CMS-10321 Revised ERRP Collection Instrument

Early Retiree Reinsurance Program

0938-1087 Revised ERRP Collection Instrument-1

Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 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

Plan Sponsor Information

*Organization’s Name (Must correspond with the information associated with the Federal Employer Tax Identification Number (EIN)
*Type of Organization (Check the one category that best describes your organization)
1. Government
2. Union
3. Religious
4. Commercial
5. Non-profit
*Organization’s Employer Identification Number (EIN)
*Organization’s Telephone Number and Extension (if applicable)
Organization’s FAX Number
*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
Organization’s Website Address

Authorized Representative Information

*First Name, Middle Initial (optional), *Last Name
*Job Title
*Email Address
*Telephone Number and Extension (if applicable)
FAX Number
*Employer Name
* Authorized Representative Business Address
1. *Street Line 1
2. Street Line 2
3. *City
4. *State/US Territory
5. *Zip Code

Account Manager Information

*First Name, Middle Initial (optional), *Last Name
*Job Title
*Email Address
*Telephone Number and Extension (if applicable)
FAX Number
*Employer Name
* Account Manager Business Address

*Street Line 1
Street Line 2
*City
*State/US Territory
*Zip Code

Part II: Plan Information

Plan Information

*Plan Name
*Plan Year Cycle:
1. Start Month/Day
2. End Month/Day

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

*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.

First Plan Year Cycle:
1. Low Estimate (optional)
2. *Most Likely Estimate
3. High Estimate (optional)
Second Plan Year Cycle:
1. Low Estimate (optional)
2. *Most Likely Estimate
3. High Estimate (optional

*Intended Use of Early Retiree Reinsurance Program Reimbursements

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.

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

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.
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.
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.
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.
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.
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.
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.
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.
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.
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:

*Enter the Pass-phrase (Designee only)
*Read and accept the user Agreement and Privacy Policy (located in “Access to ERRP Secure Website”, Part V of the document.
*First Name, Middle Initial (optional), *Last Name
*Job Title
*Date of birth (Month/Day/Year)
*Social Security Number
*Email Address
*Telephone Number and Extension (if applicable)
FAX Number
*Employer Name
*Business Address of the Registering Individual:
1. *Street Line 1
2. Street Line 2
3. *City
4. *State/US Territory
5. *Zip Code
*Login Information
1. *Login ID
2. *Password
3. *Security Question 1
4. *Answer 1
5. *Security Question 2
6. *Answer 2

Part II – Designee Invitation

*Email Address
*First Name, Middle Initial, *Last Name
*Pass-phrase
*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

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

* 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.

*Mainframe Vendor ID (assigned by HHS)
*Name of Organization Submitting Early Retiree Data
*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

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

*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.

*Mainframe Vendor ID (assigned by HHS)
*Name of Organization Submitting Claim List(s)
*Contact Information:

*First Name, Middle Initial (optional), *Last Name
*Email Address
*Telephone Number and Extension (if applicable)
FAX Number
* Address:
1. *Street Line 1
2. Street Line 2
3. *City
4. *State/US Territory
5. *Zip Code

Assign Reimbursement-Related Privilege to Account Manager

*Specify one of the following privileges for the Account Manager (Choose one)
1. Report Costs
2. Request Reimbursement
3. View Only

Banking Information

Provide the following information.

Account Information:

*Bank Name
*Account Type (Indicate Checking or Savings)
*Organization Name Associated with Account
*Account Number
*Bank Routing Number

Bank Contact Information

*First Name, Middle Initial (optional), *Last Name
*Telephone Number and Extension (if applicable)

Bank Address

Address:

*Street Line 1
Street Line 2
*City
*State/US Territory
*Zip Code

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

Initiate Reimbursement Request

An individual with the appropriate privilege must:

*Select sponsor
*Select application
*Select plan year

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

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.

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:

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

Submit Claim List(s)

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

*Reimbursement Request Number (assigned by HHS)
*Vendor ID (if applicable)
*Plan Sponsor ID (assigned by HHS)
*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

HX = Prescription Header

HX02

Member ID

A/N

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

A/N

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

A/N

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

HX05

Derived Claim Indicator

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

Date claim system adjudicated or processed the claim for payment.

CCYYMMDD

HX07

Member Date of Birth

100

107

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

108

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

109

117

*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

118

119

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

120

199

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

Filler

101

200

300

A/N

Must be spaces.

Service Item Detail

DX01

Record Type

DX = Prescription Detail

DX02

Member ID

A/N

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

A/N

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

A/N

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

DX05

Claim Line Item Number

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

101

Date Prescription was filled for prescription claims.

CCYYMMDD

DX07

Prescription Product/Service ID Qualifier

102

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

103

132

A/N

Code value used to identify the product delivered.

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

DX09

Prescription Product/Service ID Modifier1

133

134

A/N