 CHAR 51 Attorney's City 15 672-686 CHAR 52 Attorney's State 2 687-688 CHAR 53 Attorney's Zip 9 689-697 CHAR 54 Lead Contractor 9 698-706 CHAR 55 Class Action Type 2 707-708 CHAR 56 Administrator Name 32 709-740 CHAR 57 Administrator Address 1 32 741-772 CHAR 58 Administrator Address 2 32 773-804 CHAR 59 Administrator City 15 805-819 CHAR 60 Administrator State 2 820-821 CHAR 61 Administrator Zip 9 822-830 CHAR 62 WCSA Amount 9 831-842 ZD Integer value 63 WCSA Indicator 2 843-844 CHAR 64 WCMSA Settlement Date 8 845-852 ZD CCYYMMDD 65 Administrator’s Telephone Number 18 853-870 CHAR 66 Total Rx Settlement Includes decimal point: 12 871-882 CHAR Amount 9999999999.99 67 Rx $ included in the Y = Yes WCMSA Settlement 1 883 CHAR N = No Amount 68 Filler 120 884-1000 CHAR Total Length = 1000 *Indicates that these fields have same position in PRM and SUP record layouts. December 28, 2012 F-14 COB; Validated Other Health Insurance Data
Plan Communications User Guide Appendices, Version 6.3 F.5.4 Supplemental Records: Subordinate to DTL (Unlimited Occurrences) Item Field Size Position Format Valid Values/Description 1 Record Type 3 1-3 CHAR "SUP" 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 7 8 9 10 11 12 RxID Number* RxGroup Number* RxBIN Number* RxPCN Number* Rx Plan Toll Free Number* Sequence Number* COB Source Code* 20 34-53 ZD 15 54-68 CHAR 6 69-74 ZD 10 75-84 CHAR 18 85-102 CHAR 3 103-105 CHAR 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-15 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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CMS Transmittals to the Plans Plan
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ID# Transmittal Monthly Transmittal
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Medicare Advantage and Prescription Drug Plans December 28 ...

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