CMS-10321 Revised ERRP Collection Instrument

Early Retiree Reinsurance Program

0938-1087 Revised ERRP Collection Instrument-1

Private CHOW Years 2_3_4

OMB: 0938-1087

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ERRP

Early Retiree Reinsurance Program


Information Collection

U.S. Department of Health and Human Services



According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1087. The time required to complete this information collection is estimated to average 309 hours for each of the second and third years of the program (July 1, 2011 – June 30, 2012, and July 1, 2012 -June 30, 2013), and 221 hours for the fourth year of the program (July 1, 2013 – June 30, 2014), i including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

HHS Form #CMS 10321




Application


Please note that if any information in this Application changes or if the sponsor discovers that any information is incorrect, the sponsor is required to promptly report the change or inaccuracy.


Send, using the U.S. Postal Service, a hardcopy of the signed original ERRP Application (i.e. not a photocopy) and Attachments (if any) to:


HHS ERRP Application Center

4700 Corridor Place

Suite D

Beltsville, MD 20705


An asterisk (*) identifies a required field.



PART I: Plan Sponsor and Key Personnel Information

  1. Plan Sponsor Information

  1. *Organization’s Name (Must correspond with the information associated with the Federal Employer Tax Identification Number (EIN)

  2. *Type of Organization (Check the one category that best describes your organization)

    1. Government

    2. Union

    3. Religious

    4. Commercial

    5. Non-profit

  3. *Organization’s Employer Identification Number (EIN)

  4. *Organization’s Telephone Number and Extension (if applicable)

  5. Organization’s FAX Number

  6. *Organization’s Address (must be the address associated with the EIN provided)

    1. * Street Line 1

    2. Street Line 2

    3. *City

    4. *State/US Territory

    5. *Zip Code

  7. Organization’s Website Address



  1. Authorized Representative Information

  1. *First Name, Middle Initial (optional), *Last Name

  2. *Job Title

  3. *Email Address

  4. *Telephone Number and Extension (if applicable)

  5. FAX Number

  6. *Employer Name

  7. * Authorized Representative Business Address

    1. *Street Line 1

    2. Street Line 2

    3. *City

    4. *State/US Territory

    5. *Zip Code


  1. Account Manager Information

  1. *First Name, Middle Initial (optional), *Last Name

  2. *Job Title

  3. *Email Address

  4. *Telephone Number and Extension (if applicable)

  5. FAX Number

  6. *Employer Name

  7. * Account Manager Business Address

    1. *Street Line 1

    2. Street Line 2

    3. *City

    4. *State/US Territory

    5. *Zip Code



Part II: Plan Information

  1. Plan Information

  1. *Plan Name

  2. *Plan Year Cycle:

    1. Start Month/Day

    2. End Month/Day


  1. Benefit Option(s) Provided Under This Plan (This section of the application has been removed)


  2. *Programs and Procedures for Chronic and High-Cost Conditions



A sponsor cannot participate in the Early Retiree Reinsurance Program unless, as of the date of its application for the program is submitted, its employment-based plan has in place programs and procedures that have generated or have the potential to generate cost savings with respect to plan participants with chronic and high cost conditions. The program regulations define “chronic and high cost condition” as a condition for which $15,000 or more in health benefit claims are likely to be incurred during a plan year by one plan participant. Please identify at least two chronic and high cost conditions for which the employment-based plan has such programs and procedures in place, and summarize those programs and procedures, including how it was determined that the identified conditions satisfy the $15,000 threshold. Also, please identify the nature of each such program (e.g., disease management, case management, wellness program, etc.) If necessary to provide a complete response, the sponsor may submit additional pages as an attachment to the application. Please reference such attachment in this space.


  1. *Estimated Amount of Early Retiree Reinsurance Program Reimbursements



Please estimate the projected amount of proceeds you expect to receive under the Early Retiree Reinsurance Program for the plan identified in this application, for each of the first two plan year cycles identified in this application. If you wish, you may provide a range of expected program proceeds that includes: (1) a low-end estimate of expected program proceeds, (2) an estimate that represents your most likely amount of program proceeds, and (3) a high-end estimate of expected program proceeds. For purposes of this estimate only, please assume for each of those plan year cycles that there will be sufficient program funds to cover all claims submitted by the Plan Sponsor that comply with program requirements, although this might not be the case. If necessary to provide a complete response, the sponsor may submit additional pages as an attachment to the application. Please reference such attachment in this space.

  1. First Plan Year Cycle:

    1. Low Estimate (optional)

    2. *Most Likely Estimate

    3. High Estimate (optional)

  2. Second Plan Year Cycle:

    1. Low Estimate (optional)

    2. *Most Likely Estimate

    3. High Estimate (optional


  1. *Intended Use of Early Retiree Reinsurance Program Reimbursements


  1. Please summarize how your organization will use the reimbursement under the Early Retiree Reinsurance Program (ERRP) by checking the appropriate box that appears next to (a), (b) or (c):

    1. To reduce health benefit or health benefit premium costs for the sponsor of the employment-based plan (i.e., to offset increases in such costs);

    2. To reduce, or offset increases in, premium contributions, copayments, deductibles, coinsurance, or other out-of-pocket costs (or combination of these) for plan participants; or

    3. To reduce or offset increases for a combination of any of these costs (whether reducing or offsetting increases in sponsor costs or reducing, or offsetting increases in, plan participants’ costs).



For assistance with answering this question, you may wish to view the program regulations and Common Questions at www.errp.gov for information on permissible uses of ERRP reimbursement.



  1. If the sponsor indicated in Question E.1 that it intends to use any of the reimbursement under the ERRP to reduce the sponsor’s health benefit or health benefit premium costs (i.e., the sponsor checked either (a) or (c)), the ERRP regulation requires a sponsor to maintain its level of contribution toward the plan, solely as a way of ensuring that the sponsor does not violate the statutory prohibition on using program funds as general revenue. Therefore, if the sponsor checked either (a) or (c), the sponsor must attest to the following by checking this box.



Part III: Plan Sponsor Agreement

  1. Compliance: In order to receive program reimbursement(s), Plan Sponsor agrees to comply with all of the terms and conditions of Section 1102 of the Patient Protection Act (P.L. 111-148) and 45 C.F.R .Part 149 and in other guidance issued by the Secretary of the U.S. Department of Health & Human Services (the Secretary), including, but not limited to, the conditions for submission of data for obtaining reimbursement and the record retention requirements.

  2. Reimbursement-Related and Other Representations Made by Designees: Plan Sponsor may be given the opportunity to identify one or more Designees (i.e., individuals the Sponsor will authorize to perform certain functions on behalf of the Sponsor related to the Early Retiree Reinsurance Program, such as individual(s) who will be involved in making program reimbursement requests). Plan Sponsor affirms that all individuals that will be identified as Designees will have first been given authority by the Plan Sponsor to perform those respective functions on behalf of the Plan Sponsor. Plan Sponsor understands that it is bound by any representations such individuals make with respect to the Sponsor’s involvement in the Early Retiree Reinsurance Program, including but not limited to the Sponsor’s reimbursement under the program.

  3. Written Agreement: Plan Sponsor affirms that, prior to submitting a Reimbursement Request, it has executed a written agreement with its health insurance issuer(s), employment-based plan, and other entities participating in the administration of the plan, regarding disclosure of information, data, documents, and records to HHS, and the issuer, plan, and other entity participating in the administration of the plan agrees to disclose to HHS, on behalf of the Plan Sponsor, at a time and in a manner specified by the HHS Secretary in guidance, the information, data, documents, and records necessary for the Plan Sponsor to comply with the requirements of the Early Retiree Reinsurance Program, as specified in 45 C.F.R. 149.35.

  4. Use of Records: Plan Sponsor understands and agrees that the Secretary may use data and information collected under the Early Retiree Reinsurance Program only for the purposes of, and to the extent necessary in, carrying out Section 1102 of the Patient Protection Act (P.L. 111-148), 42 U.S.C. §18002, and 45 C.F.R. Part 149 including, but not limited to, determining reimbursements and reimbursement-related oversight and program integrity activities, or as otherwise allowed by law. Nothing in this section limits the U.S. Department of Health & Human Services’ Office of the Inspector General’s authority to fulfill the Inspector General’s responsibilities in accordance with applicable Federal law.

  5. Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan Sponsor application is being provided to obtain Federal funds. Plan Sponsor affirms that it requires all subcontractors, including plan administrators, to acknowledge that information provided in connection with a subcontract is used for purposes of obtaining Federal funds. Plan Sponsor acknowledges that reimbursement of program funds is conditioned on the submission of accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be presented a false or fraudulent claim. Plan Sponsor acknowledges that any excess reimbursement made to the Plan Sponsor under the Early Retiree Reinsurance Program, or any debt that arises from such excess reimbursement, may be recovered by the Secretary. Plan Sponsor will promptly update any changes to the information submitted in its Plan Sponsor application. If Plan Sponsor becomes aware that information in this application is not (or is no longer) true, accurate and complete, Plan Sponsor agrees to notify the Secretary promptly of this fact.

  6. Data Security: Plan Sponsor agrees to establish and implement proper safeguards against unauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations. Plan Sponsor affirms that its employment-based plan(s) has established and implemented appropriate safeguards in compliance with 45 C.F.R. Parts 160 and 164 (HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized use or disclosure of such information. Sponsor also agrees that if it participates in the administration of the plan(s), then it has also established and implemented appropriate safeguards in regard to PHI. Any and all Plan Sponsor personnel interacting with PHI shall be advised of: (1) the confidential nature of the information; (2) safeguards required to protect the information; and (3) the administrative, civil and criminal penalties for noncompliance contained in applicable Federal laws.

  7. Depository Information: Plan Sponsor hereby authorizes the Secretary to initiate reimbursement, credit entries and other adjustments, including offsets and requests for reimbursement, in accordance with the provisions of Section 1102 of the Patient Protection Act (P.L. 111-148), 42 U.S.C. §18002 and 45 C.F.R Part 149 and applicable provisions of 45 C.F.R. Part 30, to the account at the financial institution (hereinafter the “Depository”) identified by the Plan Sponsor. Plan Sponsor agrees to immediately pay back any excess reimbursement or debt upon notification from the Secretary of the excess reimbursement or debt. Plan Sponsor agrees to promptly update any changes in its Depository information.

  8. Policies and Procedures to Detect Fraud, Waste and Abuse. The Plan Sponsor attests that, as of the date this Application is submitted, has in place policies and procedures to detect and reduce fraud, waste, and abuse related to the Early Retiree Reinsurance Program. The Plan Sponsor will produce the policies and procedures, and necessary information, records and data, upon request by the Secretary, to substantiate existence of the policies and procedures and their effectiveness, as specified in 45 C.F.R. Part 149.

  9. Change of Ownership: The Plan Sponsor shall provide written notice to the Secretary at least 60 days prior to a change in ownership, as defined in 45 C.F.R, 149.700. When a change of ownership results in a transfer of the liability for health benefits costs, this Plan Sponsor Agreement is automatically assigned to the new owner, who shall be subject to the terms and conditions of this Plan Sponsor Agreement.

  10. Signature of Plan Sponsor Authorized Representative: I, the undersigned Authorized Representative of Plan Sponsor, declare that I have legal authority to sign and bind the Plan Sponsor to the terms of this Plan Sponsor Agreement, and I have or will provide evidence of such authority. I declare that I have examined this Plan Sponsor Application and Plan Sponsor Agreement. My signature legally and financially binds the Plan Sponsor to the statutes, regulations, and other guidance applicable to the Early Retiree Reinsurance Program including, but not limited to Section 1102 of the Patient Protection Act (P.L. 111-148), 42 U.S.C. §18002 and 45 C.F.R. Part 149 and applicable provisions of 45 C.F.R. Part 30 and all other applicable statutes and regulations. I affirm that the information contained in this Plan Sponsor Application and Plan Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and I authorize the Secretary to verify this information. I understand that, because program reimbursement will be made from Federal funds, any false statements, documents, or concealment of a material fact is subject to prosecution under applicable Federal and/or State law. (Only the Authorized Representative specified in Part I.B. can sign this agreement.)



Access to ERRP Secure Website


Part I – User Registration Information


The individual attempting to register in the ERRP Secure Website must either provide or confirm the accuracy of the following data:


  1. *Enter the Pass-phrase (Designee only)

  2. *Read and accept the user Agreement and Privacy Policy (located in “Access to ERRP Secure Website”, Part V of the document.

  3. *First Name, Middle Initial (optional), *Last Name

  4. *Job Title

  5. *Date of birth (Month/Day/Year)

  6. *Social Security Number

  7. *Email Address

  8. *Telephone Number and Extension (if applicable)

  9. FAX Number

  10. *Employer Name

  11. *Business Address of the Registering Individual:

    1. *Street Line 1

    2. Street Line 2

    3. *City

    4. *State/US Territory

    5. *Zip Code

  12. *Login Information

    1. *Login ID

    2. *Password

    3. *Security Question 1

    4. *Answer 1

    5. *Security Question 2

    6. *Answer 2



Part IIDesignee Invitation


  1. *Email Address

  2. *First Name, Middle Initial, *Last Name

  3. *Pass-phrase

  4. *Specify actions designee can perform (e.g., report costs, request reimbursement).



Part III – Login Warning


Registered secure website user must read and agree to the following terms prior to each login.


UNAUTHORIZED ACCESS TO THIS COMPUTER SYSTEM IS PROHIBITED BY LAW

The ERRP Secure Website is maintained by the U.S. Government and is protected by Federal law. Use of this computer system without authority or in excess of granted authority, such as access through use of another's Login ID and/or Password, may be in violation of Federal law, including the False Claims Act, the Computer Fraud and Abuse Act and other relevant provisions of Federal, civil, and criminal law. Violators are subject to administrative disciplinary action and civil and criminal penalties including civil monetary penalties.

For site security purposes, HHS' ERRP Center employs software programs to monitor and identify unauthorized access, unauthorized attempts to upload or change information, or attempts to otherwise cause damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process, information from these sources may be used to help identify an individual and may be used for administrative, criminal, or other adverse action. You may access the ERRP Privacy Policy by clicking on the link at the bottom of most ERRP Secure Website pages after you log in.

By clicking on "I Accept" you indicate your awareness of, and consent to, the terms and conditions of use stated in this Login Warning.

Click Decline IMMEDIATELY if you are not authorized to access this system or if you do not agree to the conditions stated in this warning.

I Accept

Decline



Part IV – User Agreement and Privacy Policy

Registered secure website user must read and agree to the following terms prior to each login.


THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS ON WHICH THE EARLY RETIREE REINSURANCE PROGRAM (ERRP) CENTER OFFERS YOU ACCESS TO THE ERRP CENTER SECURE WEBSITE.

You must read and accept the terms and conditions contained in this User Agreement expressly set out below and incorporated by reference before you may access the ERRP Center Secure Website.


The ERRP Center may amend this User Agreement at any time. Except as stated below, all amended terms shall automatically be effective 30 days after they are initially posted on the Site. This User Agreement is effective immediately.


1. Purpose of ERRP Center Secure Website

The U.S. Department of Health & Human Services (HHS) has published interim final regulations for the Early Retiree Reinsurance Program (ERRP), which is established in section 1102 of the Patient Protection and Affordable Care Act (the Affordable Care Act), 42 U.S.C. §18002. Section 1102 and its implementing regulations at 45 C.F.R Part 149 contain the provisions governing the ERRP, which is designed to assist employers and unions with continuing provision of high quality health benefit coverage to early retirees and their spouses, surviving spouses, and dependents, as well as to other individuals.


2. Privacy Policy

The U.S. Department of Health & Human Services (HHS) at (http://www.hhs.gov/), of which the ERRP Center Secure Website is a part, has a clear privacy policy. When you access the ERRP Center Secure Website, we collect the minimum amount of information about you necessary to manage your ERRP account.


Information Automatically Collected and Stored

When you browse through any website, certain personal information about you can be collected. We automatically collect and temporarily store the following information about your visit: 

  • the name of the domain you use to access the Internet (for example, aol.com, if you are using an American Online account, or stanford.edu, if you are connecting from Stanford University's domain);

  • the date and time of your visit

  • the pages you visited

  • the address of the web site you came from when you came to visit  

This information is used for statistical purposes only and to help us make this site more useful to visitors. Unless it is specifically stated otherwise, no additional information will be collected about you.


Information Collected to Process Reimbursement Requests and Manage Accounts through ERRP Center Secure Website

When Users of the ERRP Center Secure website register to use the website, we will collect personal information necessary to validate Users, to process reimbursement requests, and to manage information related to the application. The authority to collect this information is granted by § section 1102 of the Patient Protection Act (42 U.S.C. §18002) and the ERRP implementing regulations at 45 C.F.R. Part 149. The provision of this information is mandatory for participation in ERRP, and may include your name, address, telephone and fax numbers, e-mail address, social security number, Federal Employer Identification Number (FEIN), banking information, certain certifications, or other payment information. Your e-mail address will be used by the ERRP Center to send you mandatory program and account e-mail notifications. The ERRP Center may also collect a password and password hint for each User accessing the ERRP Secure Website. We use this information to verify Users' identities in order to prevent unauthorized access to Plan Sponsors' secure ERRP accounts.  ERRP Center staff has role-based access to this information, and use only the information minimally necessary to accomplish their jobs.


The personal information you provide is encrypted and sent to us using a secure method, in order to assure that your personal information is securely and safely transmitted. However, no one can give an absolute assurance that information intended to be maintained as private, whether transmitted via the Internet or otherwise, cannot be accessed inappropriately or unlawfully by third parties. We have taken and will continue to take reasonable steps to ensure the secure and safe transmission of your personal information.


Personally Provided Information

If you are not involved with the submission or management of an ERRP application, or the submission or management of data related to a reimbursement request on the ERRP Center Secure Website, you do not have to give us personal information. If you choose to provide us with additional information about yourself through e-mail, forms, surveys, etc., we will maintain the information as long as needed to respond to your question or to fulfill the stated purpose of the communication.


Disclosure

HHS does not disclose, give, sell or transfer any personal information about its visitors, unless required for law enforcement or statute.


Intrusion Detection

This website is maintained by the U.S. Government. It is protected by various provisions of Title 18, U.S. Code. Violations of Title 18 are subject to criminal prosecution in federal court.


For site security purposes and to ensure that this service remains available to all Users, we employ software programs to monitor traffic to identify unauthorized attempts to upload or change information, or otherwise cause damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process, information from these sources may be used to help identify an individual.


3. Systems of Records

Information originally collected in traditional paper systems can be submitted electronically, i.e., electronic commerce transactions and information updates about eligibility benefits. Electronically submitted information is maintained and destroyed pursuant to the Federal Records Act and in some cases may be subject to the Privacy Act. If information that you submit is to be used in a Privacy Act system of records, there will be a Privacy Act Notice provided.


4. Links

References from this website to any non-governmental entity, product, service or information do not imply endorsement or recommendation by HHS or any other HHS agency or employees.


We are not responsible for the contents of any "off-site" web pages referenced from this server. We do not endorse ANY specific products or services provided by public or private organizations. In addition, we do not necessarily endorse the views expressed by such sites, nor do we warrant the validity of any site's information or its fitness for any particular purpose.


5. Pop-up Advertisements

When visiting our website, your web browser may produce pop-up advertisements. These advertisements were most likely produced by other websites you visited or by third party software installed on your computer. HHS does not endorse or recommend products or services for which you may view a pop-up advertisement on your computer screen while visiting our site.


6. Outdated Information

Many HHS documents are time sensitive. Department policies change over time. Information in older documents may be out-dated. You also may wish to review our Privacy Policy, above.


7. Accessibility

This page provides information for those visitors who use assistive or other devices to access the content on this website. Please see the Contact Us section at http://errp.gov/contact/default.htm if you have general questions and comments or have difficulty finding something on this site.


Synopsis of Section 508 Accessibility Requirements

Section 508 requires that individuals with disabilities, who are members of the public seeking information or services from this website have access to and use of information and data that is comparable to that provided to the public who are not individuals with disabilities, unless an undue burden would be imposed on us. Section 508 also requires us to ensure that Federal employees with disabilities have access to and use of information and data that is comparable to the access to and use of information and data by Federal employees who are not individuals with disabilities, unless an undue burden would be imposed on us. (To learn more about the regulations governing the accessibility of Federal electronic information, read the Synopsis of Section 508 Accessibility Requirements at http://www.section508.gov/index.cfm?FuseAction=Content&ID=11.)


8. Freedom of Information Act (FOIA)

The ERRP Center website is a service of the U.S. Department of Health & Human Services at http://www.hhs.gov/. Any Freedom of Information Act (FOIA) requests concerning this website should be submitted in accordance with the Department's FOIA guidelines, which are online at http://www.hhs.gov/foia. Information on making FOIA requests is available at the Freedom of Information Group page. You also may wish to review our Privacy Policy above.



I accept

I decline

Reimbursement Request Information


An asterisk (*) identifies a required field.



PART I: Reimbursement Request Setup Information

  1. Early Retiree List: Submission Information (Note: The Plan Sponsor must provide the following information for each plan year.)

  1. * Early Retiree List Submission Method (Choose one):

    1. Submission via ERRP Secure Website – Response via the ERRP Website

    2. Submission via Plan Sponsor Mainframe to ERRP Data Center Mainframe – Response via ERRP Data Center Mainframe to Plan sponsor Mainframe

    3. Submission via Plan Sponsor Mainframe to ERRP Data Center Mainframe - Response via ERRP Data Center Mainframe to Plan sponsor Mainframe with a copy of all Early Retiree Response files sent to the ERRP Secure Website

    4. Submission via Vendor Mainframe to ERRP Data Center Mainframe – Response via ERRP Data Center Mainframe to Vendor Mainframe

    5. Submission via Vendor Mainframe to ERRP Data Center Mainframe - Response via ERRP Data Center Mainframe to Vendor Mainframe with a copy of all Early Retiree Response Files sent to the ERRP Secure Website



Note: Items 2-4 are required if sending data using the mainframe-to-mainframe method. If a Plan Sponsor chooses this method, it must work with HHS to establish mainframe communications protocols.

  1. *Mainframe Vendor ID (assigned by HHS)

  2. *Name of Organization Submitting Early Retiree Data

  3. *Contact Information:

    1. *First Name, Middle Initial (optional), *Last Name

    2. *Email Address

    3. *Telephone Number and Extension (if applicable)

    4. FAX Number

    5. * Address:

      1. *Street Line 1

      2. Street Line 2

      3. *City

      4. *State/US Territory

      5. *Zip Code



  1. Submit Claim List(s): Submission Information (Note: The Plan Sponsor must provide the following information for each plan year.)

  1. *Submit Claim List(s): Submission Method (Choose one):

    1. Secure file upload using Hypertext Transfer Protocol Secure (HTTPS) to ERRP Secure Website

    2. Plan Sponsor (or Vendor) Mainframe to HHS Mainframe



Note: Items 2-4, as applicable, are required if sending data using the mainframe-to-mainframe method of delivery. If a Plan Sponsor chooses the mainframe to mainframe method, it must work with HHS to establish mainframe communications protocols.

  1. *Mainframe Vendor ID (assigned by HHS)

  2. *Name of Organization Submitting Claim List(s)

  3. *Contact Information:

    1. *First Name, Middle Initial (optional), *Last Name

    2. *Email Address

    3. *Telephone Number and Extension (if applicable)

    4. FAX Number

    5. * Address:

      1. *Street Line 1

      2. Street Line 2

      3. *City

      4. *State/US Territory

      5. *Zip Code



  1. Assign Reimbursement-Related Privilege to Account Manager

  1. *Specify one of the following privileges for the Account Manager (Choose one)

    1. Report Costs

    2. Request Reimbursement

    3. View Only


  1. Banking Information

Provide the following information.

Account Information:

    1. *Bank Name

    2. *Account Type (Indicate Checking or Savings)

    3. *Organization Name Associated with Account

    4. *Account Number

    5. *Bank Routing Number


Bank Contact Information

  1. *First Name, Middle Initial (optional), *Last Name

  2. *Telephone Number and Extension (if applicable)


Bank Address

  1. Address:

  1. *Street Line 1

  2. Street Line 2

  3. *City

  4. *State/US Territory

  5. *Zip Code


  1. Affirmation by Authorized Representative



Prior to the Sponsor’s first reimbursement request for an ERRP application, its Authorized Representative must agree to the following:

As the Authorized Representative of the plan sponsor identified in this application, I hereby affirm that the sponsor will make a reasonable, good-faith effort to satisfy the following requirements, and that the sponsor will be prepared to demonstrate that it has made such a good-faith effort with respect to the following requirements, upon the request of the U.S. Department of Health & Human Services:

  • Sponsor will use any and all Early Retiree Reinsurance Program (ERRP) reimbursement proceeds to: (A) Reduce the sponsor’s health benefit premiums or health benefit costs, (B) Reduce health benefit premium contributions, copayments, deductibles, coinsurance, or other out of pocket costs, or any combination of these costs, for plan participants, or (C) Reduce any combination of the costs in (A) or (B).


  • If sponsor uses any portion of ERRP reimbursement funds to offset increases its own health benefit premiums or health benefit costs, sponsor will comply with the statutory and regulatory prohibition against using ERRP reimbursement as general revenue, by maintaining its level of contribution toward supporting the plan.


  • Sponsor will provide a notice to all plan participants notifying them that, because the plan is participating in the Affordable Care Act's Early Retiree Reinsurance Program, the plan may use the payments to reduce premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs, and therefore that plan participants may experience such changes in the terms and conditions of their plan participation. Sponsor will provide this notice, drafted by the U.S. Department of Health & Human Services (HHS), in a manner specified in HHS guidance.


  • Sponsor will submit claims only for items and services that Medicare would cover, as specified in HHS guidance.


  • Sponsor will not submit claims associated with plan participants who are not U.S. citizens or lawfully present in the U.S.

*Click here to make the affirmation



PART II: Reimbursement Request Information


  1. Initiate Reimbursement Request

An individual with the appropriate privilege must:

    1. *Select sponsor

    2. *Select application

    3. *Select plan year


  1. Submit List of Early Retirees and Process Response Files



A Plan Sponsor must submit with each Reimbursement Request an electronic cumulative list of Early Retirees for whom it is seeking or has sought program reimbursement for the plan year. The form and content of the list will vary, depending on the method of delivery, as follows.



ERRP Mainframe Early Retiree File Processing Layout

Data Element

Size

Alpha / Numeric

Incoming Early Retiree File

Outgoing Response & Notification Files

Allowable Values / Notes

HEADER RECORD






Record Type

1

A

X*

X

H”

Application ID

10

N

X*

X


Plan Year Start Date

8

N

X*

X

CCYYMMDD

Create Date

8

N

X*

X

CCYYMMDD

Create Time

6

N

X*

X

HHMMSS

Filler

217

A/N

X*

X

Must be spaces

DETAIL RECORD






Record Type

1

A

X*

X

D”

Subscriber SSN

9

N

X*

X

The Early Retiree

Member Unique Person ID

20

A/N

X*

X

Beneficiary for whom you are seeking reimbursement (For the Subscriber it will be the same as Subscriber SSN)

Unique Person ID Type

1

N

X*

X

Type of Member UPI:

1=SSN

2=Alien ID

3=I-94 ID

4=Other Federal ID

Member First Name

30

A

X*

X


Member Middle Initial

01

A

X

X

Not Required

Member Last Name

40

A

X*

X


Member Date of Birth

08

N

X*

X

CCYYMMDD

Member Gender

01

N

X*

X

0 = Unknown,

1 = Male,

2 = Female

Member Relationship to Early Retiree

02

N

X*

X

01 = Self,

02 = Spouse,

03 = Dependent


Member ID

30

A/N

X*

X

See accompanying instructions

Member Group ID

20

A/N

X*

X

See accompanying instructions

Member Coverage Effective Date

08

N

X*

X

Date coverage begins for the Member

CCYYMMDD

Member

Coverage Termination Date

08

N

X*

X

Date coverage ends for the Member

CCYYMMDD

(Blank if not terminated)

Member Coverage Termination Reason

1

N

X*

X

1 = Death,

2 = Other

(Needed for spouse/dependent coverage continuation determination)

Filler

70

A/N

X*


Must be spaces

Reason Code 1

02

N


X

Reason for full or partial denial of ERRP eligibility.

Reason Code 2

02

N


X

Reason for full or partial denial of ERRP eligibility.

Reason Code 3

02

N


X

Reason for full or partial denial of ERRP eligibility.

Reason Code 4

02

N


X

Reason for full or partial denial of ERRP eligibility.

ERRP Effective Date

08

N


X

ERRP Center calculated eligibility start date. CCYYMMDD

ERRP Termination Date

08

N


X

ERRP Center calculated eligibility end date. CCYYMMDD


Filler

46

A/N


X

Must be spaces

TRAILER RECORD




Record Type

1

A

X*

X

T”

Application ID

10

N

X*

X


Plan Year Start Date

8

N

X*

X

CCYYMMDD

Create Date

8

N

X*

X

CCYYMMDD

Create Time

6

N

X*

X

HHMMSS

Record Count

7

N

X*

X

Record count corresponds to number of Detail records only (not Header/Trailer)

Filler

210

A/N

X*

X

Must be spaces



ERRP Secure Website Early Retiree File Processing Layout

Data Element

Max Size

Alpha / Numeric

Incoming Early Retiree File

Outgoing Response & Notification Files

Allowable Values / Notes

Application ID

10

N

X*

X


Plan Year Start Date

8

N

X*

X

CCYYMMDD

Subscriber SSN

9

N

X*

X

The Early Retiree

Member Unique Person ID

20

A/N

X*

X

Beneficiary for whom you are seeking reimbursement (For the Subscriber it will be the same as Subscriber SSN)

Unique Person ID Type

1

N

X*

X

Type of Member UPI:

1=SSN

2=Alien ID

3=I-94 ID

4=Other Federal ID

Member First Name

30

A

X*

X


Member Middle Initial

01

A

X

X

Not Required

Member Last Name

40

A

X*

X


Member Date of Birth

08

N

X*

X

CCYYMMDD

Member Gender

01

N

X*

X

0 = Unknown,

1 = Male,

2 = Female

Member Relationship to Early Retiree

02

N

X*

X

01 = Self,

02 = Spouse,

03 = Dependant

Member ID

30

A/N

X*

X

See accompanying instructions

Member Group ID

20

A/N

X*

X

See accompanying instructions

Member Coverage Effective Date

08

N

X*

X

Date coverage begins for the Member

CCYYMMDD

Member

Coverage Termination Date

08

N

X*

X

Date coverage ends for the Member

CCYYMMDD

(Blank if not terminated)

Member Coverage Termination Reason

1

N

X*

X

1 = Death,

2 = Other

(Needed for spouse/dependent coverage continuation determination)

Reason Code 1

02

N


X

Reason for full or partial denial of ERRP eligibility.

Reason Code 2

02

N


X

Reason for full or partial denial of ERRP eligibility.

Reason Code 3

02

N


X

Reason for full or partial denial of coverage.

Reason Code 4

02

N


X

Reason for full or partial denial of ERRP eligibility.

ERRP Effective Date

08

N


X

ERRP Center calculated eligibility start date. CCYYMMDD

ERRP Termination Date

08

N


X

ERRP Center calculated eligibility end date. CCYYMMDD



  1. Sponsor Must Review Response Files



After submitting an Early Retiree List, a Plan Sponsor will receive from the ERRP Center a response file specifying which individuals on the Early Retiree List are approved or rejected for the purpose of submitting cost/claims data and requesting reimbursement. If an individual is approved, the response file will include the dates within the plan year for which the sponsor can submit cost/claims data and request reimbursement. Also, the response file, for records that are either rejected or approved only for a portion of the time period requested, will specify the reason(s) for the rejection or partial approval.



See the column labeled “Outgoing Response & Notification Files” in both tables in Part II.B. to identify the data elements returned to the Plan Sponsor in the response file.



  1. Submit Summary Cost Data



A Plan Sponsor must submit with each Reimbursement Request (via data entry in the ERRP Secure Website) the following summary cost data related to the Reimbursement Request, on a cumulative basis. The data must correlate to the corresponding data in the Claim List specified in E. that is submitted for the same reimbursement request:



  1. * Cost Paid by Plan - User enterable text field. This represents the aggregated actual costs for health benefits paid by the plan and incurred for Early Retirees

  2. * Cost Paid by Early Retiree - User enterable text field. This represents the aggregated actual costs for health benefits paid by approved Early Retirees

  3. * Threshold Reduction - User enterable text field. This field represents the aggregated cost threshold reduction amount for all approved Early Retirees with costs for health benefits reported for the plan year. The Plan Sponsor’s data aggregator shall be responsible for calculating and inputting the threshold reductions.

  4. Limit Reduction - User enterable text field. This field represents the aggregated cost limit reduction amount for all approved Early Retirees with costs for health benefits reported for the plan year. The Plan Sponsor’s data aggregator shall be responsible for calculating and inputting the limit reductions.


  1. Submit Claim List(s)

A Plan Sponsor must submit with each Reimbursement Request the following data:

  1. *Reimbursement Request Number (assigned by HHS)

  2. *Vendor ID (if applicable)

  3. *Plan Sponsor ID (assigned by HHS)

  4. *Application ID (assigned by HHS)



A Plan Sponsor must submit with each Reimbursement Request an electronic cumulative Claim List (via a Mainframe or Secure Website Upload method) containing the detailed claim line records supporting the costs included in its reimbursement request. The form and content of the list will vary, depending on the method of delivery, as follows.









ERRP Mainframe Claim List Layouts



ERRP File Header Layout (*left justified, space filled)

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

File Header

FH01

Record Type

2

1

2

A

R

FH = File Header

FH02

Application ID

10

3

12

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

13

20

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID.

FH04

Create Date

8

21

28

N

R

The date the file is created.

CCYYMMDD

FH05

Create Time

6

29

34

N

R

The time of day the file is created.

HHMMSS


Filler

266

35

300

A/N

R

Must be spaces.



ERRP Professional Claim Layout

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

Claim Header

HP01

Record Type

2

1

2

A

R

HP = Professional Header

HP02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members).

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

HP05

Derived Claim Indicator

1

91

91

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim

HP06

Plan Paid Date

8

92

99

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HP07

Member Date of Birth

8

100

107

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP08

Member Gender

1

108

108

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP09

Cost Paid By Early Retiree

9

109

117

N

O

The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 000054321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must be filled with zeros.


Filler

183

118

300

A/N

R

Must be spaces

Service Item Detail

DP01

Record Type

2

1

2

A

R

DP = Professional Detail

DP02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members).

This should be the same data value as what was provided on the Early Retiree List for a given individual.

DP03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

DP04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the Plan Sponsor’s claim processing system.



DP05

Claim Line Item Number



3



91



93



N



R

Line Number identifying the Service line associated with a claim assigned by the claim processing system.



A claim must contain at least one service line.

DP06

From Date of Service

8

94

101

N

R

Service Begin Date. Incurred date of claim.

CCYYMMDD

DP07

To Date of Service

8

102

109

N

R

Service Ending Date.

CCYYMMDD

DP08

Place of Service

2

110

111

N

R

Code value used to identify the location/facility where the service was rendered.

Two-digit codes for health care professional claims to indicate the setting in which a service was provided.

Value must be a valid industry standard Place of Service code.

DP09


Procedure Code

30

112

141

N

R

Code value used to designate the specific health interventions taken by medical professionals.

Must be a valid HCPCS/CPT code.

DP10

Procedure Code Modifier1

2

142

143

A/N

O

Code value used to provide further information about the service being performed.

DP11

Procedure Code Modifier2

2

144

145

A/N

O

Code value used to provide further information about the service being performed.

DP12

Procedure Code Modifier3

2

146

147

A/N

O

Code value used to provide further information about the service being performed.

DP13

Procedure Code Modifier4

2

148

149

A/N

O

Code value used to provide further information about the service being performed.

DP14

ICD Code Qualifier

1

150

150

N

R

Code value used to identify which version of ICD is being utilized

1 = ICD-9 code

2 = ICD-10 code

DP15

Principal Diagnosis Code

7

151

157

A/N

R

Primary diagnosis code associated with the Member’s condition.

Must be a valid ICD code.

DP16

Other Diagnosis Code2

7

158

164

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.

DP17

Other Diagnosis Code3

7

165

171

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.

DP18

Other Diagnosis Code4

7

172

178

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.

DP19

Quantity Qualifier

2

179

180

A

R

Code value used to identify the type of measurement used in the Unit Quantity field.

DA = Days

DH = Miles

UN = Units

MJ = Minutes

WK = Week

MO = Months

Q1 = Quarter(Time)

YR = Year

LB = Pounds

GM = Gram

F2 = International Unit 

01 = Actual Pounds

ME = Milligram

ML = Milliliter


DP20

Unit Quantity

9

181

189

N

R

Quantity of services/product delivered.

6v3

(Example: 999999999 = 999999.999)

DP21

Rendering Provider ID Qualifier

2

190

191

A/N

R

Code value used to identify the type of Provider ID reported in the Rendering Provider ID field.

XX = NPI

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

DP22

Rendering Provider ID

80

192

271

A/N

R

ID of the Provider/Supplier rendering the services to the Member.

DP23

Service Location Zip Code

5

272

276

N

R

US Zip Code of the location where service was rendered.

DP24

Item Plan Paid Amount

9

277

285

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 000054321 = 543.21)

Cannot be negative.



*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered in the Cost Summary Report in the SWS is net of rebates.


Filler

15

286

300

A/N

R

Must be spaces



ERRP Institutional Layout

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

Claim Header

HI01

Record Type

2

1

2

A

R

HI = Institutional Header

HI02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members).

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

HI05

Derived Claim Indicator


1

91

91

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim

HI06

Plan Paid Date

8

92

99

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HI07

Member Date of Birth

8

100

107

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI08

Member Gender

1

108

108

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI09

Cost Paid By Early Retiree

9

109

117

N

O

The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 000054321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must be filled with zeros.

HI10

Type of Bill

3

118

120

A/N

R

Code value which identifies the specific type of bill for institutional claims. Typically for industry standard, Type of Bill is a four byte field, with the first byte being a leading zero. For ERRP purposes it is a three byte field; drop the leading zero (first byte). For ERRP, the first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence.

HI11

Facility Provider ID Qualifier

2

121

122

A

R

Code value that defines the type of Provider ID reported in the Facility Provider ID field.

XX = NPI

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

HI12

Facility Provider ID

80

123

202

A/N

R

ID of the Facility where item/service was provided.


Filler

98

203

300

A/N

R

Must be spaces.

Service Item Detail

DI01

Record Type

2

1

2

A

R

DI = Institutional Detail

DI02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

DI03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

DI04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the Plan Sponsor’s claim processing system

DI05

Claim Line Item Number

3

91

93

N

R

Line Number identifying the Service line associated with a claim assigned by the claim processing system.

A claim must contain at least one service line.

DI06

Admission Date

8

94

101

N

R

Date admitted to facility for institutional claims. For non-acute care claims, if no Admission Date is available, use From Date of Service

CCYYMMDD

DI07

From Date of Service

8

102

109

N

R

Service Begin Date

CCYYMMDD

DI08

To Date of Service

8

110

117

N

R

Service Ending Date

CCYYMMDD

DI09

ICD Code Qualifier

1

118

118

N

R

Code value used to identify which version of ICD is being utilized.

1 = ICD-9 code

2 = ICD-10 code

DI10

Principal Diagnosis Code

7

119

125

A/N

R

Primary diagnosis code associated with the Member’s condition.

Must be a valid ICD code.

DI11

Other Diagnosis Code

7

126

132

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI12

Other Diagnosis Code2

7

133

139

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI13

Other Diagnosis Code3

7

140

146

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI14

Other Diagnosis Code4

7

147

153

A/N

O

Other diagnosis code associated with the Member’s condition.



Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI15

Other Diagnosis Code5

7

154

160

A/N

O

Other diagnosis code associated with the Member’s condition.



Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI16

Principle ICD Procedure Code

7

161

167

A/N

S

Principal procedure performed within an institutional setting.



Required when procedure is performed. Must be valid ICD Procedure Code.

DI17

Other ICD Procedure Code

7

168

174

A/N

O

Other procedures performed within an institutional setting.



Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI18

Other ICD Procedure Code2

7

175

181

A/N

O

Other procedures performed within an institutional setting.



Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI19

Other ICD Procedure Code3

7

182

188

A/N

O

Other procedures performed within an institutional setting.



Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI20

Other ICD Procedure Code4

7

189

195

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI21

Other ICD Procedure Code5

7

196

202

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI22

Revenue Code

4

203

206

A/N

R

Code value that identifies the specific cost center related to the service for institutional claims.

Always Required.

Individual services that contain Revenue Codes should be reported as documented in the claim.

Bundled Services that do not have a specific Revenue Code should be reported with a value of “XXXX”.

Revenue Code “0001” is an invalid code for ERRP purposes and a Claim List with this code will be rejected.

DI23

Procedure Code

30

207

236

A/N

O

Code value used to designate the specific health interventions taken by medical professionals.

Must be a valid HCPCS/HIPPS/CPT code.

DI24

Procedure Code Modifier1

2

237

238

A/N

O

Code value used to provide further information about the service being performed.

DI25

Procedure Code Modifer2

2

239

240

A/N

O

Code value used to provide further information about the service being performed.

DI26

Procedure Code Modifier3

2

241

242

A/N

O

Code value used to provide further information about the service being performed.

DI27

Procedure Code Modifier4

2

243

244

A/N

O

Code value used to provide further information about the service being performed.

DI28

Quantity Qualifier

2

245

246

A

S

Code value used to identify the type of measurement used in the Unit Quantity field.

Required if Revenue Code is not “XXXX”

DA = Days

DH = Miles

UN = Units

MJ = Minutes

WK = Week

MO = Months

Q1 = Quarter(Time)

YR = Year

LB = Pounds

GM = Grams

F2 = International Unit 

01 = Actual Pounds

ME = Milligram

ML = Milliliter

EA = Each

DI29

Unit Quantity

9

247

255

N

S

Quantity of services/product delivered.

Required if Revenue Code is not “XXXX”.

6v3 (Example: 999999999=999,999.999)

DI30

Service Location Zip Code

5

256

260

N

R

US Zip Code of the location where service was rendered.

DI31

Item Plan Paid Amount

9

261

269

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 000054321 = 543.21)

*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered into the Cost Summary Report in the SWS is net of rebates.


Filler

31

270

300

A/N

R

Must be spaces.



ERRP Prescription Layout

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

Claim Header

HX01

Record Type

2

1

2

A

R

HX = Prescription Header

HX02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

HX05


Derived Claim Indicator

1

91

91

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim

HX06

Plan Paid Date

8

92

99

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HX07

Member Date of Birth

8

100

107

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX08

Member Gender

1

108

108

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX09

Cost Paid By Early Retiree

9

109

117

N

O

*The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 000054321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must either be filled with zeros.

HX10

Prescription Service Provider ID Qualifier

2

118

119

N

R

Code value that defines the type of Service Provider ID reported in the Prescription Service Provider ID field.

XX = NPI

07 = NAPB

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

HX11

Prescription Service Provider ID

80

120

199

N

R

ID of the Pharmacy or Supplier for prescription claims. In most cases, will be the NAPB number.


Filler

101

200

300

A/N

R

Must be spaces.

Service Item Detail

DX01

Record Type

2

1

2

A

R

DX = Prescription Detail

DX02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members).



This should be the same data value as what was provided on the Early Retiree List for a given individual.

DX03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.



This should be the same data value as what was provided on the Early Retiree List for a given individual.

DX04

Claim Number

38

53

90

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

DX05

Claim Line Item Number

3

91

93

N

R

Line Number identifying the Service line within a claim assigned by the claim processing system.

A claim must contain at least one service line.

DX06

Filled Date

8

94

101

N

R

Date Prescription was filled for prescription claims.



CCYYMMDD

DX07

Prescription Product/Service ID Qualifier

1

102

102

A

R

Identifies if the Product/Service ID is a NDC code, HCPCS code or other value.



N = NDC

H = HCPCS

O = Other

DX08

Prescription Product/Service ID

30

103

132

A/N

R

Code value used to identify the product delivered.



Must be a valid NDC Code or HCPCS/CPT Code.

DX09

Prescription Product/Service ID Modifier1

2

133

134

A/N

O

Code value used to provide further information about the service being performed.

DX10

Prescription Product/Service ID Modifier2

2

135

136

A/N

O

Code value used to provide further information about the service being performed.

DX11

Prescription Product/Service ID Modifier3

2

137

138

A/N

O

Code value used to provide further information about the service being performed.

DX12

Prescription Product/Service ID Modifier4

2

139

140

A/N

O

Code value used to provide further information about the service being performed.

DX13

Prescription Product/Service ID Modifier5

2

141

142

A/N

O

Code value used to provide further information about the service being performed.

DX14

Prescription Product/Service ID Modifier6

2

143

144

A/N

O

Code value used to provide further information about the service being performed.

DX15

Prescription Product/Service ID Modifier7

2

145

146

A/N

O

Code value used to provide further information about the service being performed.

DX16

Prescription Product/Service ID Modifier8

2

147

148

A/N

O

Code value used to provide further information about the service being performed.

DX17

Prescription Product/Service ID Modifier9

2

149

150

A/N

O

Code value used to provide further information about the service being performed.

DX18

Prescription Product/Service ID Modifier10

2

151

152

A/N

O

Code value used to provide further information about the service being performed.

DX19

Unit of Measure

2

153

154

A

R

Code value specifies the type of Quantity Reported for prescription claims.



EA = Each (Being one or individual)

GM = Grams

ML = Milliliters

DX20

Quantity Dispensed

9

155

163

N

R

Quantity of services/products delivered for prescription claims.

6V3 (Example: 999999999=9999999.999)

DX21

Prescriber Provider ID Qualifier

2

164

165

A/N

R

Code value that defines the type of Prescriber Provider ID reported in the Prescriber Provider ID field for prescription claims.

XX = NPI

12 = DEA

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

DX22

Prescriber ID

80

166

245

N

R

ID of the Prescriber for prescription claims.

DX23

Service Location Zip Code

5

246

250

N

R

US Zip Code of the location where service was rendered.

DX24

Item Plan Paid Amount

9

251

259

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 000054321 = 543.21)

*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered into the Cost Summary Report in the SWS is net of rebates.


Filler

41

260

300

A/N

R

Must be spaces.



ERRP Cost Adjustment Layout

(For price concessions applied to costs incurred on or after June 1, 2010)

This Cost Adjustment record is not required unless Cost Adjustments apply for a given Member ID/Member Group ID.

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

Cost Adjustment Record

CA01

Record Type

2

1

2

A

R

CA = Cost Adjustment

record type for price concessions applied to costs incurred on or after June 1, 2010

CA02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.


Filler

47

53

99

A/N

R

Fill with spaces.

CA04

Member Date of Birth

8

100

107

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA05

Member Gender

1

108

108

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA06

Cost Adjustment Amount

9

109

117

N

R

The total amount of post point-of-sale concessions and rebates applied to costs incurred on or after June 1, 2010 for a particular member (i.e., one Cost Adjustment record per Member ID/Member Group ID combination). This amount must not be included in the Cost Paid by Plan in the Summary Cost Report in the Secure Website. Summing the Cost Adjustment amount for all members should equal the Total Cost Adjustment on the Claim List Trailer record.

7v2 (Example: 000054321 = 543.21)



Cannot be negative.


Filler

183

118

300

A

R

Must be spaces.



(For price concessions applied to costs incurred before June 1, 2010)

This Cost Adjustment record is not required unless Cost Adjustments apply for a given Member ID/Member Group ID.

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

Cost Adjustment Record

CB01

Record Type

2

1

2

A

R

CB = Cost Adjustment record type for price concessions applied to costs incurred before June 1, 2010

CB02

Member ID

30

3

32

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB03

Member Group ID

20

33

52

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.


Filler

47

53

99

A/N

R

Fill with spaces.

CB04

Member Date of Birth

8

100

107

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB05

Member Gender

1

108

108

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB06

Cost Adjustment Amount

9

109

117

N

R

The total amount of post point-of-sale concessions and rebates applied to costs incurred before June 1, 2010 for a particular member (i.e., one Cost Adjustment record per Member ID/Member Group ID combination).This amount must not be included in the Cost Paid by Plan in the Summary Cost Report in the Secure Website. Summing the Cost Adjustment amount for all members should equal the Total Cost Adjustment on the Claim List Trailer record.

7v2 (Example: 000054321 = 543.21)



Cannot be negative.



Filler

183

118

300

A

R

Must be spaces.





ERRP File Trailer Layout

Field No.

Name

Size

Start Pos.

End Pos.

Data Type

Required / Situational/ Optional

Description/ Value

File Trailer

FT01

Record Type

2

1

2

A

R

FT = File Trailer

FT02

Application ID

10

3

12

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application

FT03

Plan Year Start Date

8

13

20

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID field.

FT04

Create Date

8

21

28

N

R

The date the file is created.

CCYYMMDD

FT05

Create Time

6

29

34

N

R

The time of day the file is created.

HHMMSS

FT06

Total Number of Unique Retirees

6

35

40

N

R

Count of the unique Early Retirees within the Claim List.

FT07

Total Number of Claims

9

41

49

N

R

Count of unique claim records within the Claim List.

A unique claim is defined as a unique Member ID, Member Group ID, and Claim ID combination.

FT08

Total Number of Claim Service Line Records

11

50

60

N

R

Count of unique claim service line records within the Claim List.

FT09

Total Cost Paid by Plan

11

61

71

N

R

Sum of Item Plan Paid Amount fields.



Aggregated actual costs for health benefits paid by the plan for claims included in the Claim List.



Subtracting the Total Cost Adjustment amount in this Trailer record from this Total Cost Paid by Plan amount must equal the amount to be entered in the Cost Paid By Plan field in the Summary Cost Report in the Secure Website.



9v2 (Example: 55555555555=555555555.55)


FT10

Total Cost paid by Early Retiree

11

72

82

N

R

Sum of Cost Paid by Early Retiree.



Aggregated actual costs for health benefits paid by approved Early Retirees for claims included in the Claim List.



Fill with zeros if the Plan Sponsor is not requesting reimbursement for Early Retiree Paid Costs.



9v2 (Example: 55555555555=555555555.55)

FT11

Total Cost Adjustment

11

83

93

N

R

The aggregated total of all Cost Adjustment Amount fields (in the Cost Adjustment records CA06 and CB06) included in the Claim List.



Fill with zeros if there is no amount.



9v2 (Example: 55555555555=555555555.55)


Filler

207

94

300

A/N

R

Must be spaces





ERRP Secure Website Claim List Layouts



ERRP Professional Claim Layout

Field No.

Name

Max Size

Data Type

Required / Situational/ Optional

Description/ Value

Professional Claim Record

FH01

Record Type

2

A/N

R

DP = Professional

FH02

Application ID

10

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID.

HP02

Member ID

30

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP03

Member Group ID

20

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.


HP04

Claim Number

38

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

HP05

Derived Claim Indicator

1

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim

HP06

Plan Paid Date

8

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HP07

Member Date of Birth

8

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP08

Member Gender

1

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HP09

Cost Paid By Early Retiree

9

N

O

The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 54321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must be filled with zeros.

DP05

Claim Line Item Number

3

N

R

Line Number identifying the Service line associated with a claim assigned by the claim processing system.



A claim must contain at least one service line.

DP06

From Date of Service

8

N

R

Service Begin Date, Incurred date of claim

CCYYMMDD

DP07

To Date of Service

8

N

R

Service Ending Date

CCYYMMDD

DP08

Place of Service

2

N

R

Code value used to identify the location/facility where the service was rendered

Two-digit codes for health care professional claims to indicate the setting in which a service was provided.

Value must be a valid industry standard Place of Service code.

DP09


Procedure Code

30

A/N

R

Code value used to designate the specific health interventions taken by medical professionals.

Must be a valid HCPCS/CPT code.

DP10

Procedure Code Modifier1

2

A/N

O

Code value used to provide further information about the service being performed.

DP11

Procedure Code Modifier2

2

A/N

O

Code value used to provide further information about the service being performed.

DP12

Procedure Code Modifier3

2

A/N

O

Code value used to provide further information about the service being performed.

DP13

Procedure Code Modifier4

2

A/N

O

Code value used to provide further information about the service being performed.

DP14

ICD Code Qualifier

1

N

R

Code value used to identify which version of ICD is being utilized

1 = ICD-9 code

2 = ICD-10 code


DP15

Principal Diagnosis Code

7

A/N

R

Primary diagnosis code associated with the Member’s condition.

Must be a valid ICD code.

DP16

Other Diagnosis Code2

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.


DP17

Other Diagnosis Code3

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.

DP18

Other Diagnosis Code4

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary is blank. Must be a valid ICD code if provided.

DP19

Quantity Qualifier

2

A

R

Code value used to identify the type of measurement used in the Unit Quantity field.

DA = Days

DH = Miles

UN = Units

MJ = Minutes

WK = Week

MO = Months

Q1 = Quarter(Time)

YR = Year

LB = Pounds

GM = Gram

F2 = International Unit 

01 = Actual Pounds

ME = Milligram

ML = Milliliter

DP20

Unit Quantity

9

N

R

Quantity of services/product delivered.

6v3

(Example: 999999999 = 999999.999)


DP21

Rendering Provider ID Qualifier

2

A/N

R

Code value used to identify the type of Provider ID reported in the Rendering Provider ID field.

XX = NPI

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

DP22

Rendering Provider ID

80

A/N

R

ID of the Provider/Supplier rendering the services to the Member.

DP23

Service Location Zip Code

5

N

R

US Zip Code of the location where service was rendered.




DP24

Item Plan Paid Amount

9

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 54321 = 543.21)

Cannot be negative.



*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered in the Cost Summary Report in the SWS is net of rebates.





ERRP Institutional Layout

Field No.

Name

Max Size

Data Type

Required / Situational/

Optional

Description/ Value

Institutional Claim Detail Record

FH01

Record Type

2

A/N

R

DI = Institutional

FH02

Application ID

10

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID field.

HI02

Member ID

30

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members).

This should be the same data value as what was provided on the Early Retiree List for a given individual.


HI03

Member Group ID

20

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI04

Claim Number

38

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.

HI05

Derived Claim Indicator


1

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim

HI06

Plan Paid Date

8

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HI07

Member Date of Birth

8

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HI08

Member Gender

1

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.




HI09

Cost Paid By Early Retiree

9

N

O

The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 54321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must be filled with zeros.

HI10

Type of Bill

3

A/N

R

Code value which identifies the specific type of bill for institutional claims. Typically for industry standard, Type of Bill is a four byte field, with the first byte being a leading zero. For ERRP purposes it is a three byte field; drop the leading zero (first byte). For ERRP, the first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence.


HI11

Facility Provider ID Qualifier

2

A/N

R

Code value that defines the type of Provider ID reported in the Facility Provider ID field.

XX = NPI

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

HI12

Facility Provider ID

80

A/N

R

ID of the Facility where item/service was provided.

DI05

Claim Line Item Number

3

N

R

Line Number identifying the Service line associated with a claim assigned by the claim processing system.

A claim must contain at least one service line.




DI06

Admission Date

8

N

R

Date admitted to facility for institutional claims. For non-acute care claims, if no Admission Date is available, use From Date of Service

CCYYMMDD

DI07

From Date of Service

8

N

R

Service Begin Date

CCYYMMDD

DI08

To Date of Service

8

N

R

Service Ending Date

CCYYMMDD

DI09

ICD Code Qualifier

1

N

R

Code value used to identify which version of ICD is being utilized.

1 = ICD-9 code

2 = ICD-10 code

DI10

Principal Diagnosis Code

7

A/N

R

Primary diagnosis code associated with the Member’s condition.

Must be a valid ICD code.

DI11

Other Diagnosis Code

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.


DI12

Other Diagnosis Code2

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI13

Other Diagnosis Code3

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI14

Other Diagnosis Code4

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.




DI15

Other Diagnosis Code5

7

A/N

O

Other diagnosis code associated with the Member’s condition.

Not allowed if primary diagnosis is blank. Must be a valid ICD code if provided.

DI16

Principal ICD Procedure Code

7

A/N

S

Principal procedure performed within an institutional setting.

Required when procedure is performed. Must be valid ICD Procedure Code.




DI17

Other ICD Procedure Code

7

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI18

Other ICD Procedure Code2

7

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI19

Other ICD Procedure Code3

7

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI20

Other ICD Procedure Code4

7

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI21

Other ICD Procedure Code5

7

A/N

O

Other procedures performed within an institutional setting.

Not allowed if primary is blank. Must be a valid ICD Procedure Code if provided.

DI22

Revenue Code

4

A/N

R

Code value that identifies the specific cost center related to the service for institutional claims.

Always Required.

Individual services that contain Revenue Codes should be reported as documented in the claim.

Bundled Services that do not have a specific Revenue Code should be reported with a value of “XXXX”.

Revenue Code “0001” is an invalid code for ERRP purposes and a Claim List with this code will be rejected.

DI23

Procedure Code

30

A/N

O

Code value used to designate the specific health interventions taken by medical professionals.

Must be a valid HCPCS/CPT/HIPPS code.

DI24

Procedure Code Modifier1

2

A/N

O

Code value used to provide further information about the service being performed.

DI25

Procedure Code Modifer2

2

A/N

O

Code value used to provide further information about the service being performed.

DI26

Procedure Code Modifier3

2

A/N

O

Code value used to provide further information about the service being performed.

DI27

Procedure Code Modifier4

2

A/N

O

Code value used to provide further information about the service being performed.

DI28

Quantity Qualifier

2

A

S

Code value used to identify the type of measurement used in the Unit Quantity field.

Required if Revenue Code is not “XXXX”

DA = Days

DH = Miles

UN = Units

MJ = Minutes

WK = Week

MO = Months

Q1 = Quarter(Time)

YR = Year

LB = Pounds

GM = Grams

F2 = International Unit 

01 = Actual Pounds

ME = Milligram

ML = Milliliter

EA = Each

DI29

Unit Quantity

9

N

S

Quantity of services/product delivered.

Required if Revenue Code is not “XXXX”.

6v3 (Example: 999999999=999,999.999)

DI30

Service Location Zip Code

5

N

R

US Zip Code of the location where service was rendered.

DI31

Item Plan Paid Amount

9

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 54321 = 543.21)

*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered into the Cost Summary Report in the SWS is net of rebates.





ERRP Prescription Layout

Field No.

Name

Max Size

Data Type

Required / Situational/

Optional

Description/ Value

Prescription Claim Detail Record

FH01

Record Type

2

A/N

R

DX = Prescription

FH02

Application ID

10

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID field.

HX02

Member ID

30

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX03

Member Group ID

20

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX04

Claim Number

38

A/N

R

Unique ID of a given claim that is assigned by the claim processing system.




HX05

Derived Claim Indicator

1

A

R

Code value indicating whether or not a given claim was paid as a fee for service claim (Actual Claim) or paid under a capitated arrangement (Derived Claim).

Y = Derived Claim

N = Actual Claim




HX06

Plan Paid Date

8

N

R

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HX07

Member Date of Birth

8

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX08

Member Gender

1

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

HX09

Cost Paid By Early Retiree

9

N

O

*The aggregated actual costs for health benefits paid by approved Early Retirees for a given claim.

Cannot be negative.

7v2 (Example: 54321 = 543.21)

*Amount must be the full amount the member paid. (not net of rebates).



If a Plan Sponsor is not requesting reimbursement for Costs Paid by an Early Retiree, this field must be filled with zeros.

HX10

Prescription Service Provider ID Qualifier

2

N

R

Code value that defines the type of Service Provider ID reported in the Prescription Service Provider ID field.

XX = NPI

07 = NAPB

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

HX11

Prescription Service Provider ID

80

N

R

ID of the Pharmacy or Supplier for prescription claims. In most cases, will be the NAPB number.

DX05

Claim Line Item Number

3

N

R

Line Number identifying the Service line within a claim assigned by the claim processing system.

A claim must contain at least one service line.

DX06

Filled Date

8

N

R

Date Prescription was filled for prescription claims.

CCYYMMDD

DX07

Prescription Product/Service ID Qualifier

1

A

R

Identifies if the Product/Service ID is a NDC code, HCPCS code or other value.

N = NDC

H = HCPCS

O = Other

DX08

Prescription Product/Service ID

30

A/N

R

Code value used to identify the product delivered.

Must be a valid NDC Code or HCPCS/CPT Code.

DX09

Prescription Product/Service ID Modifier1

2

A/N

O

Code value used to provide further information about the service being performed.

DX10

Prescription Product/Service ID Modifier2

2

A/N

O

Code value used to provide further information about the service being performed.

DX11

Prescription Product/Service ID Modifier3

2

A/N

O

Code value used to provide further information about the service being performed.

DX12

Prescription Product/Service ID Modifier4

2

A/N

O

Code value used to provide further information about the service being performed.

DX13

Prescription Product/Service ID Modifier5

2

A/N

O

Code value used to provide further information about the service being performed.

DX14

Prescription Product/Service ID Modifier6

2

A/N

O

Code value used to provide further information about the service being performed.

DX15

Prescription Product/Service ID Modifier7

2

A/N

O

Code value used to provide further information about the service being performed.

DX16

Prescription Product/Service ID Modifier8

2

A/N

O

Code value used to provide further information about the service being performed.

DX17

Prescription Product/Service ID Modifier9

2

A/N

O

Code value used to provide further information about the service being performed.

DX18

Prescription Product/Service ID Modifier10

2

A/N

O

Code value used to provide further information about the service being performed.

DX19

Unit of Measure

2

A

R

Code value specifies the type of Quantity Reported for prescription claims.

EA = Each (Being one or individual)

GM = Grams

ML = Milliliters

DX20

Quantity Dispensed

9

N

R

Quantity of services/products delivered for prescription claims.

6V3 (Example: 999999999=9999999.999)

DX21

Prescriber Provider ID Qualifier

2

A/N

R

Code value that defines the type of Prescriber Provider ID reported in the Prescriber Provider ID field for prescription claims.

XX = NPI

12 = DEA

24 = EIN

34 = SSN

G2 = Plan Provider ID

99 = Other

DX22

Prescriber ID

80

N

R

ID of the Prescriber for prescription claims.

DX23

Service Location Zip Code

5

N

R

US Zip Code of the location where service was rendered.

DX24

Item Plan Paid Amount

9

N

R

The dollar amount paid by the Plan for this claim item.

7v2 (Example: 54321 = 543.21)

*Amount must be the full amount the plan paid. (not net of rebates). In contrast, the Cost Paid By Plan amount entered into the Cost Summary Report in the SWS is net of rebates.

ERRP Cost Adjustment Layout

(For price concessions applied to costs incurred on or after June 1, 2010)

This Cost Adjustment record is not required unless Cost Adjustments apply for a given Member ID/Member Group ID.

Field No.

Name

Max Size

Data Type

Required / Situational/Optional

Description/ Value

Cost Adjustment Record

FH01

Record Type

2

A/N

R

CA = Cost Adjustment

record type for price concessions applied to costs incurred on or after June 1, 2010

FH02

Application ID

10

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID.

CA02

Member ID

30

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA03

Member Group ID

20

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA04

Member Date of Birth

8

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CA05

Member Gender

1

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.




CA06

Cost Adjustment Amount

9

N

R

The total amount of post point-of-sale concessions and rebates applied to costs incurred on or after June 1, 2010 for a particular member (i.e., one Cost Adjustment record per Member ID/Member Group ID combination). This amount must not be included in the Cost Paid by Plan in the Summary Cost Report in the Secure Website. Summing the Cost Adjustment amount for all members should equal the Total Cost Adjustment on the Claim List Trailer record.

7v2 (Example: 54321 = 543.21)



Cannot be negative.




(For price concessions applied to costs incurred before June 1, 2010)

This Cost Adjustment record is not required unless Cost Adjustments apply for a given Member ID/Member Group ID.

Field No.

Name

Max Size

Data Type

Required / Situational/ Optional

Description/ Value

Cost Adjustment Record

FH01

Record Type

2

A/N

R

CB = Cost Adjustment record type for price concessions applied to costs incurred before June 1, 2010

FH02

Application ID

10

N

R

10-digit numeric field provided to the Plan Sponsor to identify the Application.

FH03

Plan Year Start Date

8

N

R

Date the Plan Year begins, provided in CCYYMMDD format. This date is specific to the Application ID.

CB02

Member ID

30

A/N

R

The Plan’s unique identification number for the Member associated with a given claim.

Member ID must be unique, i.e. cannot be the same for any two individuals (including family members)

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB03

Member Group ID

20

A/N

R

The Plan’s group number for the Member associated with a given claim. Plans typically categorize an individual within a specific group.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB04

Member Date of Birth

8

N

R

Date of birth for the Member associated with a given claim.

Date must be entered in CCYYMMDD format.

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB05

Member Gender

1

N

R

Gender for the Member associated with a given claim.

0 = Unknown

1 = Male

2 = Female

This should be the same data value as what was provided on the Early Retiree List for a given individual.

CB06

Cost Adjustment Amount

9

N

R

The total amount of post point-of-sale concessions and rebates applied to costs incurred before June 1, 2010 for a particular member (i.e., one Cost Adjustment record per Member ID/Member Group ID combination) This amount must not be included in the Cost Paid by Plan in the Summary Cost Report in the Secure Website. Summing the Cost Adjustment amount for all members should equal the Total Cost Adjustment on the Claim List Trailer record.

7v2 (Example: 54321 = 543.21)



Cannot be negative.




ERRP File Trailer Layout

Field No.

Name

Max Size

Data Type

Required / Situational/Optional

Description/ Value

File Trailer Record

FT01

Record Type

2

A

R

FT = File Trailer

FT02

Application ID

10

N

R

10 digit identifier assigned to the Plan Sponsor’s ERRP application.

FT03

Plan Year Start Date

8

N

R

The starting date of the Plan Sponsor’s plan year. CCYYMMDD

FT06

Total Number of Unique Retirees

6

N

R

Count of the unique Early Retirees within the Claim List.

FT07

Total Number of Claims

9

N

R

Count of unique claim records within the Claim List.

A unique claim is defined as a unique Member ID, Member Group ID, and Claim ID combination.

FT08

Total Number of Claim Service Line Records

11

N

R

Count of unique claim service line records within the Claim List.

FT09

Total Cost Paid by Plan

11

N

R

Sum of Item Plan Paid Amount fields.



Aggregated actual costs for health benefits paid by the plan for claims included in the Claim List.



Subtracting the Total Cost Adjustment amount in this Trailer record from this Total Cost Paid by Plan amount must equal the amount to be entered in the Cost Paid By Plan field in the Summary Cost Report in the Secure Website.



9v2 (Example: 55555555555=555555555.55)


FT10

Total Cost paid by Early Retiree

11

N

R

Sum of Cost Paid by Early Retiree.



Aggregated actual costs for health benefits paid by approved Early Retirees for claims included in the Claim List.



Fill with zeros if the Plan Sponsor is not requesting reimbursement for Early Retiree Paid Costs.



9v2 (Example: 55555555555=555555555.55)

FT11

Total Cost Adjustment

11

N

R

The aggregated total of all Cost Adjustment Amount fields (in the Cost Adjustment records CA06 and CB06) included in the Claim List.



Fill with zeros if there is no amount.



9v2 (Example: 55555555555=555555555.55)





  1. Submit Prima Facie Evidence of Early Retiree Payment



When required, a Plan Sponsor must submit a package containing individual pieces of prima facie evidence for each item or service for which it is seeking program reimbursement for amounts that an Early Retiree paid and a Cover Sheet summarizing what is included in the package. The evidence must correlate to the Summary Cost Data specified in Section D.

Each actual or copied piece of prima facie evidence (i.e. receipt) must include the following information:

    1. Receipt identifier;

    2. Amount paid by the individual;

    3. Date paid;

    4. Identity of individual or entity paid (i.e. the provider of the health benefit item or service); and

    5. A Description of each health benefit item or service for which the sponsor seeks reimbursement.

The Cover Sheet must include the following information:

  1. Plan Sponsor Name

  2. Application ID

  3. Plan Year Start Date

  4. Plan Year End Date

  5. Number of pages, including Cover Sheet

  6. Today’s Date

  7. Contact Name

  8. Contact Phone

  9. Information related to the Summary Cost Data:

    1. Reimbursement Request Number

    2. Current Cost Paid by Early Retiree

    3. Old Cost Paid by Early Retiree

    4. Net Cost Paid by Early Retiree

    5. Reimbursement Request Date

    6. Reimbursement Request Total

For each piece of prima facie evidence, the following data (items 10 through 15) must be included on the Cover Sheet:

  1. Receipt Identifier

  2. Claim Number

  3. Cost Paid by Early Retiree

  4. Member ID (for the applicable individual)

  5. Member Group ID (for the applicable individual)

  6. Provider ID (of the health care provider that delivered the health benefit item or service)



  1. *Authority to View Protected Health information

An individual sending and or receiving retiree data, and/or claims or summary cost data, must read and agree to the following statement:


NOTE: Your privileges permit you to access certain Electronic Protected Health Information (e-PHI) associated with this ERRP application. E-PHI is subject to protection under the federal privacy and security regulations established at 45 CFR Parts 160 and 164 and promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and other applicable statutes and regulations, and is intended for the access and use by individuals only as authorized by the Plan Sponsor. Disclosure of this e-PHI to any other party, unless authorized by the Plan Sponsor or required by law, is prohibited.


By clicking on the "I Accept" button below, you hereby acknowledge that you are authorized by the Plan Sponsor to access or use e-PHI associated with this ERRP application, and that you will do so in accordance with applicable statutes and regulations. Clicking the "Cancel" button will allow you to navigate away from this page, and you will not be permitted to access the Plan Sponsor’s Retiree Response files.



I Accept

I Decline



Appeal Information


An asterisk (*) identifies a required field.


A Plan Sponsor must submit the following information if it wishes to appeal a reimbursement determination:

  1. *Plan Sponsor ID (assigned by HHS)

  2. *Application ID (assigned by HHS)

  3. *Copy of the Determination being appealed

  4. *The findings or issues with which the sponsor disagrees, and the reason(s) for disagreement with the determination

  5. *The items and/or services at issue

  6. *The amount of reimbursement at issue

  7. *The individuals to whom the items and/or services at issue, were provided

  8. Supporting documentary evidence

  9. Will additional supporting documentary evidence be submitted?

  10. Estimated date by which any additional supporting documentary evidence will be submitted

  11. Request for extended due date for submitting any additional documentary evidence

  12. Additional supporting documentary evidence



Reopening Information


A plan sponsor must submit the following information if it wishes to submit a request for reopening:


1) *Plan Sponsor ID (assigned by HHS)

2) *Application ID (assigned by HHS)

3)*Copy of the Determination that is the subject of the reopening request

4) *A description of the issue

5) Supporting documentary evidence

6) *Analysis of the estimated financial impact, including the specific amount of reimbursement at issue.



Reporting Data Inaccuracies


To report data inaccuracies, a Plan Sponsor must submit a new reimbursement request, reflecting an accurate Early Retiree List, accurate Summary Cost Data, an accurate Claim List, and accurate Prima Facie Evidence of Early Retiree Payment (if applicable), in a form and manner specified in Reimbursement Request Information, Part II.



Reporting Change of Ownership


An asterisk (*) identifies a required field.


*When reporting a Change of Ownership, a Plan Sponsor must report the information necessary for HHS to understand the transaction and structure of the ownership change.



Other Information to be Produced Upon Request



  1. *Fraud, Waste, and Abuse (FWA) Policies and Procedures related to the ERRP

  2. *Data demonstrating the effectiveness of the FWA Policies and Procedures

  3. *Written agreement with its health insurance issuer (as defined in 45 CFR Section 160.103), group health plan, or other entities participating in the administration of the plan regarding disclosure of information to HHS

  4. *Any other documentation or data necessary for the Secretary to effectively administer the ERRP.


OMB Control Number 0938-1087 p.20


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDavid Gardner
File Modified0000-00-00
File Created2021-01-31

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