Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees (CMS-10143)

MAPD State User Guide 2018 PRA

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

OMB: 0938-0958

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0958 can be found here:

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oMB 0938-0958
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Medicare Advantage Prescription Drug
State User Guide
Version 7.0
February 28,2018

MAPD Stale |lser Guide, Verslon 7.0

Updated the version to 7.0.
Updated the publication date to February 28,2018.

Global

Updated Table of Contents, Figures, and Tables.

- Introduction
2 - Using MARx UI
3 - Entitlement, Enrollment,
1

Disenrollment Codes
Technical Inshuctions for
Submitting Files

- State MMA Requcst File Timirg

and Content
6

- MMA Request File

Section 6.1.1. Updated the information for the
Benefi ciary Matching Criteria.
Section 7.5: Added values to the

MBI

Effective Reason Code and Beneficiary's MBI End
Reason Code fields in the MMA Response File Detail
7

- MMA Response

File

Record layout.
Updated the description of the Secondary Match
Indicator (field 241) in the MMA Response File Detail
Record layout.

BEQ Request File

Section 8.3: Updates to the Beneficiary ID field name
and description in the BEQ Request Detail Record
layout.

BEQ Response File

Section 9.3: Updates to the Beneficiary ID field name
and description and the addition of the Active MBI

field in the BEQ Response Detail Record layout.

TBQ Request File

TBQ Response File

.3: Added values to the

MBI

Effective Reason Code and Beneficiary's MBI End
Reason Code fields in the TBQ Response File Detail
Record layout.

- Puerlo Rico Dual Eligibles File
13 - Glossary, Acronyms, State Codes
12

chalìge Log

THIS PAGE INTENTIONALLY BLANK

MAPD Statu Aset Guide, Veßion 7.0

lntroduction

..,...,... 1-1

1.1

1.2
1.3
2
2.1

2.2

2.3

2.4

Medicare Advantage Prescrlption Drug User lnterface (MARx Ul) System.. 2-1
Getting Started

.................-.... 2-1

2.1.1
2.1.2
2.1.3

..........................2-1

Request the State User role for MARX U|.............

..........................2-2

Logg¡ng into MARX Ul as a State User........,.,..,...

..........................2-3

Usìng the MARx Ul Screens............

...................... 2-4

2.2.1
2.2.2
2.2.3
2.2.1
2.2.2

General Properties of Screens........

......,...................2-4

Common Features of the Screens.....

..........................2-4

Common Characteristics of the Screens,..,...,.,...,

...... .... .... ............2-4

TypographicalConventions...,...

..........................2_6

CommonButtons,Links,andFields....................,

.,...,.......,............2-6

Navigating ihe MARX Ul .....................

...................... 2-8

2.3.1
2.3.2
2.3.3
2.3.4
2.3.5

How Do I Get Where I Want To Go?....

..........................2-8

Navigating Menus, Sub-menus, and Screens......

..........................2-8

ErrorMessageScreens...............

..........................2-9

Screens Available for the State User....................

..........................2-g

LoggingOnandViewingMessages......,......,.......

........................2-10

ViewingBeneficiarylnformation........

.....,.............. 2-14

2.4.1

Finding a Beneficiary..........

.........,..............2-1 4

2.4.2

Viewing Summary lnformat¡on about a Beneficiary..,..,..,.....,......

........................2-17

2.4.3

V¡ewing Detailed f nformation for a Beneficiary..........

............,.......,...2-18

2.4.4

Viewing a Snapshot of Beneficiary lnformation

........................2-19

2.4.5

Viewing Enrollment lnformation......

............,...,..,....2_23

2.4.6

............,...,..,....2-29

2.4.7

Viewing Add¡tional lnsurance lnformation
Viewing Low lncome Subsidy (LlS) lnformation of a Beneficiary

2.4.8

Viewing Eligibility lnformation for Beneficiaries..

.......................,2-35

February 28, 2018

........................2-33
Tâble ofContents

MAPD Slatu Aser Guide, Version 7.0
2.4.9

Viewing Status Act¡vity and Detail lnformation for Beneficiaries.......

..2-41

2.4.10

Logging Out of the Medicare Advantage and Part D lnqu¡ry System

.,2-50

2.4.11

Validat¡on Messages

..2-51

Entitlement Status, Enrollment, and Disenrollment Reason Codes

Submitting State Data for Medicare Modernization Act (MMA) Provisions.. 4-1

4.1

State Monthly MMA File Submission Requ¡rements....

4-1

4.2

Dual Eligible Enrollment........

4-1

4.3

Phased Down State Calculation ......................

4-1

4.4

State LIS Applications......

4-2

State MMA Request File Timing and Content..

5-1

5.1

MMA Request File Timing

5-1

5.2

MMA Request File Content......

5-2

5.2.1
5.2.2
5.2.3
5.2.4
5.2.5

CurrentDETrecords......................

.....5-2

RetroDETrecords.........................

,..,,5-2

FutureDETrecords.......................

.....5-3

LIS records

.....5-3

PRO records.......

.....5-3

5.3

PROspective Full Dual Eligibles

5-3

5.4

PRO Enrollment Process............

5-4

5.5

Submission of PRO Records

5-4

Processing of Returned PRO Records.....

5.6

MMA Request File

6
o.

6-1

Special Key Fields/User Tips for the MMA Request File
BeneficiaryMatchingCriteria.........,.......

6.1.1
6.1.2

lnstitutionalStatuslnd¡cator..

6-1

... .....

......

6-1

.......................6-2

6.2

MMA Request File Dataset Naming Conventions.........

6-3

6.3

MMA Request File Header Record Layout..

6-3

6.4

MMA Request File Detail Record Layout

6-4

6.5

MMA Request File Trailer Record Layout

..
..

.................... 6-9

7
7.1

MMA Response File Specifications......................

7-1

7.2

Special Key Fields/User Tips for the MMA Response File .....,.
7.2.1 MedicarePartDEnrollment|ndicator....,..,....,..

7-1

7.2.2
.2.3
7.2.4
7

t.,)

Managed CareOrganization (MCO)('10ôccurrences)....

... ... .7 -1

Plan Beneflt Pâckâge Enrollment (10 Occurrences) ........

.......7-2

Part D Plan Benefit Package (10 Occurrences)........,,..,..

MMA Response File Dataset Naming Conventions......-...........

February 28,2018

.......7-1

.....7-4
Table ofContents

MAPD

e Uset GuÍde, Verslon 7.0

7.4
78,

MMA Response File Header Record Layout..

7.6

MMA Response File Summary Record Layout............

.....7-6
...7-57

7.7

MMA Response File Monthly Summary Record Layout...,......

...7-60

7.8

MMA Response File ïrailer Record Layout

...7-62

7-4

MMA Response File Detail Record Layout............

Batch Eligibility Query (BEQ) Request File

8-1

8.'l

BEQ Request File Dataset Naming Conventions.....................

8-l

8.2

BEQ Request File Header Record Layout .........

8-'t

8,3

BEQ Request F¡le Detail Record Layout..

8-3

8.4

BEQ Request File Trailer Record Layout..

8-4

8.5

Sample BEQ Request File E-mail Acknowledg ments

8-5

Batch Eligibility Query (BEQ) Response Fi|e............

9.1

BEQ Response File Dataset Naming Conventions...

9.2

BEQ Response F¡le Header Record Layout..............

BEQ Response File Detail Record Layout...........

9.4

BEQ Response File Trailer Record Layout..

...

9-1

''.. ....

..... .

. .. .9-l

' .' . '...'.......9-1
.'-..........-......... 9-2

......,.......,........... 9-14

Territory Beneficiary Query (TBQ) Request Fi1e.......................,......,.............10-1

Conventions.................

10.1

TBQ Request File Dataset Naming

10.2

TBQ Request File Header Record Layout..

......,.......,..... 10-1

10.3

TBQ Request File Detail Record Layout

.................... 10-2

10.4

TBQ Request File Trailer Record

't1

Layout..

.............10-2

Territory Beneficiary Query (TBQ) Response Fi|e....................................,....11-1

11.1

TBQ Response File Dataset Naming Conventions...........

11.2

TBQ Response File Header Record Layout..

11.3

TBQ Response File Detail Record Layout

11.4

TBQ Response File Trailer Record Layout

........... 10-1

Puerto Rico Dual Eligibles File

Process

...11-1
...11-1
...11-2
.11-23

..........12-1

12.2

Puerto Rico Dual Eligibles Request File Dataset Naming Conventions.................... l2-l
..12-1
Puerto Rico Dual Eligibles Request File Header Record Layout...

12.3

Puerto Rico Dual Eligibles Request File Detail Record Layout.

..12-2

12.4

Puerto Rico Dual Eligibles Request File Trailer Record Layout

..12-2

12.5

Puerto Rico Dual Eligibles Response File Dataset Naming Conventions..,..,.......,..,

12.6

Puerto Rico Dual Eligibles Response File Header Record Layout ...........................12-3

12.7

Puerto Rico Dual Elig¡bles Response File Detail Record Layout.. ............................12-3

12.8

Puerto Rico Dual Eligibles Response File Trailer Record Layout.............................12-5

12.9

Puerto Rico Dual Eligibles File

12.1

February 28, 2018

E-mail Acknowledgement.....

2-3

12-5
Tâble ofContents

MAPD S|úe UseÌ Gaide, Version 7.0

Glossary, List of Acronyms, and State Codes

February 2E,201E

13-1

Table ofContents

MAPD State Uset Guìde, Version 7,0

FTGURE

2-1

REQUEST ACCESS TO MARX

FIGURE2-2: REQUEST

EW APPLICATION

..................2_2

ACCESS...

FIGURE 2-3: USER SECURIIY ROLE SELECIIoN (M002)
FIGURE 2-4: STATE USÊR WELCOME (M101)

...................................2-3

SCREEN

.................2-rI

SCREEN

................................2-13

FIGURE 2-5: SIATE USER BENEFICIARIES: FIND (M201.) SCREEN

........................

.......................2-1S

FIGURE 2-6: STATE USER BENEFICIARIES: SEARCH RESULTS (M202) SCREEN ..................... .....................................2-I7
FIGURE 2-7: SAMPLE HEADER FOR THE BENEFICIARY SNAPSHOT(M203) SCREEN..................................................2-19

.....

.......................2-20

SCREEN

.-.....................2-23

FIGURE 2-8: STATE USER BENEFICIARY DETAIL: SNAPSHOT (M203) SCREEN
F¡GURE 2-9: STATE USER BENËFICIARY DETAIL: ENROLLIVIENT(M204)

FIGURE 2-10: STATE USER DETAIL: ENROLLMENT (M222) SCREEN
FIGURE 2-1L: RX INSURANCE VIEW (M244) SCREEN

.
SCREEN..........

SCREEN

FIGURE 2-14: STATE USER BENEFICIARY: ELIGIBILITY (M232) SCREEN
FIGURE 2-15: STATE USER STATUS ACTIVITY (M256) SCREEN
FTGURE

...,.........................2-2S

.................................2-27

FIGURE 2-12: ADDITIONAL INSURANCE INFORMATION (M251)
FIGURE 2-13: LoW INCOME SUBSIDY (M252)

..............

........................2-29
...............................2-33

..............

..................,.........

........................2-36
.......................2-4r

2-16:STATE USER STATUS DETATL: MEDtCAtD (M257)SCREEN -VAL|D RECORD................. .....-.................2_44

FIGURE 2-17: STATE USER STATUS DETATL: MEDtCAtD (M257) -AUDtTED RECORD .......,..................................,.,...2_45
FIGURE 2-18: STATE USER STATUS DETAIL: INCARCERATION
FIGURE

2-19: STATE USER LOGOUT SCREEN

.....................

FIGURE 2-20: VALIDATION MESSAGE PLACEMENTON

F€bruary 28,2018

(M257)SCREEN

SCREEN......................

.........................2-46
.........................2-50
..........................2-51

List of Figures

THIS PAGE INTENTIONALLY BLANK

MAPD Støte Uset culde, Version 7.0

IABLE 2-1: TYPOGRAPHICAL

CONVENT1ONS.......................

TABLË 2^2: COMMON BUTTONS AND LINKS

TABLE 2-5: STAIE USER SCREEN
TABLE 2-6: M002 SCREEN

........................

........................2-6

1OOKUP.................

....................................2-9

MESSAGES

.........................2-LL

TABLE 2-7: STATE USER (M101) FIELD DESCRIPTIONS AND ACTIONS

.........................2-6

BLE 2-8: STATE USER (M101)SCREEN

.....

MESSAGES..........

TABLE 2-9: STATE USER (M201) FIELD DESCRIPTIONS AND
TABLE 2-10:sTATE USER (M201) SCREEN

ACT|ONS.....

TABLE 2-12: STATE USER (M202) SCREEN

TABLE 2-14: STATE USER (M203) FIELD DESCRIPTIONSAND

.....

ACT|ONS.....

................................2-r7
......................2-r7

.....

......................2-22
................................2-23

MESSAGES..........
.....

......................2-24
................................2-Zs

MESSAGES..........

TABLE 2-20: STATE USER (M244) FIELD DESCRIPTIONS AND ACTIONS

.....

...................2-18

................................2-ZO

MESSAGES..........

TABLE 2-18: STATE USER (M222) FIELD DESCRIPTIONS AND ACTTONS

TABLE 2-21: STATE USER (M244) SCREEN

......................2-16

INFORMAT|ON....

TABLE 2-16: STATE USER (M204) FIELD DESCRIPTIONS AND ACTIONS

TABLE 2-19: STATE USER (M222) SCREEN

..................................2-1S

MESSAGES..........

TABLE 2-13: MENU ITEMS FOR VIEWING BENEFICIARY DETAIL

TABLE 2-1.7: STATE USER (M204) SCREEN

........................2-13

MESSAGES..........

TABLE 2-11: STATE USER (M202) FIELD DESCRIPTIONS AND ACT|ONS

TABLE 2-15:STATE USER (M203)SCREEN

..................................2-13

......................2-26
..................-.............2-27

MESSAGES..........

................-.....2-29

IABLE 2-22: ADDITIONAL INSURANCE INFORMATION (M251) FIELD DESCRTPTTONSAND ACTIONS.......................2-29
TABLE 2-23: ADDITIONAL INSURANCE INFORMATION (M251) SCREEN MESSAGES............. ...................................2-32
TABLE 2-24: LOW INCOME SUBSIDY (M252) FIELD DESCRIPTIONSAND
TABLE 2-25: STATE USER (M252)SCREEN

February 28, 20 ¡E

ACT|ONS......

MESSAGES..........

..............2-33
......................2-34
List ofTables

MAPD Sk te Uset Guide, Version 7.0

TABLE 2-26: STATE USER

(M232) FIELD DESCRIPTIONS AND AcTloNs

TABLE 2-27: STATE USËR (M232)SCREEN
TABLE 2-28: STATUS ACTIVITY
TABLE 2-29: STAIUS DETAIL

.....

..',....... .................2-36

M8SS4GES..............

(M256) FIELD DESCRIPTIoNS AND

(M257) FIELD DESCRIPTIONS AND

ÎABLE 2-30: STATUS DETAIL (M257)SCREEN

ACT|ONS.....

.... .'...-.'....-..... 2-42

ACTIONS.....

...".'................. ..2-46

MESSAGES....

TABLE2-31: STATE USER LOGOUT SCREEN FIELD DESCRIPTIONS AND
TABLE 2-32: STATE USER LOGOUT SCREEN

.........'...."..2-39

......'....'."'..'....2-49

ACTIONS

MESSAGES,,,,,,,,

CODES

..........'....".2-50

"..." . 2-50

...... ....

.....'...'.. .... ...........3-1

TABLE3-L: PART A

ENTITLEM ENT STATUS

TABLE 3-2: PART A

NON ENTITLEMENT STATUS

TABLE 3-3: PART A

ENROLLMENT REASON

CODES

............... ... .............3-L

TABLE 3-4: PART B

ENTITLEMENT STATUS

CODES

............ ..

TABLE

3-5:

TABLE

3-6: PART B - ENROLLMENT REASON

PART B

NON ENTITLEMENT REASON

TABLE 3-7: DISENROLLMENT REASON

.............3-1

...............3-2

CODES,.,,,,,,.....

CODES.

'...........3-2
.........". ...... ...

CODES........

DOCUMENT

... ...

TABLE 13-2:ACRONYMS USED IN THIS

Febr!¡ary 28,201E

COD8S...............

.... ..3-3

...... ........ ...... ..... ... 3-3

. ....................13-4

List ofTables

MAPD Stúe Users Guide, Vetsion 7.0

1.1

Document Over-view

The Medicare Advaatage Prescription Drug (MAPD) State Users Guide (SUG) provides
information for all of the fifty states, the District of Columbia, and Puerto Rico's Medicaid
Agencies (States) Users regarding the use of the Centers for Medicare & Medicaid Services

(CMS) Medicare Advantage Prescription Drug System (MARx). The SUG was specifically
developed for individuals with the "State User" role in MARx.
The SUG provides instructions for use of the MARx User Interface (UI) System, including
screenshots and screen content descriptions. States may use the MARX UI to obtain online
Medicare eligibility, enrollment, and prescription drug information for beneficiaries.
Beginning with the May 2017, Version 6.0, the SUG also contains information about the data
files that are exchanged between the States and CMS to submit the monthly dual-eligible
enrollment, and to request eligibility, entitlement, and effollment information.

1.2

f)ocutnent

Section 1, lnúro 36
months.

LIS record not scan¡ed.
Note: Detail record is valid if ERC
99

00 or 99.

0
I

Value is valid.
Value is not in Valid Value

PRO record Eligibility Status

Set.

Eligibility Status ERc

185- 186

CHAR

LIS record not scanned,

Note; Detail recold is valid if ERC

Fobruary 28,2018

-7

00 or 99.

MMÀ Response File

MAPD Støte Users Guide, Versíon 2.0

Item

0 - Value is valid.
1-

Value is nor in Valid Value
Set.

Benefi ciary's ldentifi er ERC

187-188

03 - Field is ernpty.
Note: Detail record is valid if ERC

CHAR

:00,

Detail record is also valid if ERC
0l or 03 and Social Secu¡ity ERC

:00.
35

Beneficiary

Indicator

Code ERC

189-190

CMS does not use Beneficiary
Identifi er lndicator Code.

CHAR

valid

Value is not in Valid Value
Set.

2 - Value is not numeric.
36

Beneficiary's SSN ERC

t9l-t92

CHAR

- Value is missing.
Note: Detail record is valid if ERC
= 00.
Detail record is also valid if ERC =
03

01, 02 o¡ 03 and Beneliciary,s

ldentifier ERC

00.

0 - Value
37

Beneficiary's Gender ERC

t93-194

CHAR

Value is not in Valid Value
Set.

Note: Detail record is valid if ERC

:00.
00-

02
04

valid.

Value is not numeric.

Date is unknown.
Value
is future.
1 1 - Month value is not within
range of 01-12.
10

Beneñciary's Date of Bi¡th ERC

195-196

CHAR

Day value is out ofrange.

2l -Year <

1899.

Note: Detail record is valid if ERC

February 28,2018

?-8

00 or 21.

MMA Response Fiìe

MAPD Støtc Users Guide, Version 7.0

Field

Itèm

Description

0 - Value is valid.

Value is not in Valid Value
Set.

07
39

Dual Status Code ERC

197-198

CHAR

PRO record with Dual Status

Code

á2,

04 or 08

DET record has dual status
code

of99

LIS record not scanned.
Note: Detail record is valid if ERC
= 00, 40 or 99.

0
140

FPL % Indicator ERC

199-200

CHAR

Value is valid.
Value is not in Valid Value
Set.

LIS record not scanned.
Note: Detail record is valid if ERC
99

: 00 or 99.
0 - Value is valid.
1 Value is not in Valid Value

Drug Coverage Indicator ERC

201-202

CHAR

Set.
99 - LIS record not scan¡ed.
Note: Detail record is valid if ERC

: 00 or 99.
0 - Value is valid.

1 - Value is not in Valid Value

Institutional Status Indicator
ERC

203-204

CHAR

Set.
99 - LIS record not scanned.
Note: Detail record is valid if ERC

: 00 or 99.
0 - Value is valid.

1 - Value is not in Valid Value
Set.

LIS Application Approval Code
ERC

205-206

CHAR

DET or PRO record not
scanned.

Note: Detail record is valid if ERC

February 28,2018

7-9

00 or 98.

MMA Rosponse File

MAPD Støte

Itèm

r.r

L4sers

Guide, Versiorr 7,0

Si¿è:ìi iPôsüiirä,r

linor;e¡¡
00

04
10

LIS Approved/Disapproved Date
ERC

Value is valid.
Value is not numeric.
Date is unknown.

Value is future.
Month value ís not within
range of01-12.

207-208

CHAR

Day value is out ofrange.
Value is later than Low-

Incoure Subsidy End Date.
- DET or PRO record not

scanned.

Note: Detail record is valid if ERC

:00
00

or 98.

Value is valid.
Vahle is not numeric.

04
1

- Date is unknown,
I - Month value is not within
range

l2
31
45

LIS Start Date ERC

209-2t0

CHAR

of0l -12.

Day value is out ofrange.

* Value

is later tlmr Lr)w-

Incorne Subsidy End Date.
36 - Value is earlier than Janualy

1,2006.

Day value is not first day

the month.
98

DET or PRO record not
scanned.

Note: Detail record is valid if ERC
00, 37 or 98.

fobruâry 28,2018

7-t0

MMA Response Fiìe

MAPD Slate Users Guide, Version 7.0

Item

Siqe:

Position

f'oÍmât.

Description

Value is valid.

04 -

Value is not numeric.
Date is unknown.
Month value is not .¡/ithin

range
12

of0l -12.

Day value is out ofrange.
Value is earlier than LowIncome Subsidy
Approved/Disapproved Date.

Part D End Date ERC

211-212

CHAR

Value is earlier than LowIncome Subsidy Effective
Date.

Value is earlier than LowIncome Subsidy
Approved/Disapproved Date
ard Low-Iucome Subsitly
Effective Date

DET or PRO record not
scanned.

Note: Detail record is valid if ERC
= 00 or 98.

- Value is valid.
- Value is not numeric
98 - DET or PRO record not
00
02

4'7

Income as % ofFPL ERC

213-214

CHAR

scanned,

Note: Detail record is valid if ERC

: 00 or 98.
0 - Value is valid.
I - Value is not in Valid Value
Set.

LIS Level ERC

215-2t6

CHAR

DET or PRO record not
scanned.

Note: Detail record is valid if ERC

:00

or 98.

0 - Value is valid.

Income Used for Determination
ERC

Value is not in Valid Value
Set.

217

-218

CHAR

DET or PRO record not
scanned.

Note: Detail record is valid if ERC

:00or98

February 28, 2018

1-ll

MMA Response File

MAPD Støte Users Guide, Veßion 7,0

l,s¿¿f

r.t9u

ì'f9o¡1¡9i'.,

¡'ormat

0 - Value is valid.
1-

Value is not in Valid Value
Set.

Resource Level ERC

219-220

CHAR

DET or PRO record not
scanned.

Note: Detail record is valid if ERC
: 00 or 98.

Basis ofPart D Subsidy Denial

ERC

Value is valid.

Value is not in Valid Value
Set.

221-222

CHAR

DET or PRO record not
scanned,

Note: Detail record is valid if ERC
: 00 or 98.

0 - Value is valid.

Value is not in Valid Value
Set.

Result of an Appeal ERC

223-224

CHAR

DET or PRO record not
scanned.

Note: Detail TecoÌd is valitl if ERC
: 00 or 98.

Value is not in Valid Value
Set.

Change to Previous

Determination ERC

Value is valid.

225-226

CHAR

DET or PRO record not
scanned

Note; Detail record is valid if ERC

:00

or 98.

Value is valid.

Value is not in Valid Value
Set.

Detennination Cancelled ERC

227-228

CHAR

DET or PRO reco¡d not
scanned.

Note; Detail record is valid if ERC
= 00 o¡ 98,

F€bruary 28, 2018

7-12

MMA Response File

MAPD Slate Users Gaide, Version 7.0

an assessment ofthe

detail record.
000000: DET, PRO or LIS record
is accepted with no errors or

wamings.
000001: DET, PRO or LIS record
is accepted with warnings.

Q!!!Q!: Detail record is rejected
because Record Identification

Code is not DET, PRO or LIS.

Q@:

DET, PRO or LIS record

is rejected because it was not
uratched.

(May indicate

mismatch on the

submitted date of bil1h.)

Q!!!![:

DET rccortl is rejeclctl:

record has no enhy in required

field or has entry that does not
55

Record Retum Sùmmary Code

229-234

CI]AR

pass validation edits.

000005: LIS record is rejected:

record has no entry in required

field or has enhy that does not
pass validation edits.

000006: DET record is rejected:
record is a duplicate of another

DET record.

!@f:

LIS record is rejected:
record is a duplicate ofanother
LIS record.

000009: PRO record is rejected:
record has no entry in required

field or has entry that does not
pass validation edits.

9000!0: PRO record is rejected:
record is a duplicate of another
PRO record.

February 28, 2018

-t3

MMA Rosponse File

MAPD Støte Users Guitle, Version 7.0

Item

stze

,:ÞäÀition.r.

,,Fórrirrf.l
QQQ!!!: PRO Record is rejecred:
record is a duplicate ofa DET

Cont,

Record Retum Summary Code
Cont,

record in saure file.
000012: PRO record is rejected:
record is a duplicate ofa DET
record in previous file,
Values:

Medicare Part D Eligibility
Indicator

23s

Beneficiary is eligible for
Medicare Pad D.

Beneficiary is not eligible for
Medicare Part D.

CHAR

For DET and PRO records, this

field indicates the presence

Medicare Part D eligibility during
the Eligibility Month/Year.
Values:

Medicare Part D Enrolhnent
Indicator

z5l-t

Beneficiary is enrolled in a
Medicare Parl I) plan,

Beneflrciary is not enrolled in a
Medicare Paft D p1an.

CHAR

For DET and PRO records, rhis
field indicates Medicare Part D
enrollment during the Eligibility
Montb/Year.

ffi

ffi4ñ.ìì--F4ñEm¡- {ñ snãFifü

The number identifying the

Beneficiary's Claim Account
Number

237-245

CHAR

primary Medicare benefi ciary
under the SSA or RRB programs.
This number along with the
Benefi ciary Identifi cation Code
uniquely identiflres a Medicare
beneficiary.

February 28,2018

-14

MMA Response Filo

MAPD StaÍe Users Guide, Version 7.0

Item

Size

Po,.rtiÞ¡t

.Description

Format

A code that is used in conjunction
with the Beneficiary CAN to
uniquely identifo a Medicare
beneficiary.
Beneficiary's Identification

Code (BIC)

246-247

CHAR

The BIC Code establishes the

beneficiary's relationship to a
primary SSA or RRB wage eamer
and is used to justify entitlement to

Medicare henefits.
60

Beneficiary's Birth Date

248-255

Beneficiary's Death Date

256-263

NUM
NUM

MMDDCCYY
MMDDCCYY
Values:

Beneficiary's Gencìer

Beneficiary's First Name

Benefi ciary's Middle Name

264

CHAR

265-294

CHAR

295

CHAR

Unknown

Mate

Female

First narne of the Medicare
beneficiary

Middle initial of the Medicare
beneficiary
Last name of the Medicare

Beneficiary's Last Name

296-335

CHAR

beneficiary including any titles or
suffixes.

'CroSS

l9l.ú.oq!:,I19lnilerosqrlgf qlenf êr,:

efglþi'ice..I,{.uniÞldr'i.(10:opoU¡renc!

'Médiò, lô.rrii-iùif¿¡;,.:,r.''.

¡'.,'.1',': :i'::'-:ì -i,r'.:

An additional beneficiary claim
account nùmber associated with
the Medicare beneflrciary. The

Cross-Reference Benefi ciary
66

Claim Account Number
(Occurrence 1)

336-344

CHAR

beneficiary's entitlement has been
cross-referenced fiom this number
to the beneficiary's active clairn
account number.
The benefi ciary's identifi cation

Cross-Reference Beneficiary
67

Identification Code
(Occurence 1)

34s-346

Claim Account Number

34'1-355

356-35'7

(Occurrence 2)
Cross-Reference Benefi ciary
69

Identification Code

code associated with the Medicare
benefi ciary's cross-referenced

claim account number.

Cross-Reference Benefi ciary
68

CHAR

See

item

66.
See item

67.

(Occurrence 2)

lìeìrrùåry 28,2018

1-t5

MMA Response File

MAPD Støte Users Guide, Version 2,0

I t"u

Iúem

Claim Account Numbe¡

l,.rg1,ta1',

358-366

367

See item

66.

(Occurrence
Cross-Reference Beneficiary
Identification Code

-368

item

See

67.

(Occurrence 3)
Cross-Reference Benefi ciary
72

Claim Account Numbe¡
(Occurrence 4)

369-377

item

See

66.

Cross-Reference Benefi ciary
73

Identification Code
(Occurence 4)

378-379

Sec itcm

67.

Cross-Reference Benefliciary

Clain Account Number

380-388

See iteu.r

oo.

(Occurrence 5)
Cross-Reference Benefi ciary
75

Identification Code
(Occunence 5)
Cross-Reference Beneficiary
Claim Account Numbc¡
(Occunence 6)

/t)

Identification Code
(Occunence 6)

Identification Code

391-399

400-401

402-410

4t t-412

Claim Account Numbe¡
(Occurence 8)

Identification Code

413-421

February

See item

See

item

66.
See item

67.
See

item

422-423

See

item

67.

Claim Account Nunber
(Occunence 9)

Identification Code
(Occunence 9)

8, 20 I 8

item

66.

(Occurrence 8)
82

See

67.

(Occurrence 7)
80

See itern

67.

Claim Account Number
(Occurence 7)

389-390

424-432

433-434

See item

66.
Scc

iterr

67.

7-16

MMA R€spolNe Filo

MAPD Slate Users Guíde, Vercion 7.0

Size

Posltíoir

435-443

444-445

446-454

Beneficiary Social Security
Number (Occurrence 2)

455-463

Beneflrciary Social Security

464-4'72

Itém

¡eld

Cross-Reference Benefi ciary
84

Claim Account Number
(Occurrence 10)
Cross-Reference Beneficiary

ldentification Code
(Occurrence

l0)

Description

Format
See item

66.

See

item

6'7.

Sòciâl
86
87
88

89
90

Beneficiary Social Security

Nutrber (Occunence

Number (Occunence 3)

Beneficiary Social Security
Number (Occurrence 4)
Benefrciary Social Security
Number (Occurrence 5)

473-481

4A2-490

NUM

The benehciary's identification

number that was assigned by SSA.

See item

86.
See

item

86.
See item

86.

Mailing Address Line I

49t-530

CHAR

1st line of address

Mailing Address Line 2

531-570

CHAR

2nd line ofaddress

Mailing Address Line

s7 t-610

CHAR

3rd line of address

Mailing Address Line 4

611-650

CHAR

4th line of address

Mailing Address Line

6s l-690

CHAR

5th line of address

Mailing Address Line

691-'130

CHAR

6th line of address

Mailing Address City Name

731-'7'70

City name

Mailing Address State Code

771-',172

CHAR
CHAR

Mailing Address Zip Code

773-781

CHAR

Postal state code

MMDDCCYY
100

Mailing Address Change Date

782-189

NUM

The date a new or coffected
address becomes effective for a

Medicare beneficiary.

Address Line

101

102

Filler

180

103

Residence Address City Name

104

Residence Address State Code

105

Residence Address Zip code

February 28, 2018

CHAR

60
850-1029
10301069

10701071

t0'721080

'7-t7

CHAR

Spaces

CHAR
CHAR
CHAR

MMA Response File

MAPD Støte (Jsers Guide, Version 7.0

It€m

Field

Size

106

Residence Address Change Date

tPo.'sitio¡i

l08l1088

Formât
NUM

MMDDCCYY
A switch

whether the
beneficiary has a representative
payee according to SSA.

t0't

Benefi ciary Representative

Values are:
1089

Payee Switch

CHAR

Beneficiary has a designated
representative payee.

N or space

beneflrciary has no

designated representâtive

for the
benefi ciary's cunent non-

entitlement status to Paft A
Medicare benefits.
Values are:
D
F

- Coverage was denied.
- Tcrminated due to invalid
enrollment or enrollment

108

Part A Non-Entitlement Status
Code

voided,
1090

CHAR

- Not eligible for free part A, or
did not enroll for prerniurn
Part A.

- Not valid SSA HIC,

but used

by CMS Third Party system to
indicate potential Part A
entitlement date.
R

Refused benefits.

Space

No non-entitlement reason

applies.
a

cuffent non-entitlement status to
Part B Medicare benefits.
109

Part B Non-Entitlement Status
Code

Values are:
1091

CHAR

- Coverage was denied,
N - Not entitled.

Refused benefits.

Space No non-entitlement

reason

applies to the beneficiary.

February 28, 2018

MMA Response File

MAPD Støte Users Gaide, Version 7.0

ryl

lt - ,

Beneficiary Entitlement Reason
Code Change Date

(Occurence I )
Benefi ciary' Entitlement Reason
111

Description

l.l

:i¡f¡9"']

ll0

Foóition

Field.

Code

(Occurence 1)

1092-

NUM

1099

I 1001103

MMDDCCYY

CHAR
See

112

Beneficiary Entitlement Reason
(Occuruence 2)

1104-

items

1115

110 and

l
See

Benefi ciary Entitlement Reason

(Occurrence 3)

items

1116-

tt27

l0 and

lll
See

t14

Benefi ciary Entitlement Reason

(Occurrence 4)

items

11281139

l0 and
111
See

115

Benefi ciâry Entitlement Reason
(Occurrence 5)

140-

items

l5l

110 and

lll
MMDDCCYY.
The date beneficiary became
116

Beneflrciary Part A Entitlement

tl52-

Start Date (Occurrence 1)

1159

entitled to Mediqare benefits.

NUM

This field is filled with zeroes ifno
Part A Entitlement Start Date is
found.

February 28,2018

1-t9

MMA Response File

MAPD State Users Guide, Version 7.0

Item

.Siiel..

i;iio¡itioì:

forrn¡1,;
The last day that beneficiary is

entitled to Medicare benefits.

Ifboth

the Part A Entitlement Start

and End Dates are fi1led with

tl7

Beneficiary Part A Entitlement
End Date (Occurrence 1)

11601167

NUM

zeroes, then no entitlement period

was found.

Ifthe Part A Entitlement Staft Date
is a valid date and the Part A
Entitlement End Date is filled with
9s, then the entitlernent has not
ended.

A
B

Equitable

Disability.

Attainment of âge 65.

relief

- General enrollment pedod.
H - Entitled based on hcalth
G

haza¡d..

- Initial enrollment period.
- MQGE entitlement.
K - Renal disease is or was a
J

reason for entitlement prior to
age 65 or 25th month of

disability.
118

Beneficiary Paft A Entitlement
Reason Code (Occurrence 1)

1168

CHAR

Late filing.

M - Termination

based on renal
entitlement but entitlement

based on disability continues.

- Age 65 and uninsured.
Potentially insured beneficiary

is enrolled for Medicare
coverage only.
Q

QuaÍers ofcoveruge
requirements are involved.

Residency requirements are

involved.
S

State buy-in.

Disabled working individual.

U * Unknown.
This held is fillcd with a space
no entitlement is found,

Februâry28,2018

-20

MMA Respo¡so File

MAPD Støte Users Guide, Version 7.0

. Sizg

' Item

.Position,

D€scription

Forinât
Values:
E

F¡ee Part A Entitlement.

G
Y

Entitled due to good cause.

Cunently entitled, premiur is
payable.

Values when there is a tennination
date:
C
I 19

Beneficiary Part A Entitlement
Status Code (Occuuence l)

1169

CHAR

No longer entitled due to

disability cessâtion.

S
T

Tenninated, no longer entitled
under ESRD provision.
for non-payment
of premiums,

- Teminated

Voluntary withdrawal from
premium coverage.

Free Pafi A terminated or
refused HI.

This field is filled with a space
no entitlement pedod is found.

See

120

Part A Entitlement

I 170-

items

(Occurence 2)

I 187

116

Same as Occurrence

119
See

121

Pafi A Entitlement
(Occunence 3)

188-

1205

items
11ó

Sarne as Occurrence 1.

tt9
See

t22

Part A Entitlement
(Occurrence 4)

1206-

items

1223

116-

Same as Occurrence

119

123

Pal1 A Entitlement

(Occurrence 5)

t224-

items

1241

ll6119

Beneficiary Part B En¡ollment
124

Staft Date

(Occurence 1)

February 28, 201E

t2421249

'7,21

MMDDCCYY
NUM

This field is filled with zeroes ifno
Part B enrollment period is found.

MMA Responsê File

MAPD State Users Guide, Version 7.0

Item

,sYg,l. t:Positión'::

Formaf

When no PaÍ B enrolhnent period
is found, this field and the Part B

Benehciary Part B Enrollment
125

End Date

(Occurrence 1)

12501257

Effollment Starl Date
NUM

are

fllled

with zeroes.

lfthere is

valid Part B

Enrollment Start Date and the
period is still active, then rhis field
is filled witlì 9s.

- Equitable relief.
C - Good cause.
D - Deemed date ofbíth.
F - Working aged.
G - General en¡olhnent period.
I - Initial enrollmcnt period.

H
K

Beneficiary Parl B Enrollment

t26

Reason Code

1258

CHAR

Health hazard.
Renal disease is or was a
reason fo¡ enrollment prior to
age 65 or 25th month of

disability.

(Occurrence 1)

M -Termination based on renal
enrollment but en¡ollment

based on disability continues.

Residency requirements are

involved,
S

State buy-in.

Disabled wor.king beneficiary.
U -Unknown.
This field is filled with a space

no enrollment is found.

February 28,2018

7-22

MM.A Respoîs€ File

MAPD Støte Useß Guide, Versíon 7.0

Field

Item

.Sizè.' ' Pobitüin

,tr'oimat

Description
Values when there is a Part B

Enrollment Start Date and no Palt

B Enrollment End Date:

G
Y

Enrolled due to good cause.
Currently eruolled, premium is
payable.

Values when Part B Eruolhnent
End Date is present:
C

Beneficiary Pafi B Effollment
l2'7

1259

Status Code

No longer entitled due to

disability cessation,
Terminated due to invalid
enrollment or enrollment

CHAR
F

(Occurrence 1)

voided.
S

Terminated, no longer entitled
under ESI{D provision,

Telminatcd for non-payment
of premiums.

Voluntary withdrawal ftom
premiuut coverage.

This held is filled with a space
no en¡ollment is found.

See

128

Parl B Effollment
(Occuruence 2)

1260-

items

127',l

124

Same as Occurrence 1.

t27.
See

t29

Part B Enrollment

(Occunence 3)

1278-

iterns

1295

t24

t27

Same as Occurrence I

See

130

Part B En¡ollment

1296-

items

313

t24

(Occurrence 4)

127

Same as Occunence I

See
131

Part B Effollment

(Occurrence 5)

t314-

items

1331

124,

Same as Occurrence 1.

127.

Beneficiary Hospice Coverage

t32

Start Date

(Occurence
Februâry 28,2018

13328

I339

NUM

This field is filled with zeroes if
beneficiary has no hospice benefit
or coverage,

-23

MMA Responso File

MAPD State Users Guide, Version 7,0

' - - -.----:
F¡eld . :'..

Item

dirùát
Ifhospice coverage has

Benehciary Hospice Coverage
133

End Date

1340-

(Occunence 1)

1347

NUM

valid

Hospice Staft Date and no Hospice
End Date, then this field is filled

with 9s.
Ifthere is no Hospice Starl Date,
then this field is filled with zeroes.
See

134

Benefi ciary Hospice Covcrage

(Occurrence 2)

1348-

items

1363

132

Sane as Occurrence

Same as Occunrence

Same as Occunence

Sane as Occurrence

133.
See

135

Benehciary Hospice Coverage
(Occurrence 3)

1364-

items

t3'79

132

133.
See

136

Beneficiary Hospice Coverage
(Occurrence 4)

1380-

items

1395

132

133.
See

t37

Benefi ciary Hospice Coverage

(Occunence 5)

1396-

items

t4It

132

l3 3.

138

Beneficiary Disability Insurance
Benefits (DIB) Entitlement Start
8

Date

(Occurence

t4t2-

l4t9

NUM

The date that a beneficiary covered
by the SSA disability program
becomes entitled to Medicare
benehts.

If no DIB Enritlement Start Date is
found, then this field is filled with
zeroes.

February28,20l8

1-24

MMA Response File

MAPD Sføte Users Guide, Version 7.0

Item

'Position

Fic!4

tr'oimàt.

Descripfion

MMDDCCYY
The date that a beneficiary covered
by the SSA disability program is
no longer entitled to Medicare
benefits.

Beneficiary DIB Entitlement
139

End Date

(Occunence

t4201427

Ifthere is
NUM

valid DIB Entitlement

Start Date and no DIB Entitlement
End Date, then this field is filled

with

9s.

Ifthere is no DIB Entitlement Statt
Date and no DIB Entitlement End
Date, then this freld is filled with
zeroes.
The Justitication code for a

beneficiary's Part A and /or Part B
Medicare benefit dates based upon
beneflrciary's DIB status.
Values:
1

prior perìods of SSA disability

Beneficiary DIB Entitlement

r40

Date Justification Code

(Occunence

Beneficiary is entitled to
Medicare coverage due to

1428

entitlement.

CHAR

Beneficiary is entitled to
Medicare based upon SSA

disability and the 24 month
waiting period has been
waived.

Beneficiary is entitled to
Medicare due to health hazard.

This held will have a space
DIB is found.

ifno

See

t4t

Beneficiary DIB Entitlement
(Occurrence 2)

1429-

items

1445

138

Sarne as Occurrence

140.
See

142

Beneficiary DIB Entitlement
(Occunence 3)

1446-

items

1462

138

Same as Occurence 1.

t40.

Februâry 28, 2018

MMA R€sponse Filc

MAPD Støte Users Guide, Version 7.0

Item

Field

lr,'Siie

Position

Forùif

llra',ÍtiY:l'./.,jìil

Managed Care

t43

MMDDCCYY.

Organization (MCO) Enrollment
Start Date

1463-

1470

NUM

(Occunence 1)

This field is hlled with zeroes if no
tnaraged care organization
enrollment is found.

MMDDCCYY.
This field is filled with
Benefi ciary MCO Enrollnent

144

End Date

zeroes

there is no managed care
1471

14',78

(Occurrence 1)

organization eff ollürent found.

NLIM
This held is filled with 9s ifrhere
is a MCO Contract Enrollment
Starl Date and no MCO Conhact

Enrollment End Date.
Unique identification for an
agreement between CMS and a
MCO. The organizations can be

distinguished by the first position:

H
9

145

Beneficiary MCO Number
(contract level)
(Occurrence l)

Local MA, local MAPD, or
non-MA Plan.
Non-MA Plan (no longer
assigned).

t4'79-

1483

CHAR

R
S

Regional MA or MAPD Plan.
Regular standalone

Prescdption Drug Plan (PDP).
Employer direct PDP.
Limited-Income Newly
Eligible Transition (LiNET).

Note: Stand-alone plans are not
included in this section. This field
is filled with spaces

ifno

enrollment is found.
See

t46

Beneficiary MCO
(Occurrence 2)

1484-

items

1504

143

Same as Occurence 1.

145.
See

147

Beneficiary MCO
(Occurrence 3)

21,

1505-

items

1525

143

Sane as Occur¡ence

145.

February 28, 2018

-26

MMA Respotìse File

MAPD Støte Users Guide, Version 7.0

Item

'Sizé,

.Posltitin

t'dimat

t526t546

items

Description

See

148

Beneficiary MCO
(Occunence 4)

1,43

Same as Occurrence I

145.
Se€

t49

Benefllciary MCO
(Occurrence 5)

1547-

items

1567

t43

Sarne as Occurrence

145.
See

1s0

Beneficiary MCO
(Occuffence 6)

1568-

items

1588

143

Sarne as Occutrence 1.

145.
See
151

Beneficiary MCO
(Occurrence 7)

589-

1609

items
143

Same as Occurrence

Same as Occu¡rence

145.
See

152

Beneficiary MCO
(Occunence 8)

1610-

iteurs

1630

143

t45.
See

153

Beneficiary MCO
(Occunence 9)

163 1-

items

1651

143

t45.
See

t54

Beneficiary MCO
(Occurrence 10)

1652-

items

16'.72

t43

Same as Occurrence 1.

145.

;yäcå4tj¡¡ ç¡ire+!!.Ð

MMDDCCYY.
155

Group Health Plan Enrollment
Stalt Date (Occurrence 1)

l-"-1

The date ofthe beneficiary's

16731680

NUM

enrollment at the contract level.
This field is filled with zeroes
there is no enrollment found,

MMDDCCYY.
The date ofthe beneficiary's

Plan Benefit Package (PBP)
156

Enrollment Start Date
(Occurrence 1)

16818

1688

effollment at the PBP level,

NUM
This field is filled with zeroes

the beneltciary has no PBP

enrollment.
February 28, 2018

-2'Ì

MMA Response Filo

MAPD Støte Users Guide, Version 7,0

Item

Field

Size.,

1!l!itro4: , Ilorqr4C,.
MMDDCCYY.
The date the beneficiary's pBp

157

enrollment ends.

Plan Benefit Package Enrollment
End Date

(Occurrence

1689-

1696

NUM

This field is hlled with zeroes
there is no PBP Start Date.

This field is filled with 9s ifthere
is a PBP Staft Date and no pBp
End Date.

A unique identifier for the
managed care plan benefit
158

package.

Plan Benefit Package Number

(Occurrence

1697

1699

CHAR

This flield contains spaces ifthe
managed care plan has no pBp. If
a Cost Plan has

no PBP, the field

contains'999'.

February 28, 2018

-2E

MMA l{esponse File

MAPD Slote Users Guide, Version 7.0

Item

Sizè

Posifioí. iFgImat

Dêscription
Identifies the type of managed care
plan benefit package in which the
beneficiary is enrolled.
Values:

Pay

bill option not found for

this contract.
03 - CCP (Coordinated Care PlaQ.
04 - MSA (Medicare Medical
Savings Account).

5 - PFFS (Private Fee For
Service).

6 - PACE (Program ofAll
Inclusive Ca¡e for the
Plan Benefit Package Coverage
159

Tlpe Code
(Occunence

17001701

Elderly).

CHAR

7
8
09
l0

Regional.
Demo (Demonshation).
FFS (Fee For Service).
Cost / HCPP (Health Ca¡e

Prepayment Plan).
I

I - PDP (Part D Drug Plan)
Election).

12- Chronic Care Demo.
13 - MSA (Medicare Medical
Savings Account)

Demonstration.

MMP(MedicareÀ4edicaid
Plan).

This field is filled with spaces
PBP effollment is found.

ifno

See

r60

PBP Effollment

(Occunence 2)

1702-

items

1730

155

Same as Occurrence

Same as Occurence

Same as Occur¡ence

ls9.
See

l6l

PBP Enrolhnent
(Occurrence 3)

1731.
17

items
155

159.
See

162

PBP Enrollment
(Occurrence 4)

t7 60-

items

1788

155

159.

February 28,2018

7-29

MMA Responso File

MAPD Stste Users Guide, Version 7.0

It€m

Field

t,l¡"ò.,

lPositiôä

.r:,

:,
.

Fórmat

, : :.

Descl¡ption';

See
163

PBP Effollment

(Occunence 5)

1789-

items

1817

155

Same as Occurrence I

159.
See

164

PBP Eruollment
(Occurrence 6)

1818-

items

1846

155

Same as Occurrence 1.

159.
See

165

PBP Enrollment
(Occurrence 7)

t847 -

iterns

1875

155

Sarne as Occurrence I

159.
See

166

PBP Enrollment
(Occurrence 8)

187

904

items
155

Sarne as Occurrence

ls9.
See

t67

PBP Effollment
(Oocunence 9)

1905-

items

1933

155

Same as Occur¡ence 1.

159.
See

168

PBP Enrollment

(Occunence 10)

1934-

items

t962

155

Same as Occurrence

159.

M MDDCCYY,

t69

Benefi ciary ESRD Coverage

1963-

Start Date

1970

The date on which the beneficiary
is entitled to Medicare in some part

NIÃ4

because

ofa diagnosis ofEnd

Stage Renal Disease.

This field is hlled with ze¡oes if
beneficiary has no ESRD coverage.

MMDDCCYY.
The date on which the beneficiary
is no longer entitled to Medicare

t70

Benehciary ESRD Coverage

1971.

MMDD

End Date

1978

CCYY

under ESRD provision.

This field is filled with zeroes if
beneficiary has no ESRD coverage.
This field is filled with 9s ifthere
is no ESRD Coverage Eud Date.

Fehnìary 28,2018

-30

MMA Response ¡ile

MAPD Slate Users Guide, Vercion 7.0

Descript¡on

X'ield

Item

The reason Medicare ESRD
coverâge was terminated.
Values:

Month oftransplant plus 36
months,

171

Benefi ciary ESRD Tetmination

Reason Code

t979

CHAR

B
C
D
E

Last month ofchronic dialysis,
Part A termination,
Death, and

ESRD ended.

This flreld is filled with spaces

benehciary has no ESRD coverage
or ifthere is no ESRD Coverage
End Date.

:Eû(
oce

MMDDCCYY,

Benehciary ESRD Clinical

The date when ESRD tlialysis

Dialysis Start Date

(Occurrence 1)
172

C)ccurrence 1 is the latest

19808

t987

starts.

NUM
This field is filled with zeroes

dialysis period if rnultiple

beneficiary has no ESRD Dialysis

periods exist.

Staft Date.

MMDDCCYY.
The date when ESRD dialysis
ends.

Benefi ciary ESRD Clinical
173

Dialysis End Date
(Occunence 1 )

19888

1995

NUM

This field is filled with zeroes if
beneficiary has no ESRD Dialysis

Staf Date.
This field is filled with 9s if there
is no ESRD Dialysis End Date.

174

Benefi ciary ESRD Transplant

1996-

Start Date

2003

The date that a kidney transplant

NIIM

operation occùraed. This field is
flrlled with zeroes when no ESRD

Transplant Start Date is found.

February 28,2018

-3t

MMA Respo

Filo

MAPD Støte Users Guide, Version 7.0

Item

The date that a kidney hansplant
fails or transplant benefit ends.

175

Benefi ciary ESRD Transplant

End Date

20042011

NIJM

This field is filled with zeroes
when no ESRD Transplant Staft
Date is found.

This field is fi1led with 9s when
there is a valid ESRD Transplant
Start Date and there is no ESRD

Tmnsplant End Date.

176

Beneficiary Part A Third party
Stalt D¿tc
(Occunence l)

20122019

MMDDCCYY.
The start date ofa private third
paúy gloup's or State,s liability for
NUM

beneficiary's Part A premium.

This field is filled with zeroes

there is no Part A Third Party Start
Date.

identiher
Party
agency (either a private group or
State buy-in agency) responsible
Beneficiary Part A Third party
177

Prenium Payer Code
(Occurrence 1)

20202022

CHAR

for paying a benehciary's
Medicare Part A premiurn.
Values:
S01 rhIu S99 - State Bi ing and
T01 thrl 298 - Private Third parry

Billing
The end date ofa private third
pafty goup's or State,s liability for
a beneficiary's Part A premium.

Beneficiary Part A Third party
178

End Date

2023-

(Occurrence 1)

2030

NT]M

This field is filled with zeroes ifno
Part A Third Paúy Start Date was
found.

This field is filled with 9s ifthere
is a Third Party Start Date and no

Thixl Party End Date.

Beneficiary
179

A Third Party
Buy-in Eligibility Code

203

(Occurrence

Febn¡ary 28, 2018

1-32

CHAR

This data element is obsolete.

MMA Response

Þ-ile

MAPD State Users Guide, Version 7.0

.':

Item

Size

' .Pqsitiòn

tr'o¡mat

Description

See

180

Third Party Pârt A Histoly
(Occurrence 2)

2032-

items

2051

176

Same as Occunence

179.
See

Third Parly Part A History
(Occurence 3)

2052-

items

2071

176

Same as Occurrence I

179.
See

182

Third Pafiy Parl A History
(Occunence 4)

2072-

items

209t

t'76

Same as Occurence

Same as Occurrence

179.
See

Third Party Part A History
(Occurrence 5)

2092-

items

2ttl

176

179,

MMDDCCYY.
The stal1 date of a private third

party group's or State's liability for

Beneficiary Part B Third Party
184

Start Date

2112-

2lt9

(Occurrence 1)

NUM

a Pafi

B premium.

This field is filled with zeroes

ifno

Part B Third Party benefit is found

for the beneficiary.

Febroary 28,2018

-33

MMA l{esponse File

MAPD Støte Users Guùle, Version 7.0

Item

Fietd

l.,Sit;'' Position

'Forùa1,:
The identifier for a third palty
agency (either a private group,
State buy-in agency or the Office
of Persomel Management (OPM))
responsible for paying a
benehciary's Medicare Part B
premiurn.

Values:

0
185

Beneficiary Part B Third Party
Premium Payer Code
(Occurrence 1)

2tz02122

Bcncficiary is having Part B
premiutn deducted fiom

CHAR

Title iI check,

I
005

Uninsuredbenefìciary,

006

- Insured beneficiary,
- Program Service Center

007

Special age 72 enrollee,

008

PSC annual billing,

control, no bill,

010
700 -

650

State

billing,

Office ofPersonnel
Managernent (OPM), and

401

R99

Group payers for Part

B premiums.
MMDDCCYY.

186

Beneficiary Part B Third Party
Termination Date
(Occurrence 1)

The end date ofa private third
party group's or State's liability for
a benehciary's Paft B premium.

21232130

NUM

This held is filled with zeroes if no
Pal1 B Third Parry Sart Date is
found,

This field is filled wirh 9s if there
is a Third Pafty Start Date and no
Third Paty End Date.

Þ-ebruâry

28,2018

MM^

Response Filc

MAPD Støte Users Guide, Version 7.0

Item

lize

.Positidn

D€scriptiol

'F:ôrmal

Reason for Part B State buy-in

eligibility. Vatues:
A

Aged recipient of SSI
payments (CMS to State).

Blind recipient of SSI
payments (CMS to State).

Entitled to Part A of Title IV
(TANF) (Srare to CMS).
Disabled recipient ofSSI
payments (CMS to State).

Aged recipient ofsupplemental

payment administered by SSA
(CMS to State).
F

- Rlind recìpient of supplemental
payrnent administered by SSA

(CMS t0 State).
G

Benehciary Part B Third Paty
187

Buy-in Eligibility Code

2131

CHAR

(Occurrence 1)

Disabled recipient of
supplemental payment
administered by SSA (CMS to
State).

Aged, blind, or disabled
recipient of a one-time
payment (OTP) (CMS to
State).

Speciflred Low Income

Beneficiary (SLMB).

Entitled to medical assistance
only (MAO), non-cash
recipient (State to CMS).

Qualified Medicare
Beneficiary (QMB).

Qualifred Individual One (QI-

l).

Deemed categorically needy

(stare to cMs).
Note: States can use any other
alphabetic character.
See

188

Third PaÍy Part B History
(Occurrence 2)

2132-

items

2t5t

184

Same as Occurrence 1.

187.

Fobruary 28, 2018

'7,35

MMA Response Filo

MAPD State Users Guide, Versíon 7.0

Item
,rS-ize'

. 'Þosittoñ

lFórm¿
See

189

Third Party Part B History
(Occuuence 3)

2152-

items

2171

184

Same as Occurrence 1.

187.
See

190

l',,
[.*t

Thjrd Parb/ Part B History
(Occurence 4)

Third Party Part B History
(Occunence 5)

2t72-

items

2191

184

t87

2192-

items

2211

r84

Satne as Occurrence l

Same as Occurrence

187.

The date when the beneficiary
becomes eligible for Part D
benefits.

192

Benehciary Part D Eligibility

2212-

Start Date

2219

This field is filled with zeroes
Part D Starl Date is found.

NUM

ifno

This field indicates eligibility only,
not effollment in a plan with drug
coverage.

If there are multiple Part D
eligibility periods, then this field

will contain the earliest Parl D
Start Date.

that

chooses not to be automatically

enrolled by CMS into a part D
193

Beneficiary Paxt D Opt-Out
Indicator

plan.
2220

CHAR
Values:

- Yes.
N-No.
Space No.

Februâry 28,2018

't -36

MMA Response File

MAPD Støte Users Guide, Version 7.0

Item

süel,:

.Pôsitión.

Foi.mat

Description

A code indicating whether the
benefi ciary was determined

eligible for low-income subsidy
194

Benefi ciary Co-Payrnent T¡'pe

(Occunence

2221

CHAR

(LIS) or deemed eligible.
Values:

L
D

Determined eligible.
Deemed,

An indicator providing the level of
co-payment granted to the
beneficiary.
Values:
195

Ifbene co-pay type is 'L', then

Beneficiary Co-Payment Level
(Occurrence 1)

2222

CHAR

4
lf

high.

t5%.

bene co-pay type is

2
3

'D',

then:

high.

low.
0 (zero).

MMDDCCYY.
Beneficiary Co-Payment Start
196

Date

¿2258

2230

(Occuuence 1)

The effective date ofthe co-

NUM

payment period. This held is filled

with zeroes ifthere is no CoPayment Start Date.

MMDDCCYY.
The end date ofthe co-paynent

period.
Benehciary Co-Payment End
197

Date

223t2238

(Occurence 1)

NUM

This field is filled with zeroes

there is no Co-Payment Start Dâte.

This field is f,rlled with 9s ifthere
is a Co-Payment Starl Dâte and no
Co-Payment End Date.
See

198

Beneficiary Co-Payment History
(Occunence 2)

2239-

items

2256

t94

t97

Same as Occurrence 1.

See

t99

Benefi ciary Co-Payment History

(Occurrence 3)

2257-

items

22'74

194

Same as Occurrence I

197.

Februåry 28,2018

-3'l

MMA Response File

MAPD State Users Guide, Version 7.0

Item

Fiètd

200

Benefi ciary Co-Payment History
(Occurrence 4)

ri$i¿çr,,, '."òóiiiôñ.'
..'.:,,.1._.r"'

.,r.iirntat:
See

2275-

items

2292

t94

t9'7

History

(Occurrence 5)

2293-

items

23r0

194

197

History

Same as Occurrence

Same as Occunence

Same as Occurrence

See

Benefi ciary's Co-Payment

202

See

Benehciary's Co-Payment
201

Same as Occur¡ence

(Occurrence 6)

23tt-

items

2328

194
t97.
See

Benefi ciary's Co-Payrent

203

History

(Occuuence 7)

2329-

iterns

2346

194

t97

See

Benefi ciary's Co-Payment

204

History

(Occuuence 8)

2347 -

items

2364

t94

Same as Occunence 1.

t97.
See

Beneficiary's Co-Payment
205

History
(Occurence 9)

2365-

items

2382

t94

197

See

Benehciary's Co-Payment
206

Same as Occunence 1.

History

2383-

items

(Occunence 10)

2400

t94
197

Same as Occurrence

Unique identification for an
201

Benefi ciary Contract Nunber

(Occunence 1)

2401.
2405

CHAR

agreement between CMS and a
MCO or PDP sponsor enabling the
Plan to provide Medicare Paú D
prescription drug coverage,

MMDDCCYY.

208

Beneficiary Part D PBP
Enrollment Staft Date
(Occunence l)

February 28, 20i

24062413

NUM

The date thâf the beneficiary was
enrolled in the plan benefit
package.

This held is filled with zeroes if no
MAPD or Part D PBP enrollment
is lound for the benehciary

1-38

MMA Rosponse File

MAPD Støte Usets Guíde, Version 7.0

'Positioä

Item

;Formât

Descrþtion

MMDDCCYY.
The end date ofthe beneficiary's

enrollment in the plan benefit
package.

Beneficiary PaIt D PBP
209

Effolhnent End Date
(Occurence 1)

24t42421

NUM

This field is filled with zeroes if
there is no Patt D PBP En-rollment
Start Date.

This field is hlled with 9s if there
is a Parl D PBP En¡ollment Start
Date and no Pai:t D PBP

En¡ollurent End Date.
Bcnoficiâry Part D PBP Plan

2t0

Number

(Occurence

Feb¡uary 28, 2018

2424

-39

CHAR

A unique identifier for the
managed care benef,tt package.

MMA Response File

MAPD Støte Users Guide, Versbn 2.0

Item
providing

type

enrolhnent performed.
Values:

A - Auto enrolled by CMS.
B - Beneficiary election.
C

Facilitated enÌolhnent by
CMS.

System-Generated effollment

(Rollover).
E

Plall submifted âutoen¡ollments,

2tl

Plan subnitted facilitated
enrolhnents.

Point ofSale (POS) sübmitted

CMS or plan submitted reassignment enrollments.

Benefi ciary Enrollnent T¡'pe

enrollments.

Code

2425

CHAR

(Occunence I )
I

- Non-MMP

Plan submitted
transactions with enrollment
source other than any

ofthe

following: B, E, F, G, and
blank

State submitted MMP passive

effollment.
K

CMS submitted MMP passive
emollment.

Beneficiary MMP election.
M - Default for FA Demo plan
enrollments submitted without
an Enrollment Source Code

(M is not submitted on an
enrolhnent).
See

212

Part D Plan Benefit package
(Occurrence 2)

2426-

items

2450

20'7

Same as Occurrence I

211.
213

Part D Plan Benefit Package
(Occurrence 3)

2451-

items

2475

207

Same as Occu.rence I

211.

Februa¡y 28, 2018

7-40

MMA Response File

MAPD Slø\e Users Guide, Versìon 7.0

Item

Positiätt" ¡ ryqrùat

Description

See

2t4

Part D Plan Benefit Package
(Occurrence 4)

2476-

items

2500

207

Same as Occurrence

Same as Occur¡ence

Same as Occurrence

2tl.
See

2t5

Part D Plan Benefit Package

(Occunence 5)

2s01.

items

2525

207

21r.
See

216

Part D Plan Benefit Package
(Occuruence 6)

2526-

iteurs

2550

207

21t.
See

2t7

Part D Plan Bcncfit Package
(Occurrence 7)

255t-

iterns

257 5

207

2ll.
Scc

218

Part D Plan Benefit Package
(Occurrence 8)

25762600

items
207

Same as Occur¡ence 1.

2lr.
See

219

Parl D Plan Benefit Package
(Occurrence 9)

260t-

items

2625

207

Same as Occurrence

Same as Occurence

2tt.
See

220

Part D Plan Beneltt Påckage

(Occunence 10)

2626-

items

2650

207

211.
Relates to the first occurrence
221

Part C Organization Name

(contract level)

265t2705

CHAR

the beneficiary's MCO conftact
number in item 145 (positions

t479-1483).
222

PaÍ C PBP Name

270627 55

Relates to the first occutence

CHAR

tbe beneficiary's PBP in item 158

(positions \ 697 -1699).
Relates to the first occurrence

223

Part D Organization Name

2'156-

(conûact level)

2810

Part D PBP Name
225

Part D Organization Plan Benefit

February 2E,2018

2811.
2860
2861

-41

CHAR

the beneficiary's contract number

in Parl D PBP in item 207
(positions 2401-2405).
Relates to the flirst occurrence

CHAR

the beneficiary's PBP in itern 210

CHAR

This field is filled with a space.

(po sitiors 2422 -2 424).

MMA Responso File

MAPD Støte Ilsers Guíde, Version 7.0

Item

F¡etd

.'''.1

,S¡i",

rì.Positidn.

.E;;,t;¿
identifies
that the beneficiary requested SSA
to use for beneficiary notices.
Values:

Blank
226

Benefi ciary Language Indicator

2862

- English assumed for
Non-Puerto Rican ZIp codes

CHAR

and Spanish assurned for
Puerto Rican ZIP codes.

English requested (allowed
only for Puerto Rican Zlp
codes).

requested.

Indicates

enrolled in a special needs plan.
Special Needs Plan (SNp)

227

Values:

Indicator
(Occurrence 1)

2863

CHAR

- Not SNP.

SNP, and

Corresponds to the first occurrence
ofplan benefit package in item 159

(positions 1700-1701),
228

Saure as Occunence 1.

SNP Indicator

2864

(Occuuence 2)

See

item

227

Corresponds to Occurrence 2 of
plan benefit package in item l60

(positions
229

230

SNP Indicator
(Occunence 3)

as
1

2865

item

227.

02-1730\,

Coresponds to Occurrence 3 of
plan benefit package in item 161
(positions 1731-17 59).
Same as Occurrence I

SNP Indicator

(Occunence 4)

See

Occurence

2866

See itern
227

Corresponds to Occurrence 4 of
plan beneflrt package in item 162
1760-1788).

231

as Occurrence

SNP lndicator

(Occurence 5)

2867

See

item

227

Corresponds to Occurrence 5 of
plan benefit package in item 163

(positions 1789-1817).
232

Same as

SNP lndicator

(Occunence 6)

2868

See

itern

227.

Corresponds to Occurrence 6 of
plan benefit package in itenr 164

(positions 1818-1846).

Februâry 28,2018

7-42

MMA l{esponse File

MAPD Stafe Users Guide, Versìon 7,0

Item

ield

PòÌ¡itibn

'tr'orùat

Description
Same as Occunence 1.

233

SNP Indicator

2869

(Occurrence 7)

See item
227

Corresponds to Occurence 7

plan benefÍ package in item 165

(positions 1847-1875).
Same as Occurrence

234

SNP Indicator

(Occurence 8)

2870

See item

227.

Coresponds to Occurrence 8 of
plan benefit package in item 166
(positions 187ó-1904).
Same as Occunence 1.

235

SNP Indicator

2871

(Occurrence 9)

See

iten

227

Corresponds to Occurrence 9

plan beneht package in item 167

(positions 1905-1933).
Same as Occuffence

236

SNP Indicator
(Occurence 10)

2872

See

item

227

Conesponds to Occurence 10

plan benefit package in item 168

(positiorrs

I 93 4 - I 9

62).

This date is provided solely to
show why a dual eligible is not

Medicare Plan Ineligibility Due
237

to Incarceration Stafi Date

(Occurence

28732880

auto-effolled.

NUM
Ifthere is no Medicare Plan
Ineligibility Due to Incarceration
Start Date, then this field is fil1ed

with zeroes.

Februâry 28,2018

-43

MMA Response t-ile

MAPD Støte Users Guide, Version 7.0

f ield

Item

r's.¿e

,Pôsitidnr.

¡¡4òry.ra1r

..,

':'

Þ.ese.ipqon

,..

MMDDCCYY.
This date is provided solely to
show why a dual eligible is not
auto-enrolled.

If there is no Medicare Plan
Ineligibility Due to Incarceration
238

Starl Date and no Medicare Plan

Medicare Plan Ineligibility Due
to Incarceration End Date
(Occurrence I )

2881.
2888

NIIM

Ineligibility Due to Incarceration
End Date, then this field is filled
with zeroes.

Ifthere is

Medicare Plan

Ineligibility Due to Incarceration
Staft Date and no Medicare Plan

Ineligibility Due to Incarceration
End Date, then this field is hlled
with
239

Filler

2889-

2899

CHAR

9s.

Spaces.

Code tlìat irìdical.es how

beneficiary was last classified in
enrollment and disenrollment
counts for the Eligibility
Month,/Year of this ¡ecord,
Values:

E
D

240

Previous Month SPD

Calculation Code

C
2900

Enrollment count,
Disenrollment count,

Cany forward enrollment
count,

CHAR

M -Missing state file (counted

effollment),N

Not counted

(this also indicates future
Medicaid DET records),
P

Prospective Duals, not
considered in Clawback
counts, and

Space

No historical entries found

for this Eligibility
Montb/Year,

Februâry 28,2018

-44

MM,4 Response File

MAPD State Users Guide, Version 7.0

process
was able to match the Detail record

in the related Request file under
the Secondary Beneficiary Match

algorithm. This algorithm uses
values for the following fields

ftom the beneficiary's Detail
record in the Request file:

Individual Medicare
Identiher (i.e., the HICN,
RRB Number or MBI) and/or
the Indiviclual SSN.

First six characters ofthe

Individual Last Name.

First letter of the Individual
First Name.

Sex Code.

The process

241

Secondary Match Indicator

2901

CHAR

will retum one of the

following values:

Space The process found a
match for the beneflrciary, but

it did not use the Secondary
Benefi ciary Match algorithm

to do so or the process did not

find

a uratch

for the

beneficiary.

The process used the

Secondary Beneficiary Match

algorithm to match the
benefrciary).
Note: A matched detail record is
indicated by the presence

alphanumeric values in the fields
'Benefi ciary Claim Account

Number' and'Beneficiary
Identification Code' (fields 58 and
59) and a Record Return Code

(RRC) of '000000' or '000001'.

F€bruary 28,2018

'1-45

MMA Response File

MAPD State Userc Guide, Version 7.0

Item

ti!.u;

,[',t1"+q'.,

Description
how
beneficiary is counted in
enrollment and diseffollment
counts for this record.
Values:

E
D
242

Daily State Phase-Down
Calculation Code

C
1

2902

CHAR

Enrollment count,
Disenrollment count,

- Carry forward

effollment

coùnt,

Missing state file (counted

enrolhnent),
N

- Not counted

(This also

includes future Medicaid DET
records), and

Prospective Duals, not
considered in Clawback
counts.

Iai¡iúIlfÍèûc(

MMDDCCYY.
243

RDS Start Date

(Occurence

29032910

The start date ofthe beneficiary,s

NUM

enrollment in employer plan.

Ifthere is no RDS Start Date, then
this held is hlled with zeroes.
The end date offhe beneficiary,s

effollment in employer plan.

If there
244

RDS Ten¡ination Date

(Occunence

291t.
2918

are multiple RDS coverage

periods, overlapping dates are

NUM

possible.

Ifthere is no RDS Staft Date, then
this field is filled with zeroes.

Ifthere is a RDS Start Date and no
RDS End Date, then this field is

filled with

9s.

See

245

RDS Coverage Period
(Occurrence 2)

29t9-

items

2934

243

Sarne as Occur¡ence I

244.

Fehnrary 28, 2018

7-46

MMA RespoDse File

MAPD Støte Users Guide, Yersion 7.0

Pqsition

Item

Description

.Fdrmât
See

246

RDS Coverage Period
(Occurence 3)

2935-

items

2950

243

Sarne as Occurrence I

244.
See

247

RDS Coverage Period
(Occurrence 4)

2951.

items

2966

243

Sarne as Occunence I

244.
See

248

RDS Coverage Period
(Occurrence 5)

2967-

items

2982

243

2983

CHAT{

Sarne as Occuffence

244.

Filler

Spaces.

Indicates the date that beneficiary

250

Palt D Eligibility Stârt Date
(Occurrence 1)

29842991

became eligible for Part D benefits.

NUM
This held is filled with zeroes if no
Part 8D Eligibility Start Date is
found.
Indicates the date that beneficiary
is no longer eligible for Part D
benefits.

25l

Part D Eligibility End Date

(Occurrence 1)

29922999

This field is filled with zeroes

NUM

ifno

Pat D Eligibility Start Date is
found.
This field is filled with 9s if there
is a Pafi D Eligibility Start Date
and no Part D

Eligibility End Date.

See

252

Part D Eligibility Dates

(Occunence 2)

3000-

items

3015

250

Same as Occurrence

251.
See

253

Part D Eligibility Dates

(Occurence 3)

3016-

items

3031

250

251.
See

254

Part D Eligibility Dates
(Occurrence 4)

items
3047

250

251.

Fcbruary 28,2018

7-4'7

MMA Response File

MAPD Stste Users Guide, Version 7.0

Item

Field
|

255

S¡¿e:,

.:!.
' ''

Part D Eligibility Dares

ì,:

.Poòitión

(Occunence 5)

Ì'o¡niàt

3048-

items

3063

250

Sar¡e as Occurrence I -

251.

--lInfo¡m¡ l!þ¡i(l:q,úi

.currences)

poÍion ofthe Part
Premium subsidized.
Values:
100

o75
256

Subsidy Level
(Occunence 1)

3064-

3066

050

CHAR

02s
Relates to the numbered

-occurences ofthe Beneficiary

Co-

Payment History, e.g. first
oçcuüence here relates to first
occurrence of Co-Payment in item
195 (pos\tíon 2222).
source

LIS/Deeming action found in CoPaynent History Occurrence, itenr
194 (position 2221) and Subsidy
Level, item 256 (position3064).
Values for D (Deemed):

02 01

) \'7

LIS/Deern Source code
(Occurrence 1)

3067-

3068

CHAR

MBD Third Pafty.
EEVS (State data baseline).

03 _ SSA.

4 - State.
5 - Point ofSale.
06

CMS User.

Values for L (LIS):

ss - ssA.
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File Modified 0000-00-00
File Created 2018-04-12

File Type	application/pdf
File Modified	0000-00-00
File Created	2018-04-12