Track Change: User Guide

MAPD SUG 2018 to 2023 tracked changes.docx

State Data for the Medicare Modernization Act (MMA) (CMS-10143)

Track Change: User Guide

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Medicare Advantage Prescription Drug

State User Guide

Version 11.0

February X, 2023

Map of the United States, including Puerto Rico.

























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Change Log

Section

Changes

Global

Updated the version to 11.0.

Updated the publication date to February X, 2023.

Updated Table of Contents, Figures, and Tables.

1 – Introduction


2 – Using MARx UI


3 – Entitlement, Enrollment, Disenrollment Codes

  • Added Enrollment Reason Code ‘P,’ Medicare Part B Immunosuppressive Drug (Part B-ID).

4 – Technical Instructions for Submitting Files


5 – State MMA Request File Timing and Content

  • Added new Section 5.8: Part B Immunosuppressive Drug (Part B-ID).

6 – MMA Request File


7 – MMA Response File

  • Added Part B Enrollment Reason Code ‘P,’ Medicare Part B Immunosuppressive Drug (Part B-ID), to the MMA Response File Detail Layout.

8 – BEQ Request File


9 – BEQ Response File


10 – TBQ Request File


11 – TBQ Response File

  • Added Part B Enrollment Reason Code ‘P’, Medicare Part B Immunosuppressive Drug (Part B-ID), to the TBQ Response File Detail Layout.

12 – Puerto Rico Dual Eligibles File


13 – Glossary, Acronyms, State Codes




























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Table of Contents



Change Log i

Table of Contents ii

List of Figures iv

List of Tables vi

1 Introduction 1-1

1.1 Document Overview 1-1

1.2 Document Organization 1-1

1.3 Contacting the MAPD Help Desk 1-2

2 Medicare Advantage Prescription Drug User Interface (MARx UI) System 2-1

2.1 Getting Started 2-1

2.1.1 Register in IDM 2-1

2.1.2 Request the State User role for MARx UI 2-2

2.1.3 Logging into MARx UI as a State User 2-3

2.2 Using the MARx UI Screens 2-4

2.2.1 General Properties of Screens 2-4

2.2.2 Common Features of the Screens 2-4

2.2.3 Common Characteristics of the Screens 2-4

2.2.4 Typographical Conventions 2-6

2.2.5 Common Buttons, Links, and Fields 2-6

2.3 Navigating the MARx UI 2-8

2.3.1 How Do I Get Where I Want To Go? 2-8

2.3.2 Navigating Menus, Sub-menus, and Screens 2-8

2.3.3 Error Message Screens 2-9

2.3.4 Screens Available for the State User 2-9

2.3.5 Logging on and Viewing Messages 2-10

2.4 Viewing Beneficiary Information 2-14

2.4.1 Finding a Beneficiary 2-14

2.4.2 Viewing Summary Information about a Beneficiary 2-17

2.4.3 Viewing Detailed Information for a Beneficiary 2-18

2.4.4 Viewing a Snapshot of Beneficiary Information 2-19

2.4.5 Viewing Enrollment Information 2-23

2.4.6 Viewing Additional Insurance Information 2-29

2.4.7 Viewing Low-Income Subsidy (LIS) Information of a Beneficiary 2-33

2.4.8 Viewing Eligibility Information for Beneficiaries 2-35

2.4.9 Viewing Status Activity and Detail Information for Beneficiaries 2-41

2.4.10 Logging Out of the Medicare Advantage and Part D Inquiry System 2-49

2.4.11 Validation Messages 2-50

3 Entitlement Status, Enrollment, and Disenrollment Reason Codes 3-1

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

4.1 State Monthly MMA File Submission Requirements 4-1

4.2 Dual Eligible Enrollment 4-2

4.3 State Phased-Down Calculation 4-2

4.4 State Low-Income Subsidy (LIS) Applications 4-2

5 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 Current DET Records 5-3

5.2.2 Retro DET Records 5-3

5.2.3 Future DET Records 5-6

5.2.4 LIS Records 5-6

5.2.5 PRO Records 5-6

5.3 Prospective Full-Benefit Dually Eligible Individuals 5-7

5.4 PRO Enrollment Process 5-7

5.5 Submission of PRO Records 5-7

5.6 Processing of Returned PRO Records 5-8

5.7 Dual Status Codes 5-9

5.8 Part B Immunosuppressive Drug (Part B-ID) 5-10

6 MMA Request File 6-1

6.1 Special Key Fields/User Tips for the MMA Request File 6-1

6.1.1 Beneficiary Matching Criteria 6-1

6.1.2 Institutional Status Indicator 6-1

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 MMA Response File 7-1

7.1 MMA Response File Specifications 7-1

7.2 Special Key Fields/User Tips for the MMA Response File 7-1

7.2.1 Medicare Part D Enrollment Indicator 7-1

7.2.2 Managed Care Organization (MCO) (10 Occurrences) 7-2

7.2.3 Plan Benefit Package Enrollment (10 Occurrences) 7-2

7.2.4 Part D Plan Benefit Package (10 Occurrences) 7-3

7.3 MMA Response File Dataset Naming Conventions 7-4

7.4 MMA Response File Header Record Layout 7-4

7.5 MMA Response File Detail Record Layout 7-6

7.6 MMA Response File Summary Record Layout 7-57

7.7 MMA Response File Monthly Summary Record Layout 7-60

7.8 MMA Response File Trailer Record Layout 7-62

8 Batch Eligibility Query (BEQ) Request File 8-1

8.1 BEQ Request File Dataset Naming Conventions 8-1

8.2 BEQ Request File Header Record Layout 8-1

8.3 BEQ Request File Detail Record Layout 8-3

8.4 BEQ Request File Trailer Record Layout 8-4

8.5 Sample BEQ Request File E-mail Acknowledgments 8-5

9 Batch Eligibility Query (BEQ) Response File 9-1

9.1 BEQ Response File Dataset Naming Conventions 9-1

9.2 BEQ Response File Header Record Layout 9-1

9.3 BEQ Response File Detail Record Layout 9-2

9.4 BEQ Response File Trailer Record Layout 9-16

10 Territory Beneficiary Query (TBQ) Request File 10-1

10.1 TBQ Request File Dataset Naming Conventions 10-1

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 Layout 10-2

11 Territory Beneficiary Query (TBQ) Response File 11-1

11.1 TBQ Response File Dataset Naming Conventions 11-1

11.2 TBQ Response File Header Record Layout 11-1

11.3 TBQ Response File Detail Record Layout 11-2

11.4 TBQ Response File Trailer Record Layout 11-24

12 Puerto Rico Dual Eligibles File Process 12-1

12.1 Puerto Rico Dual Eligibles Request File Dataset Naming Conventions 12-1

12.2 Puerto Rico Dual Eligibles Request File Header Record Layout 12-1

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 12-3

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

12.7 Puerto Rico Dual Eligibles 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 – E-mail Acknowledgement 12-5

13 Glossary, List of Acronyms, and State Codes 13-1



List of Figures



























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List of Tables

Table 2‑1: Typographical Conventions 2-6

Table 2‑2: Common Buttons and Links 2-6

Table 2‑3: Common Fields 2-7

Table 2‑4: Main Menu Items 2-8

Table 2‑5: State User Screen Lookup 2-9

Table 2‑6: M002 Screen Messages 2-11

Table 2‑7: State User (M101) Field Descriptions and Actions 2-13

Table 2‑8: State User (M101) Screen Messages 2-13

Table 2‑9: State User (M201) Field Descriptions and Actions 2-15

Table 2‑10: State User (M201) Screen Messages 2-16

Table 2‑11: State User (M202) Field Descriptions and Actions 2-17

Table 2‑12: State User (M202) Screen Messages 2-17

Table 2‑13: Menu Items for Viewing Beneficiary Detail Information 2-18

Table 2‑14: State User (M203) Field Descriptions and Actions 2-20

Table 2‑15: State User (M203) Screen Messages 2-22

Table 2‑16: State User (M204) Field Descriptions and Actions 2-23

Table 2‑17: State User (M204) Screen Messages 2-24

Table 2‑18: State User (M222) Field Descriptions and Actions 2-25

Table 2‑19: State User (M222) Screen Messages 2-26

Table 2‑20: State User (M244) Field Descriptions and Actions 2-27

Table 2‑21: State User (M244) Screen Messages 2-28

Table 2‑22: Additional Insurance Information (M251) Field Descriptions and Actions 2-29

Table 2‑23: Additional Insurance Information (M251) Screen Messages 2-32

Table 2‑24: Low-Income Subsidy (M252) Field Descriptions and Actions 2-33

Table 2‑25: State User (M252) Screen Messages 2-34

Table 2‑26: State User (M232) Field Descriptions and Actions 2-36

Table 2‑27: State User (M232) Screen Messages 2-39

Table 2‑28: Status Activity (M256) Field Descriptions and Actions 2-42

Table 2‑29: Status Detail (M257) Field Descriptions and Actions 2-45

Table 2‑30: Status Detail (M257) Screen Messages 2-48

Table 2‑31: State User Logout Screen Field Descriptions and Actions 2-50

Table 2‑32: State User Logout Screen Messages 2-50

Table 2‑33: Validation Messages 2-50

Table 3‑1: Part A – Entitlement Status Codes 3-1

Table 3‑2: Part A – Non-Entitlement Status Codes 3-1

Table 3‑3: Part A – Enrollment Reason Codes 3-1

Table 3‑4: Part B – Entitlement Status Codes 3-2

Table 3‑5: Part B – Non-Entitlement Reason Codes 3-2

Table 3‑6: Part B - Enrollment Reason Codes 3-3

Table 3‑7: Disenrollment Reason Codes 3-3

Table 13‑1: Glossary 13-1

Table 13‑2: Acronyms Used in this Document 13-3

Table 13‑3: State Codes 13-5



  1. Introduction

    1. Document Overview

The Medicare Advantage Prescription Drug (MAPD) State User Guide (SUG) provides information for all of the fifty states, the District of Columbia, and the US Territory Medicaid Agency users regarding the use of the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Prescription Drug System (MARx). CMS developed the SUG specifically 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 dually eligible enrollment, and to request eligibility, entitlement, and enrollment information.

    1. Document Organization

Section 1 Introduction- provides general information about the organization and content of this document.

Section 2 Using the Medicare Advantage Prescription Drug User Interface (MARx UI) System- provides information for state users to access enrollment, eligibility, and 4Rx information for beneficiaries.

Section 3 Entitlement Status, Enrollment, and Disenrollment Reason Codes- provides Medicare Part A and Part B Entitlement, Non-Entitlement, Enrollment, and Disenrollment codes.

Section 4 Technical Instructions for Submitting State Data for Medicare Modernization Act (MMA) Provisions- provides information for the States when exchanging files with CMS.

Section 5 State MMA Request File Timing and Content- provides information about the timing and content for the MMA Request File.

Section 6 MMA Request File- provides file layout information for the MMA Request File, the monthly file(s) the states must send with the dual eligible individuals enrolled in their state.

Section 7 MMA Response File- provides file layout information for the MMA Response File sent by CMS to the state in response to their MMA Request file.

Section 8 Batch Eligibility Query (BEQ) Request File- provides information about the BEQ Request File sent by the state to request eligibility information.

Section 9 Batch Eligibility Query (BEQ) Response File- provides information about the BEQ Response File sent by CMS to the state in response to its BEQ Request file.

Section 10 Territory Beneficiary Query (TBQ) Request File- provides information about the TBQ Request File sent by the state & territories to request entitlement and enrollment information.

Section 11 Territory Beneficiary Query (TBQ) Response File- provides information about the TBQ Response File sent by CMS to the state & territories in response to its TBQ Request file. Note: Territories receive the TBQ, which is the territory equivalent to the plan/state BEQ.

Section 12 Puerto Rico Dual Eligibles File Process- provides information about the specific process for Puerto Rico Dual Eligibles Request and Response file data exchanges.

Section 13 Glossary, List of Acronyms, and State Codes- provides a glossary, list of acronyms, and state codes used throughout the SUG.

    1. Contacting the MAPD Help Desk

The MAPD Help Desk provides technical system support to states for the use of the MARx UI and file exchanges.

Contact the MAPD Help Desk at [email protected] or 1-800-927-8069.

Visit the MAPD Help Desk website at http://go.cms.gov/mapdhelpdesk.



  1. Medicare Advantage Prescription Drug User Interface (MARx UI) System

This section provides information necessary to conduct online operations in the MARx UI:

    1. Getting Started

A new state user must follow the steps below to be granted access to MARx UI:

  • Register for a User ID in the Identity Management (IDM) system.

  • Request the state user role for appropriate access to MARx UI.

  • Log into MARx UI as a state user.

      1. Register in IDM

CMS has established the Identity Management (IDM) system to provide MAPD Business Partners with a means to apply for, obtain approval, and receive a single User ID they can use to access one (1) or more CMS applications.

For more information about IDM, visit the IDM page on the CMS.gov website at this link:

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/IdentityManagement/IDM-Overview.

In the left navigation panel, click the Guides and Documentation link and review the CMS IDM User Guide for complete instructions on registering in IDM, performing Remote Identity Proofing (RIDP), and Multi-factor Authentication (MFA).

Note: IDM has password requirements that are noted when entering your password. MARx UI has an additional requirement limiting the password to exactly 8 characters and cannot contain any special characters.



      1. Request the State User role for MARx UI

To fulfill security goals, MARx UI is a role-based system that provides functionality and data filtering based on the user role.

The state users’ role is for an individual who works for or on behalf of a state Medicaid agency. State users can access Medicare eligibility, Low-Income subsidy (LIS) status, and detailed health and drug Plan enrollment information at a beneficiary level.

Below are the key steps to request a state user role for MARx UI:

  1. After you have created your IDM User ID and password, navigate to the CMS Enterprise Portal: https://portal.cms.gov.

  2. Enter your User ID and password and check the box, “I agree to the Terms & Conditions.”

  3. On the My Portal page, select + Add Application.

  4. The Request Application Access screen is displayed; Select an Application for MARx UI in the ‘MARx – Medicare Advantage & Prescription Drug System’ box. See Figure 2-1.

Figure 2‑1 Request Access to MARx UI



  1. Select the MA state/territory user role from the Select a Role: drop-down menu in Figure 2-2.


Figure 2‑2: Request New Application Access


  1. Complete “Identity Verification” by selecting Launch. Read through the information on the next screen (Step #1) and select Next. “Accept Terms & Conditions” on Step 2. Enter and/or verify your information on the next page (Step #3). Once your identity has been verified, return to the “Request Application Access” page.

  2. Complete Step 4 (Enter Business Contact Information), Step 5 (Enter Role Details), Step 6 (Enter Reason for Request).

  3. Upon approval of your request, you will have access to the MARx UI.


Note: These instructions are outlined in more detail on pages 9 – 15 in the CMS Enterprise Portal User Guide.

      1. Logging into MARx UI as a State User

  1. Upon receiving the confirmation email of access to MARx UI, navigate to the MARx URL: https://marx.cms.hhs.gov.

  2. Accept the Terms and Conditions.

  3. Enter your IDM User ID and password.

  4. Obtain and enter your MFA code.

  5. The User Security Role Selection (M002) screen is presented with the state user role preselected.



    1. Using the MARx UI Screens

      1. General Properties of Screens

MARx UI screens share many properties. Once users understand the screens’ organization, they can access information quickly and easily.

There are two main types of general screen layouts: primary and secondary. The principal differences between a primary window and a secondary window are the header design and content and how the screens are navigated. A third special screen type, the log-out window, remains in the background for the duration of the session.

      1. Common Features of the Screens

Below the headings, most of the screens are in the same format. The top of the screen contains a title line with the following information:

  • Screen name, which describes the screen’s purpose.

  • Primary screen’s name reflects the navigation to the screen using the menu and submenu.

  • Screen identifier, which starts with an M. This identifier is useful when asking for help, reporting a problem to the MAPD Help Desk, or using the SUG.

  • User ID.

  • User’s current role.

  • Current date.

  • [Print] and [Help] buttons (and the [Close] and other buttons for secondary windows).

The message line appears below the title line. Error messages display in red and success messages display in green. If there is no message, this area of the screen is blank.

Many screens include instructions at the top, which are displayed on the screen with a yellow background to provide information on using the screen. Additional information is available by clicking on the [Help] button. A screen may contain input (data entry fields), output (information fields), and links to other screens and tables, etc.

      1. Common Characteristics of the Screens

Screens may carry out one (1) or more of the following functions:

  • Find specific information.

  • Display information.

  • Provide links/buttons to additional functions.

Many screens contain fields that the user must populate and buttons that the user must click on to carry out an action. A red asterisk (*) appears next to an input field label to indicate that it is required. If more than one of those fields is required, a red plus sign (+) appears next to field labels.

Sometimes there are additional rules regarding the combination of acceptable fields; those rules are often indicated in instructions on the screen.

There are different options for entering information into a field:

  • Text entry: Most fields, such as beneficiary identifier or contract, allow the user to type in the information.

  • Dropdown list: Some fields, such as file type, provide a list of values from which to select. The user clicks on the down arrow next to the field to display the list, and then clicks on a value to select it.

  • Radio buttons: The user chooses one of the items in a group by clicking on the circle next to that item.

  • Check boxes: The user selects any number of the items in a group by clicking on the box next to each item.

Some fields are initialized with default values. For example, date fields are often initialized with the current date. The information that the user enters in a field is validated to ensure the request is valid, and an error message is displayed to inform the user of an error.



      1. Typographical Conventions

Table 2‑1: Typographical Conventions

Typographical Conventions

Example

Description

<Alt-P>

Keystroke. Less than and greater than signs (< >) are placed around any keyboard entries. For instance, <ENTER> means pressing the Enter key.

[Find]

Button Name. Square brackets ([ ]) are placed around the references to all button names displayed on the screen.

|Beneficiaries|

Menu or Submenu Name. Menus are shown with bars on either side as a horizontal list at the top of a screen. Submenus list items below the menu; items vary based on the menu item selected.

Beneficiaries: Find(M201)

Screen Name. All screen names are shown in the top left corner of each screen.

Label Names

Label Name. All field labels, for input and output, referenced in the text are shown as mixed-case alphanumeric characters.

Smith

Input. Input fields are locations that accept input on the screens. The input is in the form of mixed-case alphanumeric characters.

FEMALE

Selection. A dropdown list offers a choice of options from which to select. Selections from a dropdown option are generally presented on the screen in upper case.

The claim…

Error Message. If a problem occurs after the user clicks on an action button, such as [Find] or [Submit], an error message is provided in red on the upper left-hand corner of the screen.

The request…

Status Message. Status messages are provided in green on the upper left corner of the screen.

06/2002

Link. A hyperlink is a word or group of words that the user clicks to access additional information in another location. Links are displayed in underlined blue text.

Note

Note. Notes indicate important information. The accompanying text is enclosed in a box with Note as a header.

Tip

Tip. Tips alert the user to shortcuts and troubleshooting techniques. Accompanying text is enclosed in a box with Tip as a header.

Note: When screens are shown in this document, the browser title, menu, buttons, and other items are hidden to display the content as large as possible.

      1. Common Buttons, Links, and Fields

Table 2‑2: Common Buttons and Links

Common Buttons and Links

Example

Description

[Print]

Print. Every screen contains a [Print] button. The [Print] button supports printing the entire contents of the active webpage. It displays the ‘Printer Options’ pop-up screen.

[Help]

Help. Every screen contains a [Help] button, which invokes a menu of topics. At the top of the menu is a link to information specific to the current screen. Below that link are topic links that display for each screen. When the user clicks on a link, the help button displays in a separate window using Adobe Acrobat Reader. The help button provides more instructions for use of the MARx UI

[Close]

Close. Closes the pop-up window without submitting the data. This button does not appear on any screens accessed directly from an item on the MARx UI main menu.

[Cancel]

Cancel. Closes the pop-up window without submitting the data.

Screen navigation arrows. When all list items do not fit on the screen, use the navigation arrows to scroll through the list. These arrows are shown at the top and the bottom of the list items on the screen. The arrows function as follows:

– go to the first page of items in the list

– go to the previous page of items in the list

– go to the next page of items in the list

– go to the last page of items in the list

Go to Page Number. In addition to the screen navigation arrows, [Go to Page Number] is displayed at the top of the list items. It allows the user to jump directly to a particular page. Select the page number to display, and click on the [Go] button. The page numbers in the dropdown list reflect the actual number of pages in the list.

[Reset]

Reset. Resets the entered data to their previous values.



Table 2‑3: Common Fields

Common Fields

Field

Format

Claim #

One of two formats is permitted. This field consists of a Claim Account Number (CAN) and a Beneficiary Identification Code (BIC). Whether a BIC is or is not optional depends on the screen and format:

Social Security Administration (SSA) – 9-digit Social Security Number is the Claim Account Number (CAN) followed by a 1- or 2-character BIC, where the first character is a letter and the second is a letter or number.

Railroad Retirement Board (RRB) – RRB identifier starts with a 1-to-3-character BIC, which has one of these values: CA, A, JA, MA, PA, WA, WCA, WCD, PD, WD, H, MH, PH, WH, WCH, followed by a 6- or 9-digit number, i.e., CAN. The BIC is not optional.

Contract #

Starts with an ‘H’, ‘9’, ‘R’, ’S”, ‘E’, or ‘X’ and is followed by four numbers:

H = Local Medicare Advantage (MA), local MAPD, or non-MA Plan.

9 = Non-MA Plan (no longer assigned).

R = Regional MA or MAPD Plan.

S = Regular standalone Prescription Drug Plan (PDP).

E = Employer direct PDP.

X = Limited-Income Newly Eligible Transition (LiNET).

Plan Benefit Package (PBP)

Three alphanumeric characters.

Segment #

Three digits. A value of 000 indicates that there is no segment.

Date

Month, day, and four-digit year. A zero in front of a single-digit month or day is optional: (M)M/(D)D/YYYY.

Month/Year

Month and four-digit year. A zero in front of a single-digit month is optional: (M)M/YYYY.

Last Name

May contain letters, upper and lower case; apostrophe; hyphen; and blank; with a maximum length of 40 characters.



    1. Navigating the MARx UI

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

The user has access to certain functions/tasks depending on their role. See Table 2-4 for the names of the main menu items for state users.

Table 2‑4: Main Menu Items

Menu Item

Description

|Welcome|

Messages, current payment month, and calendar.

|Beneficiaries|

Search for beneficiaries and view beneficiary information.



The MARx UI uses the drill-down method. This means that the user starts at a very high level, and drills down to more specific detailed information.

      1. Navigating Menus, Sub-menus, and Screens

The menus and sub-menus all work in the same way, as follows: the first view of the MARx UI main menu appears with the |Welcome| menu item highlighted on the screen.



When the user selects an item from the MARx UI main menu by clicking on the general area, e.g., the |Beneficiaries| menu item, the screen changes.

  • The selected menu item; in this case, the |Beneficiaries| menu item, is highlighted in yellow on the screen.

  • The associated submenu displays just below the main menu, the first item in the submenu is selected and highlighted in yellow on the screen as well, by default, and the associated screen; in this case, the Beneficiaries: MCO (M201) displays in the form area.

  • To view any of the other selections, click the menu or submenu item, e.g. the |Eligibility| menu item, to see the associated screen.

After accessing a screen, the user may search to find information about a particular beneficiary or month. The user can assess more detail by clicking on links and/or buttons that lead to additional screens.

      1. Error Message Screens

If a screen is unavailable for display, the screen displays “Error 404 Page Not Found” notifying the user of the problem. If a time-out occurs during an attempt to display a screen, the screen displays “Error 408: Your request has timed out” notifying the user of the problem.

      1. Screens Available for the State User

MARx UI enables state users to access enrollment, eligibility, and 4Rx information for beneficiaries. Table 2-5 lists the screens that the state user can view.

Table 2‑5: State User Screen Lookup

State User Screen Lookup

Screen Name

Screen Number

Logon and Welcome Screen

User Security Role Selection

M002

Welcome

M101

Beneficiaries Screens

Beneficiaries: Find

M201

Beneficiaries: Search Results

M202

Beneficiary Detail: Snapshot

M203

Beneficiary Detail: Enrollment

M204

Enrollment Detail

M222

Beneficiaries: Eligibility

M232

Rx Insurance View

M244

Additional Insurance Information

M251

Low-Income Subsidy

M252

Status Activity

M256

Status Detail

M257



State users are not given access to the Payment, Adjustments, or Premium screens. Information is available for enrollments from the start of the program.

All beneficiary, contract, and user information in the screen snapshots in this document are fictional. Names and Social Security Numbers do not identify any person living or dead. Claim numbers start with ‘997,’ ‘998,’ or ‘999’ because those numbers are never assigned. On certain screens, if no end date displays for the subsidy period, this does not mean the beneficiary’s status is terminated; rather, a blank Subsidy End date means that the status rolled over to the current year.

The MARx UI meets U.S. Regulations, Section 508 of the Rehabilitation Act Amendments of 1998, requiring all U.S. Federal agencies to make their Information Technology accessible to their employees and customers with disabilities.

The System meets the following criteria for users employing assisting technologies, such as screen readers:

  • Text equivalents are provided for non-text elements such as graphics.

  • All information conveyed with color is also available without color.

  • Web-based reporting tools and Hypertext Markup Language (HTML) generated data support the use of row and column headings.

  • HTML 4 tagging format is used.

  • The System is designed to allow users to skip repetitive navigation links. A link, which is only visible with a screen reader, is placed at the start of the page. When clicked, the link skips over the menu and submenu.

      1. Logging on and Viewing Messages

The user will access the MARx UI via https://marx.cms.hhs.gov and enter their User ID and password. The User Security Role Selection (M002) screen displays, Figure 2-3, and the state user role is preselected. The screen displays the last successful login date and time. If the system is down when the user tries to log on, the browser displays a message that the Page is Unavailable or the Page cannot be found. The content of this message is dependent on the browser, not on the system. Table 2-6 describes these messages.

User Security Role Selection (M002) Screen Figure 2‑3: User Security Role Selection (M002) Screen

If the system is up and the logon is unsuccessful, the Logon Error (M009) screen displays an error message describing why the logon failed. See below verbiage:

The following error has occurred during the logon process. Close or exit the current window and go to the Portal Window and click on the MARx-UI application again.

Table 2‑6: M002 Screen Messages

M002 Screen Messages

Message Type

Message Text

Suggested Action

Workstation setup

Click on the message ‘Pop-up blocked. To see this pop-up or additional options click ‘here…,’ then click ‘Always Allow Pop-ups from This Site…’

Follow the directions in the message to enable pop-ups from the MARx UI. When a message is displayed asking if the user wants to allow pop-ups from the site, click [Yes]. The next message asks if the user wants to close the window. Click [No]. The Welcome (M101) screen then displays.

Software or Database Error

No security roles are defined for your user ID

Contact the MAPD Help Desk.

Software or Database Error

Error retrieving your security roles from the database

Contact the MAPD Help Desk.

Software or Database Error

Your user ID does not exist

Contact the MAPD Help Desk.

Software or Database Error

Your user ID was not supplied

Enter your user id, if you did enter a user id, contact the MAPD Help Desk.

Software or Database Error

Your user ID profile is inactive

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from the database while retrieving your security roles

Contact the MAPD Help Desk.

Software or Database Error

Error retrieving the expected number of security setting results. Retrieved <# of results sets retrieved> out of <# of results sets expected>

Contact the MAPD Help Desk.

Software or Database Error

No screen items defined for this role

Contact the MAPD Help Desk.

Software or Database Error

Error retrieving your security settings

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from the database while retrieving your security settings

Contact the MAPD Help Desk.

Software or Database Error

Error retrieving the expected number of dropdown list results. Retrieved <# of results sets retrieved> out of <# of results sets expected>

Contact the MAPD Help Desk.

Software or Database Error

The dropdown lists result set is empty

Contact the MAPD Help Desk.

Software or Database Error

Error retrieving dropdown lists from the database

Contact the MAPD Help Desk.

Software or Database Error

No current payment month has been set

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from the database while retrieving the dropdown lists

Contact the MAPD Help Desk.

Software or Database Error

Connection error

Contact the MAPD Help Desk.



The user clicks on the [Logon with Selected Role] button and the Welcome (M101) screen appears, as shown in Figure 2-4 and described in Table 2-7, with error and validation messages provided in Table 2-8.

State User Welcome (M101) Screen

Figure 2‑4: State User Welcome (M101) Screen


Table 2‑7: State User (M101) Field Descriptions and Actions

State User (M101) Field Descriptions and Actions

Item

Input/Output

Description

Broadcast Messages

Output

Provides general information about the system’s actions, e.g. month-end processing started. The list of messages refreshes every time the user returns to the screen.

User Messages

Output

Indicates if there are any messages for the user.

Current Payment Month (CPM)

Output

The payment month/year currently being processed by the system. All payments and adjustments calculated will affect the payment the Plan receives for this month.

Current Calendar Month (CCM)

Output

The calendar month/year currently being processed by the system. This is the actual month in place today. All enrollment edits are based on CCM.

Session Timeout

Output

After 15 minutes of inactivity, you will be logged out of MARx UI. You will need to go through the login process to regain access.

MARx Version

Output

The region and release information of the MARx UI display.

MARx Calendar

Link

Provides general information about what is happening in the system, e.g. month-end processing started. The list of messages refreshes every time the user returns to the screen.



Table 2‑8: State User (M101) Screen Messages

State User (M101) Screen Messages

Message Type

Message Text

Suggested Action

Software or Database Error

The result set that contains the system message is empty.

Contact the MAPD Help Desk.

Software or Database Error

Database errors occur in retrieving the system messages.

Contact the MAPD Help Desk.

Software or Database Error

Invalid input.

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from database.

Contact the MAPD Help Desk.

Software or Database Error

Connection error.

Contact the MAPD Help Desk.



    1. Viewing Beneficiary Information

      1. Finding a Beneficiary

To find information about a beneficiary who is enrolled in a contract, either currently, in the past, or in the future, the user accesses the Beneficiaries: Find (M201) screen. Once the beneficiary is located, the user can view information on that beneficiary.

STEP 1: Accessing the Beneficiaries: Find (M201) Screen

From the main menu, the user clicks on the |Beneficiaries| menu item. The |Find| submenu item is already selected and displays the Beneficiaries: Find (M201) screen as shown in Figure 2-5. It is described in Table 2-9, with screen messages provided in Table 2-10.

STEP 2: Using the Beneficiaries: Find (M201) Screen

The MARx UI allows a user with the state user role to:

  • Search for beneficiaries by claim number OR last name, first name, and date of birth (DOB). Note: The state user is not required to enter the contract number or other fields when searching with the name and DOB.

  • View detailed Low-Income Subsidy (LIS) information with historical information, including valid and audited periods and denied LIS information.

  • View detailed Medicare Secondary Payer (MSP) information for both Medical and Drug coverage.

Please note that the above search is restricted to returning a single beneficiary. If more than one beneficiary meets the last name, first name, and date of birth search criteria, the user is prompted to enter additional selection criteria or the claim number.

The user enters search criteria and clicks on the [Find] button.

State User Beneficiaries: Find (M201) Screen

Figure 2‑5: State User Beneficiaries: Find (M201) Screen


Table 2‑9: State User (M201) Field Descriptions and Actions

State User (M201) Field Descriptions and Actions

Item

Input/Output

Description

Claim #

Required data entry field

The user finds beneficiaries with this claim number.

Note: The BIC is optional except when an RRB number is entered.

Last Name

Required data entry field if Claim # is not entered.

The user finds beneficiaries with this Last Name, the entered First Name, and Birth Date. (Note: All 3 fields are required.)

First Name

Required data entry field if Claim # is not entered.

The user finds beneficiaries with this First Name, the entered Last Name, and Birth Date. (Note: All 3 fields are required.)

Birth Date

Required data entry field if Claim # is not entered.

The user finds beneficiaries with this Birth Date, the entered Last Name, and First Name. (Note: All 3 fields are required.)

M.I.

Optional data entry field

The Middle Initial is added to the required information to narrow the beneficiary search.

Sex

Optional data entry field

The Sex is added to the required information to narrow the beneficiary search.

Mailing State

Optional data entry field

The state of the beneficiary’s mailing address is added to the required information to narrow the beneficiary search.

Residence State

Optional data entry field

The state of the beneficiary’s residence address is added to the required information to narrow the beneficiary search.

[Find]

Button

After entering a claim number or combination of other fields, the user clicks this button to initiate the search for beneficiaries.

[Reset]

Button

This button clears the information already entered on the screen.






Table 2‑10: State User (M201) Screen Messages

State User (M201) Screen Messages

Message Type

Message Text

Suggested Action

Missing entry

Enter a claim number.

The user must enter a valid claim number or a combination of Last Name, First Name, and Birth Date.

Invalid format

The claim number is not a valid SSA, RRB, or CMS internal number.

The user re-enters the claim number.

No data

No beneficiary records were found for the search criteria.

The user should verify the accuracy of the information entered. The user should perform a more general search, in case the constraints are too restricting.

Software or Database Error

Error occurred while retrieving beneficiary search results.

Contact the MAPD Help Desk.

Software or Database Error

Error occurred while retrieving beneficiary records.

Contact the MAPD Help Desk.

Software or Database Error

Missing input.

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from database=<error code>.

Contact the MAPD Help Desk.

Software or Database Error

Connection error.

Contact the MAPD Help Desk.





      1. Viewing Summary Information about a Beneficiary

Beneficiaries meeting the search criteria display on the Beneficiaries: Search Results (M202) screen.

STEP 3: Using the Beneficiaries: Search Results (M202) Screen

If the search is successful, the Beneficiaries: Search Results (M202) screen displays as in Figure 2-6 and as described by Table 2-11. For state users, only one beneficiary will be returned. Because any error associated with the search would display on the Beneficiaries: Find (M201) screen, no error messages are displayed on the M202 screen. If a user enters an inactive Claim Number for the Beneficiary, a message displays to indicate the beneficiary’s active claim number, as shown in Table 2-12.

State User Beneficiaries: Search Results (M202) Screen

Figure 2‑6: State User Beneficiaries: Search Results (M202) Screen


Table 2‑11: State User (M202) Field Descriptions and Actions

State User (M202) Field Descriptions and Actions

Item

Input/Output

Description

Claim #

Link

The user clicks on the beneficiary’s Claim # link to display the Beneficiary Detail: Snapshot (M203) screen.

Name

Output

Name of the beneficiary.

Birth Date column

Output

DOB of the beneficiary.

Date of Death column

Output

DOD, if applicable, of the beneficiary.

Sex column

Output

Sex of the beneficiary.

State column

Output

State of residence of the beneficiary.

County column

Output

County of residence of the beneficiary.


Table 2‑12: State User (M202) Screen Messages

State User (M202) Screen Messages

Message Type

Message Text

Suggested Action

Informational

The beneficiary’s active claim number is displayed for the claim number entered

None needed.





      1. Viewing Detailed Information for a Beneficiary

The user finds the beneficiary on the Beneficiaries: Search Results (M202) screen and drills down for more information.

Table 2‑13: Menu Items for Viewing Beneficiary Detail Information

Menu Items for Viewing Beneficiary Detail Information

Menu Item

Screen Name

Description

|Snapshot|

Beneficiary Detail: Snapshot (M203)

Displays an overall information summary for the beneficiary as of the date specified. If the beneficiary is not currently enrolled, the summary of the last available information displays. When the screen first displays, the date defaults to the current date.

|Enrollment|

Beneficiary Detail: Enrollment (M204)

Displays a summary list of enrollment information, by contract, for the enrollments to which the user has access. It also provides links to drill down to more detailed enrollment information for the beneficiary on a selected contract.

|Eligibility|

Beneficiary: Eligibility (M232)

Displays information regarding a beneficiary’s entitlement for Part A, Plan B, and eligibility for Part D, as applicable and relevant to the Plan. If the beneficiary is eligible for Part D LIS, the number of uncovered months and the details of that subsidy are indicated.

|Rx Information|

Rx Information (M244)

Displays the beneficiary’s 4Rx history, both primary and secondary (if applicable) for beneficiaries enrolled in a Plan.

|Additional Insurance Information|

Additional Insurance Information (M251)

Displays detailed Additional Insurance Information for both Medical and Drug coverage.

|Low-Income Subsidy Information|

Low-Income Subsidy (M252)

Displays detailed LIS information with historical information, including valid and audited periods and denied LIS information.

[Status Activity Information]

Status Activity (M256)

Displays a beneficiary’s current health status information, as well as current values for eligibility, uncovered months, low-income subsidy, and state and county codes.

[Status Detail Information]

Status Detail (M257)

Displays data specific to each of the special statuses (e.g., ESRD, MSP, etc.) and, if applicable, the data records/periods that are valid and audited.



STEP 4: Viewing Detailed Information for a Beneficiary

To see detailed information about any of the beneficiaries listed in the Beneficiaries: Search Results (M202) screen, the user clicks on the associated Claim #.

Note: Instead of seeing a screen in the same area as previously displayed, a new window with a new screen and a new header appear. This pop-up window displays header information specific to the selected beneficiary. The beneficiary’s latest mailing address is displayed, along with the current State and County Code (SCC). The header, by itself, is shown in Figure 2-7.

Sample Header for the Beneficiary Detail Screens

Figure 2‑7: Sample Header for the Beneficiary Snapshot (M203) Screen


Directly below the header is a set of menu items, described in Table 2-13. The user can switch back and forth among the six different screens by clicking the menu items. Each screen pertains to the beneficiary selected from the Beneficiaries: Search Results (M202) screen. The Beneficiary Snapshot (M203) screen is the default screen displayed when the beneficiary is selected from the Beneficiaries: Search Results (M202) screen.

      1. Viewing a Snapshot of Beneficiary Information

A snapshot provides a summary of the beneficiary’s entitlement, eligibility, and enrollment information.

STEP 4a: Viewing the Beneficiary Detail: Snapshot (M203) Screen

The Beneficiary Detail: Snapshot (M203) screen, as shown in Figure 2-8 and described in Table 2-14, provides beneficiary entitlement, eligibility, and enrollment status as of the date the user specifies. Table 2-15 describes screen messages. If the beneficiary is enrolled in two contracts, one for Part A and/or Part B and the other for Part D, information is displayed on both contracts based on the current date. To view the details of a past or a future date, the user changes the “As of” date to a specific point in time in the “As of” data entry area and clicks on the [Find] button. D

State User Beneficiary Detail: Snapshot (M203) Screen Figure 2‑8: State User Beneficiary Detail: Snapshot (M203) Screen


Table 2‑14: State User (M203) Field Descriptions and Actions

State User (M203) Field Descriptions and Actions

Item

Input/Output

Description

As Of

Optional data entry field

Enter a valid date in the form (M)M/(D)D/YYYY. The user may change the As Of date. After doing so, the user clicks on the [Find] button to bring up the information for that date.

[Find]

Button

Displays the information for the specified As Of date.

The following fields are repeated for each contract, up to two, in which the beneficiary is enrolled

Contract

Output

Contract number for this beneficiary on the As Of date.

MCO Name

Output

Managed Care Organization (MCO) Contract name for this beneficiary on the As Of date.

PBP Number

Output

PBP number on the contract for this beneficiary on the As Of date.

Segment Number

Output

Segment number on the contract and PBP for this beneficiary on the As Of date.

Demonstration Type and Description

Output

The two-digit Demo Code for this enrollment and its description.

Enrollment Source Code and Description

Output

The source for this enrollment, along with the associated description. Examples:

  • B = Beneficiary Election

  • J = State-submitted Passive Enrollment


Special Needs Type

Output

Indicates the special needs population that the contract serves, if applicable.

Bonus Payment Portion

Percent

Output

The percentage is applied to the payment to determine the bonus

amount to pay the MCO. This does not apply to a PDP.


Residency Status


Output

The residency status (In Area or Out of Area) for this

beneficiary in this Plan on the As of Date and is determined by the current payment month.

Bonus Payment Portion Percent

Output

The percentage applied to the payment to determine the bonus amount to pay the MCO. This does not apply to a PDP.

Residency Status

Output

The residency status (In Area or Out of Area) for this beneficiary in this Plan on the As Of Date and is determined by the current payment month.

Part B Premium Reduction Benefit

Output

The Part B Premium Reduction Benefit amount is shown only for a non-drug contractor. For the Pre-2006 Part B Premium Reduction Benefit, multiply the Benefits Improvement & Protection Act of 2000 (BIPA) amount by 0.80.

Residence for Payments: State

Output

State used for payment calculation, which may differ from the state in the mailing address in the screen header.

Residence for Payments: County

Output

County used for payment calculation, which may differ from the county in the mailing address in the screen header.

Status Flags

Output

The flags set for the beneficiary on the As Of date.

Payment Flags

Output

The flags set for the beneficiary on the As Of date.

Low-Income Subsidy

Output

Date range; subsidy start date and end date, co-payment level, and amount of the LIS on the As Of date.

Original Reason for Entitlement

Output

The reason for the beneficiary’s original entitlement to Medicare; disabled or aged.

Aged/Disabled Medicare Secondary Payer (MSP) Factor

Output

Beneficiary’s aged/disabled reduction factor.

End State Renal Disease (ESRD) MSP Factor

Output

Beneficiary’s ESRD Medicare Secondary Payer reduction factor.

Entitlement, Eligibility, and Enrollment Information

Entitlement Information

Output

Entitlement Start Date and End Date, as well as Option for Part A and Part B for this beneficiary on the As Of date.

Eligibility Information

Output

Eligibility Start Date and End Date for Part D for this beneficiary on the As Of date.

Enrollment Information

Output

Provides the Start Date and the End Date for this beneficiary’s enrollment under the user’s contract on the As Of date.



Table 2‑15: State User (M203) Screen Messages

State User (M203) Screen Messages

Message Type

Message Text

Suggested Action

Missing entry

As of Date must be entered.

The user enters the date.

Invalid format

As of Date is invalid. Must have format (M)M/(D)D/YYYY.

The user re-enters the date in one of the required formats.

Informational

The latest available Snapshot information is for payment month of <actual payment month>.

None.

No data

No payment profile information for claim number <claim number> and coverage date as of <date>.

There is no payment data available for that claim number on the As Of date entered on the screen. If the user expects to see payment data, the user verifies the date and month and re-enters the corrected information. If the date and month are correct, the user contacts the MAPD Help Desk for assistance.

No data

Invalid input for claim number <claim number> and coverage date as of <date>.

There is no payment data available for that claim number on the As Of date entered on the screen. If the user expects to see payment data, the user verifies the date and month and re-enters the corrected information. If the date and month are correct, the user contacts the MAPD Help Desk for assistance.

Software or Database Error

Error occurred while retrieving beneficiary snapshot data for claim number <claim number> and coverage date as of <date>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Unexpected error code from database=<error code>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Connection error.

Contact MAPD Help Desk for assistance.



      1. Viewing Enrollment Information

An enrollment history displays the beneficiary’s past, present, or future enrollment periods in any contract.

STEP 4b: Viewing the Beneficiary Detail: Enrollment (M204) Screen

To access the Beneficiary Detail: Enrollment (M204) screen, the user clicks on the |Enrollment| menu item. This displays a screen, as shown in Figure 2-9, with a summary list of the beneficiary’s enrollments by contract, PBP, and segment numbers, as applicable. When the beneficiary is enrolled in a contract for Part A and/or Part B and another for Part D, two rows covering the same time period may display. The screen is described in Table 2-16, with screen messages provided in Table 2-17.

State User Beneficiary Detail: Enrollment (M204) Screen Figure 2‑9: State User Beneficiary Detail: Enrollment (M204) Screen


Table 2‑16: State User (M204) Field Descriptions and Actions

State User (M204) Field Descriptions and Actions

Item

Input/Output

Description

Contract

Output

Contract in which the beneficiary is enrolled. The values displayed in this column link to display the Enrollment Details (M222) screen for the enrollment on this line.

PBP #

Output

PBP number for the enrollment on this line.

Segment #

Output

Segment number for the enrollment on this line.

Drug Plan

Output

Indicates whether the contract/PBP on this line provides drug insurance coverage. (Y or N).

Start

Output

Start date for the beneficiary’s enrollment in this Contract/PBP/Segment.

End

Output

End date for the beneficiary’s enrollment in this Contract/PBP/Segment.

Source

Output

The person or system that submitted the enrollment; contract number when entered by an MCO; user ID when entered at CMS, SSA, or Medicare Customer Service Center (MCSC).

Demonstration Type and Description

Output

The two-digit Demo Code for this enrollment and its description.

Enrollment Source Code and Description

Output

The source for this enrollment, along with the associated description. Examples:

  • B = Beneficiary Election

  • J = State-submitted Passive Enrollment

  • etc.

Disenrollment Reason

Output

If the enrollment on this line includes an end date, the reason for the beneficiary’s disenrollment is provided.

Primary Drug Insurance

Link

Click the View link in the Primary Insurance Information column to display all occurrences of primary insurance information associated with the beneficiary’s enrollment. This information displays in the bottom portion of the screen.



Table 2‑17: State User (M204) Screen Messages

State User (M204) Screen Messages

Message Type

Message Text

Suggested Action

No data

No enrollment information found for claim number <claim number> and coverage date <coverage date>.

No corresponding data is available for that claim number on that date. If the user expects to see enrollment data, the user verifies the date and month and re-enters the corrected information. If no enrollments appear, contact MAPD Help Desk for assistance

Software or Database Error

Error occurred while retrieving enrollment results for claim number <claim number> and coverage date <coverage date>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Error occurred while retrieving enrollment history for claim number <claim number> and coverage date <coverage date>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Missing input on retrieval of beneficiary enrollment history.

Contact MAPD Help Desk for assistance.

Software or Database Error

Invalid screen ID.

Contact MAPD Help Desk for assistance.

Software or Database Error

Unexpected error code from database=<error code>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Connection error.

Contact MAPD Help Desk for assistance.



STEP 4c: Viewing the Enrollment Detail (M222) screen

The enrollment details show the enrollment and disenrollment information for a beneficiary.

The Enrollment Detail (M222) screen is accessible by selecting a Contract # link from the Beneficiary Detail: Enrollment (M204) screen.

The screen, as shown in Figure 2-10, provides details of the selected enrollment or enrollment period. The screen is described in Table 2-18, with screen messages provided in Table 2-19.

Shape1 State User Detail: Enrollment (M222) Screen Figure 2‑10: State User Detail: Enrollment (M222) Screen


Table 2‑18: State User (M222) Field Descriptions and Actions

State User (M222) Field Descriptions and Actions

Item

Input/Output

Description

Contract

Output

Contract number in which the beneficiary is enrolled.

MCO Name

Output

Name of the contract.

PBP Number

Output

PBP in which the beneficiary is enrolled, when applicable.

Segment Number

Output

Segment in which the beneficiary is enrolled, when applicable.

Drug Plan

Output

Indicates whether the contract provides drug insurance coverage. The user sets to Y or N.

Effective Start Date

Output

Start of enrollment.

Effective End Date

Output

End of enrollment, when applicable.

EGHP

Output

Indicates whether the enrollment is an Employer Group Health Plan (EGHP). The user sets to Y or N.

Enrollment Forced Code

Output

Reason for overriding certain membership validation rules, when applicable.

Disenrollment Reason Code

Output

Reason for disenrollment, when applicable.

Application Date

Output

The date the Plan received the beneficiary’s completed enrollment application.

Enrollment Election Type

Output

Type of election period when enrollment took place.

Disenrollment Election Type

Output

Type of election period when disenrollment took place.

Special Needs Type

Output

Type of special needs population for which the Plan provides coverage, e.g., Institutional, Dual Eligible, or Chronic or Disabling Condition.

Enrollment Source

Output

The action that triggered the enrollment: automatically enrolled by CMS, beneficiary election, or facilitated enrollment by CMS.

Part D Auto-Enrollment Opt-Out

Output

Indicates whether the beneficiary opted out of Part D coverage. Applies only to automatic enrollments by CMS. Set to Y or N.

Part D Rx Bin

Output

Card issuer identifier or a bank identifying number used for network routing.

Part D Rx PCN

Output

Processing Control Number (PCN) assigned by the processor.

Part D Rx Group

Output

Identifying number assigned to the cardholder group or employer group.

Part D Rx ID

Output

Beneficiary ID assigned to the beneficiary.



Table 2‑19: State User (M222) Screen Messages

State User (M222) Screen Messages

Message Type

Message Text

Suggested Action

Software or Database Error

Error occurred while retrieving beneficiary enrollment information.

Contact the MAPD Help Desk.

Software or Database Error

Invalid input retrieving beneficiary enrollment information.

Contact the MAPD Help Desk.

Software or Database Error

Beneficiary enrollment information is missing.

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from database = <error code>.

Contact the MAPD Help Desk.

Software or Database Error

Connection error.

Contact the MAPD Help Desk.

Step 5: Viewing the Rx Information for a Beneficiary

States can access the M244 screen, Figure 2-11, to view the Rx Insurance history, both primary and secondary, if applicable, for beneficiaries enrolled in a Plan. To access the Rx Insurance (M244) screen, select the Rx Insurance tab. The screen is described in Table 2-20, with screen messages provided in Table 2-21.

Rx Insurance View (M244) Screen Figure 2‑11: Rx Insurance View (M244) Screen


Table 2‑20: State User (M244) Field Descriptions and Actions

State User (M244) Field Descriptions and Actions

Item

Input/Output

Description

Primary Drug Insurance Information

This section contains one line for each period that the beneficiary had a unique combination of Contract, PBP, and Primary 4Rx information.

Contract

Output

The contract for the applicable period.

PBP #

Output

The PBP for the applicable period.

Primary Drug Insurance Start Date

Output

Start date for Primary 4Rx information on this line.

Primary Drug Insurance End Date

Output

End date for the Primary 4Rx information on this line.

Primary BIN

Output

Part D insurance Plan’s Beneficiary Identification Number (BIN) for the primary contract, PBP, and period specified.

Primary PCN

Output

Part D insurance Plan’s PCN for the primary contract, PBP, and period specified.

Primary GRP

Output

Part D insurance Plan’s group (GRP) number for the primary contract, PBP, and period specified.

Primary RxID

Output

Identifier assigned to the beneficiary by the primary Part D insurance plan for drug coverage.

Source

Output

Source of enrollment into the contract and the PBP for period specified.

Record Update Timestamp

Output

Date that Rx insurance information was added or updated.

Secondary Drug Insurance Information

This section contains one line for each period that the beneficiary had a unique combination of Contract, PBP, and Secondary 4Rx information.

Insurance Creation Date

Output

Date reported for the initiation of this secondary insurance period.

Secondary BIN

Output

Secondary drug insurance Plan’s BIN number.

Secondary PCN

Output

Secondary drug insurance Plan’s PCN number.

Secondary GRP

Output

Identifier for a group providing secondary drug insurance.

Secondary RxID

Output

Identifier assigned to a beneficiary by secondary drug insurance.

Record Update Timestamp

Output

Date this row was added or updated.



Table 2‑21: State User (M244) Screen Messages

State User (M244) Screen Messages

Message Type

Message Text

Suggested Action

No data

No primary drug insurance information found for <claim number>.

No corresponding data is available for the claim number. If the user expects to see data, verify the claim number and try again. If the claim number is correct, the user contacts MAPD Help Desk for assistance.

No data

No secondary drug insurance information found for <claim number>.

No corresponding data is available for the claim number. If the user expects to see data, verify the claim number and try again. If the claim number is correct, the user contacts MAPD Help Desk for assistance.

Software or Database Error

Invalid primary drug insurance results retrieved for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Invalid secondary drug insurance results retrieved for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Error occurred while retrieving drug insurance information for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Invalid input retrieving drug insurance information for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Unexpected error code from database=<error code>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Connection error.

Contact MAPD Help Desk for assistance.



      1. Viewing Additional Insurance Information

The Additional Insurance Information (M251) screen, Figure 2-12, shows a beneficiary’s medical insurance and drug insurance information.

Step 6: Viewing the Additional Insurance Information (M251) Screen

To search for a beneficiary, the user logs into the system and navigates to the |Beneficiary| link. Clicking the |Additional Insurance Information| menu item at the top of the screen displays a summary list of medical insurance and drug insurance information by start and end dates. The fields on the screen are described in Table 2-22, with screen messages provided in Table 2-23.

Additional Insurance Information (M251) Screen Figure 2‑12: Additional Insurance Information (M251) Screen


Table 2‑22: Additional Insurance Information (M251) Field Descriptions and Actions

Additional Insurance Information (M251) Field Descriptions and Actions

Screen Area

Item

Type

Description

Additional Medical Insurance

Coverage Type

Output

Can populate as:

  • Primary to Medicare.

  • Secondary to Medicare.

Additional Medical Insurance

Start Date

Output

Start date for each medical insurer for the beneficiary.

Additional Medical Insurance

End Date

Output

End date for each medical insurer for the beneficiary.

Additional Medical Insurance

MSP Reason

Output

Can populate as:

  • Working Aged.

  • ESRD.

  • No-fault Automobile Insurance.

  • Working Disabled.

  • Liability.

  • Worker’s Compensation.

  • Federal (Public Health).

  • Black Lung.

  • Veterans.

Additional Medical Insurance

Insurer Name

Output

Medical insurance company name.

Additional Medical Insurance

Insurer Address

Output

Address of medical insurance company.

Additional Medical Insurance

MSP Qualifier

Output

MSP Qualifier code assigned by Medicare Beneficiary Database (MBD).

Additional Medical Insurance

Added Date

Output

Date the additional medical insurance was added.

Additional Medical Insurance

Updated Date

Output

Date the additional medical insurance was updated.

Additional Drug Insurance

Coverage Type

Output

Can populate as:

  • Primary to Medicare.

  • Secondary to Medicare.

Additional Drug Insurance

Start Date

Output

Start date for each drug insurer for the beneficiary.

Additional Drug Insurance

End Date

Output

End date for each drug insurer for the beneficiary.

Additional Drug Insurance

MSP Reason

Output

Can populate as:

  • Working Aged.

  • ESRD.

  • No-fault Automobile Insurance.

  • Working Disabled.

  • Liability.

  • Worker’s Compensation.

  • Federal (Public Health).

  • Black Lung.

  • Veterans.

Additional Drug Insurance

Insurer Name

Output

Drug insurance company name.

Additional Drug Insurance

Insurer Address

Output

Address of drug insurance company.

Additional Drug Insurance

Policy Holder Name

Output

Name of the policy holder.

Additional Drug Insurance

Beneficiary Relationship

Output

Can populate as:

  • Bene is Policy Holder.

  • Spouse.

  • Natural Child.

  • Insured Financially Responsible.

  • Insured Not Financially Responsible.

  • Stepchild.

  • Foster Child.

  • Ward of the Court.

  • Employee.

  • Unknown.

  • Handicapped Dependent.

  • Organ Donor.

  • Cadaver Donor.

  • Grandchild.

  • Niece/Nephew.

  • Injured Plaintiff.

  • Sponsored Dependent.

  • Minor Dependent.

  • Of A Minor Dependent.

  • Parent.

  • Grandparent Dependent.

  • Life Partner.

Additional Drug Insurance

Supplemental Type

Output

Can populate as:

L – Supplemental.

M – Medigap.

O – Other.

P – Patient Assistance Program.

Q – Qualified State Pharmaceutical Assistance Program (SPAP).

R – Charity.

S – AIDS Drug Assistance Program.

T – Federal Health Program.

1 – Medicaid.

2 – Tricare.

Additional Drug Insurance

Person Code

Output

The person code assigned by the Drug Plan.

Additional Drug Insurance

Beneficiary ID

Output

Membership ID assigned by the Drug Plan to the beneficiary.

Additional Drug Insurance

Secondary Rx BIN

Output

Identification number for the PDP providing secondary Rx insurance.

Additional Drug Insurance

Secondary Rx PCN

Output

Processor control number for the PDP providing secondary Rx insurance.

Additional Drug Insurance

Secondary Rx Group

Output

Identifier for the group providing secondary Rx insurance. Not applicable unless the Secondary Drug Insurance indicator is Yes.

Additional Drug Insurance

Secondary Rx ID

Output

Identifier assigned to a beneficiary by the secondary insurance company for drug coverage. Not applicable unless the Secondary Drug Insurance indicator is Yes.

Additional Drug Insurance

Secondary Rx Phone

Output

The secondary insurance company for drug coverage phone number.

Additional Drug Insurance

Added Date

Output

Date the additional drug insurance was added.

Additional Drug Insurance

Updated Date

Output

Date the additional drug insurance was updated.



Table 2‑23: Additional Insurance Information (M251) Screen Messages

Additional Insurance Information (M251) Screen Messages

Message Type

Message Text

Suggested Action

No data

No additional insurance information found for <claim number>.

No corresponding data is available for the claim number. If the user expects to see data, verify the claim number and try again. If the claim number is correct, the user contacts MAPD Help Desk for assistance.

Software or Database Error

Invalid additional insurance results retrieved for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Error occurred while retrieving additional insurance information for <claim number>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Unexpected error code from database=<error code>.

Contact MAPD Help Desk for assistance.

Software or Database Error

Connection error.

Contact MAPD Help Desk for assistance.

      1. Viewing Low-Income Subsidy (LIS) Information of a Beneficiary

The Low-Income Subsidy screen shows a beneficiary’s valid LIS and LIS denied periods. The Low-Income Subsidy (M252) screen, Figure 2-13, is only available to the state user role.

Step 7: Viewing the Beneficiary Detail: Low-Income Subsidy (M252) Screen

The user logs into the system and navigates to the |Beneficiary| link to search for a beneficiary. Then the user clicks the |Low-Income Subsidy| menu item at the top of the screen, which displays the beneficiary’s low-income status periods. The fields on the screen are described in Table 2-23, with screen messages provided in Table 2-24.

Low Income Subsidy (M252) Screen Figure 2‑13: Low-Income Subsidy (M252) Screen


Table 2‑24: Low-Income Subsidy (M252) Field Descriptions and Actions

Low-Income Subsidy (M252) Field Descriptions and Actions

Screen Area

Item

Type

Description

Low-Income Subsidy

Subsidy Start Date

Output

Date the beneficiary’s LIS period started.

Low-Income Subsidy

Subsidy End Date

Output

Date the beneficiary’s LIS period ended.

Low-Income Subsidy

Premium Subsidy Level

Output

Part D premium LIS percent level. Values are:

  • 100

  • 75

  • 50

  • 25

Low-Income Subsidy

Co-Pay Level

Output

The number to indicate the co-payment level assigned to the beneficiary.

0 – None, not low-income.

1 – High – Assigned to Full Duals with income > 100% FPL, Partial Duals, and Recipients of SSI.

2 – Low – Assigned to Full Duals with income at or below 100% FPL.

3 – No Copay – Assigned to Full Duals who are institutionalized or receiving home and community-based services (HCBS).

4 – 15%.

5 – Unknown.

Space – Not applicable.

Low-Income Subsidy

Subsidy Source

Output

A – Approved SSA or state applicant.

D – Deemed eligible by CMS.

Space – Not applicable.

Low-Income Subsidy

Added Date

Output

Date the low-income subsidy period was added.

Low-Income Subsidy

Updated Date

Output

Date the low-income subsidy period was updated.

Low-Income Subsidy

Audited Date

Output

Date the low-income subsidy period was audited.

Low-Income Subsidy

Record Type

Output

Valid (V) or Audited (A) row.

Low-Income Subsidy Denied

Subsidy Disapproval Date

Output

Date the low-income subsidy period was disapproved.

Low-Income Subsidy Denied

Audited Date

Output

Date the low-income subsidy period was audited

Low-Income Subsidy Denied

Record Type

Output

Valid (V) or Audited (A) row.



Table 2‑25: State User (M252) Screen Messages

State User (M252) Screen Messages

Message Type

Message Text

Suggested Action

No data

No Low-Income Subsidy information found for claim number

No corresponding data is available for that claim number.

Software or Database Error

Error occurred while retrieving beneficiary results for claim number <claim number>

Contact the MAPD Help Desk.

Software or Database Error

Error occurred while retrieving beneficiary Low-Income Subsidy history for claim number <claim number>

Contact the MAPD Help Desk.

Software or Database Error

Missing input on retrieval of beneficiary Low-Income Subsidy history

Contact the MAPD Help Desk.

Software or Database Error

Invalid screen ID

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from database=<error code>

Contact the MAPD Help Desk.

Software or Database Error

Connection error

Contact the MAPD Help Desk.



      1. Viewing Eligibility Information for Beneficiaries

Step 8: Viewing Beneficiary Eligibility

Beneficiary eligibility provides information regarding a beneficiary’s entitlement for Part A, Plan B, and eligibility for Part D, as applicable and relevant to the Plan. If the beneficiary is eligible for Part D LIS, then the number of uncovered months and the details of that subsidy are indicated. Periods, when a beneficiary is covered in a Plan that qualifies for the Retiree Drug Subsidy (RDS), are shown. Periods, when a beneficiary was covered in a Part D Plan, are also shown. A display of all of a beneficiary’s enrollments is shown in the Enrollment Information section of the screen with the most recent enrollment as the top row.

Drug Plan information is shown as a column in the Enrollment Information section. Please note that multiple lines do not necessarily mean there were multiple periods of enrollment. The lines denote the timeframes during which the contract provided drug coverage.

STEP 8a: Viewing the Beneficiary: Eligibility (M232) screen

From the main menu, the user clicks on the |Beneficiaries| menu item and then clicks on the |Eligibility| submenu item to view the Beneficiary: Eligibility (M232) screen.

The next step is to identify the beneficiary by claim number on the Beneficiary: Eligibility (M232) screen, Figure 2-14. Field descriptions are listed in Table 2-26, with screen messages provided in Table 2-27.

Picture 1 Figure 2‑14: State User Beneficiary: Eligibility (M232) Screen


Table 2‑26: State User (M232) Field Descriptions and Actions

State User (M232) Field Descriptions and Actions

Item

Inputs/Outputs

Description

Search Criteria

Claim #

Required data entry field

Identifies the beneficiary whose eligibility information displays.

Date

Date field

Provide eligibility information as of this date.

[Find]

Button

The user clicks on this button after entering the beneficiary claim number. If the beneficiary is found, eligibility information for the beneficiary is displayed.

Beneficiary Identification

Claim Number

Output

Claim number of the beneficiary.

Claim Number Cross Reference

Output

Most recent cross-referenced claim number of the beneficiary.

Name

Output

Name of the beneficiary.

Birth Date

Output

Date of birth of the beneficiary.

Date of Death

Output

Date of death of the beneficiary.

Sex

Output

Sex of the beneficiary.

Address

Output

Mailing address: street, city, state, and zip code of beneficiary.

Most recent state

Output

The most recent state on record for the beneficiary.

Most recent County

Output

The most recent county on record for the beneficiary.

Enrollment Information

Contract

Output

Contract number for the beneficiary’s enrollment(s).

PBP

Output

PBP number for the beneficiary’s enrollment(s).

Start

Output

Start date of the beneficiary’s enrollment(s).

End

Output

End date of the beneficiary’s enrollment(s).

Drug Plan

Output

Drug Plan indicator for the beneficiary’s enrollment(s).

Entitlement Information

Part column

Output

Entitlement information that applies to the Part A and Part B of Medicare.

Start column

Output

When the entitlement period began.

End column

Output

When the entitlement period ended, as applicable.

Option column

Output

Option selected for this part. See Section 3 for Entitlement Code values.

Eligibility Information

Part column

Output

Eligibility information that applies to this Part D of Medicare.

Start column

Output

When the eligibility period began.

End column

Output

When the eligibility period ended, as applicable.

Number of Uncovered Months (NUNCMO)

Start Date

Output

Start Date for uncovered months’ period.

Indicator

Output

Indicator showing record type. Values are:

R = Reset

L = LIS

A = Aged 65 IEP

NUNCMO

Output

Number of Uncovered Months.

Total NUNCMO

Output

Total NUNCMO based on the Indicator.

Record Add-Timestamp

Output

Timestamp for when the record was added.

Employer Subsidy

Start Date column

Output

When a Retiree Drug Subsidy (RDS) coverage period began.

End Date column

Output

When an RDS coverage period ended.

Part D Enrollment

Start Date column

Output

When a Part D enrollment began for the beneficiary.

End Date column

Output

When a Part D enrollment ended for the beneficiary.

Low-Income Status

Subsidy Start Date column

Output

When the subsidy of Part D premiums began.

Subsidy End Date column

Output

When the subsidy of Part D premiums ended, as applicable.

Premium Subsidy Level column

Output

Level at which the premiums are subsidized. Values are:

  • 100

  • 75

  • 50

  • 25

Co-Payment Level column

Output

The number to indicate the co-payment level assigned to the beneficiary.

0 – None, not low-income.

1 – High – Assigned to Full duals with income > 100% FPL, Partial Duals, and Recipients of SSI.

2 – Low – Assigned to Full Duals with income at or below 100% FPL.

3 – No Copay – Assigned to Full Duals who are institutionalized or receiving home and community-based services (HCBS).

4 – 15%.

5 – Unknown.

Space – Not applicable.

Subsidy Source Column

Output

A – Approved SSA or state applicant.

D – Deemed eligible by CMS.

Space – Not applicable.



Table 2‑27: State User (M232) Screen Messages

State User (M232) Screen Messages

Message Type

Message Text

Suggested Action

No claim number

User must enter a claim number.

The user enters the claim number.

Invalid format

The claim number is not a valid SSA, RRB, or CMS internal number.

The user re-enters the claim number.

Invalid format

The claim number is missing the required BIC.

The user re-enters the claim number to include both CAN and BIC.

Invalid date

Date is invalid. Must have format (M)M/(D)D/YYYY

The user re-enters the date.

Informational

The beneficiary is not enrolled in any Plan for “MM/DD/YYYY.”

None

Informational

There is no eligibility information for the beneficiary.

None

Informational

There are no employer subsidies for the beneficiary

None

Informational

There is no Part D enrollment information for the beneficiary

None

Informational

There are no low-income subsidies for the beneficiary

None

Informational

There are no number of uncovered months for the beneficiary

None

Informational

Pre-enrollment information for the beneficiary is displayed

None

No data

Beneficiary not found

The user checks the claim number. If it is incorrect, the user re-enters it.

Software or Database Error

Error occurred while retrieving beneficiary entitlement information

Contact the MAPD Help Desk.

Software or Database Error

Error occurred while retrieving Part D Enrollment information for claim number<claim number>

Contact the MAPD Help Desk.

Software or Database Error

Error occurred while retrieving the number of uncovered months information for claim number<claim number>

Contact the MAPD Help Desk.

Software or Database Error

Error occurred while retrieving beneficiary low-income status information for claim number<claim number>

Contact the MAPD Help Desk.

Software or Database Error

Unexpected error code from database=<error code>

Contact the MAPD Help Desk.

Software or Database Error

Connection error

Contact the MAPD Help Desk.

Entitlement, Eligibility, employer subsidy, and LIS are displayed as follows:

  • If a date is entered, then only the information for that date is shown.

  • If a date is not entered and the beneficiary is enrolled in a Plan, then-current, historical, and future information is shown.

  • If the beneficiary is not enrolled in a Plan, then only the current information is shown.

  • When the beneficiary is not covered by a Plan that received the RDS, a message is displayed in the Employer Subsidy section.

  • When the beneficiary does not receive a Part D LIS, a message displays in the LIS section.

NUNCMO section displays as follows:

  • The 10 most recent periods of Part D enrollment are shown, including Plans with employer subsidies.

  • If there are several Part D enrollments back to back, the screen displays the start date of the first enrollment and the end date of the last enrollment.

  • When the beneficiary does not have Part D Enrollment information, a message displays in the Part D Enrollment section.

Tooltips display when hovering over the Indicator and Record Type columns Part D enrollments.

Enrollment Information displays as follows:

  • The Contract number, Effective date, PBP, Plan Type Code & Description, and Drug Plan indicator of the beneficiary’s current enrollment in the PBP are displayed.

  • If the beneficiary is dual enrolled, the system displays the drug and non-drug Contract information for both of the beneficiary’s current enrollments in PBPs.

  • If the beneficiary is enrolled in a Plan that does not have PBPs, the Contract, Drug Plan indicator, and the Effective Date of the beneficiary’s current enrollment are displayed.

  • If the user enters a date in the “Date” field, the system considers the entered date as the current date when displaying the beneficiary’s current enrollment information.



      1. Viewing Status Activity and Detail Information for Beneficiaries

Step 9: Viewing Status Activity

The Status Activity (M256) screen, Figure 2-15, displays a beneficiary’s current health status information, as well as current values for eligibility, uncovered months, low-income subsidy, and state and county codes. Field descriptions are listed in Table 2-28.

The following special status categories will display on the screen:

  • SSA State and County Codes

  • Low-Income Subsidy

  • Number of Uncovered Months

  • Health Status Flags (ESRD, MSP, Home and Community Based Services (HCBS), Medicaid)

  • Eligibility Status Flags (Part A, Part B, and Part D)

  • Incarceration

  • Not Lawfully Present

  • Employer Subsidy

  • IC Model Status

  • Opt-Out Part D

  • Opt-Out MMP

M256 Screen Figure 2‑15: State User Status Activity (M256) Screen

If a beneficiary has a history of special status, a “View” hyperlink will be displayed in the history column for that special status. When the user selects the hyperlink, the user can view the special status history on the Status Detail screen.



Table 2‑28: Status Activity (M256) Field Descriptions and Actions

Status Activity (M256) Field Descriptions and Actions

Item

Type

Description

[Close]

Button

Click this button to exit the active window.

[Print]

Button

Click this button to produce a paper-based copy of the screen content

[Help]

Button

Click this button to open the MARx Help system

SSA State and County Codes‑State

Output

Current state of residence abbreviation and number as provided by SSA

SSA State and County Codes‑County

Output

Current county of residence abbreviation and number as provided by SSA.

SSA State and County Codes‑History

Link

View link appears for the user to access the Status Detail: [status category] (M257) screen, when detailed information exists for a specific beneficiary’s status. Otherwise, this field is blank.

Health Status Flags‑Active

Output

A yes or no indicator to show that the status is either active or audit information for the beneficiary as of today.

Y’ = status active.

N’ = status is not active.

Health Status Flags‑Type

Output

Current health status information for these special status subcategories:

  • ESRD (End-Stage Renal Disease)

  • MSP (Medicare Secondary Payer)

  • NHC (Nursing Home Certifiable)

  • HHC (Home Health Care)

  • Medicaid

  • Hospice

  • HCBS (Home and Community Based Services)

  • XREF (Cross Reference)

  • Institutional

  • Long Term Institutional

  • Disabled

Health Status Flags‑History

Output

View link appears for the user to access the Status Detail: [status category] (M257) screen, when detailed information exists for a specific beneficiary’s status. Otherwise, this field is blank.

Eligibility Status Flags – Active

Output

A yes or no indicator to show that the status is either active or audit information for the beneficiary as of today.

Y’ = status active.

N’ = status is not active.

Eligibility Status Flags‑Type

Output

Current active or audit eligibility status listed for each of these eligibility subcategories:

  • Part A

  • Part B

  • Part D

  • Incarceration

  • Not Lawfully Present

  • Employer Subsidy

  • IC Model Status

  • Opt-Out Part D

  • Opt-Out MMP

Eligibility Status Flags‑History

Output

View link appears for the user to access the Status Detail: [status category] (M257) screen, when detailed information exists for an eligibility type. Otherwise, this field is blank.

Low-Income Subsidy‑LI Subsidy Start

Output

The effective date (MM/DD/YYYY) when this LIS begins.

Low-Income Subsidy‑LI Subsidy End

Output

The effective date (MM/DD/YYYY) when this LIS ends.

Low-Income Subsidy‑LI Premium Subsidy Level

Output

Percentage of LI subsidy for this LIS event expressed as ###%, where values are:

  • 100

  • 75

  • 50

  • 25

Low-Income Subsidy‑Co‑payment Level

Output

The number to indicate the co-payment level assigned to the beneficiary.

0 – None, not low-income.

1 – High – Assigned to Full duals with income > 100% FPL, Partial Duals, and Recipients of SSI.

2 – Low – Assigned to Full Duals with income at or below 100% FPL.

3 – No Copay – Assigned to Full Duals who are institutionalized or receiving home and community-based services (HCBS).

4 – 15%.

5 – Unknown.

Space – Not applicable.

Low-Income Subsidy‑History

Link

View link appears for the user to access the Status Detail: [status category] (M257) screen, when detailed information exists for an eligibility type. Otherwise, this field is blank.

Uncovered Months‑Months

Output

The current and total number of months that a beneficiary was without creditable coverage.

Uncovered Months‑History

Link

View link appears for the user to access the Status Detail: [status category] (M257) screen, when detailed information exists for an eligibility type. Otherwise, this field is blank.



Step 9a: Viewing Status Detail

The Status Detail: Medicaid (M257) screen, Figure 2-16, displays data specific to each of the special statuses (e.g., ESRD, MSP, Medicaid, HCBS, Incarceration, etc.) and, if applicable, the data records/periods that are valid and audited. The most common data values populated on the Status Detail screen are:

  • Status Start and End Date

  • Valid/Audit Record

  • Record Add Timestamp

  • Record Update Timestamp

  • Record Audit Timestamp

State User Status Detail Valid Record (M257) Screen Figure 2‑16: State User Status Detail: Medicaid (M257) Screen - Valid Record

If an entry contains audited information, the user can select the “View Audit” link to view the audited information history for most of the statuses, Figure 2-17.

State User Status Detail Audited Record (M257) Figure 2‑17: State User Status Detail: Medicaid (M257) - Audited Record

The Status Detail Screen also contains information on periods of incarceration and not lawfully present that restricts the beneficiary’s eligibility for enrollment. The screen displays the start and end dates of ineligibility from Medicare Plan enrollment and the start and end dates of SSA benefits suspension. If applicable, the Status Detail: Incarceration (M257) screen, Figure 2-18, displays by selecting the “Incarceration” Eligibility Status Flag from the Status Activity (M256) Screen. Field descriptions are listed in Table 2-29, with screen messages provided in Table 2-30.

Status Detail  ̶  Incarceration (M257) Screen Figure 2‑18: State User Status Detail: Incarceration (M257) Screen



Table 2‑29: Status Detail (M257) Field Descriptions and Actions

Status Detail (M257) Field Descriptions and Actions

Item

Type

Description

[Close]

Button

Click this button to exit the active window

[Print]

Button

Click this button to produce a paper-based copy of the screen content.

[Help]

Button

Click this button to open the MARx Help system.

View Audit/Hide Audit

Link

Click this link to change the default display of valid records to display both valid and audited records for this status category/subcategory

Status Period Start Date

Output

The effective date (MM/DD/YYYY) for this status record.

Status Period End Date

Output

The effective date (MM/DD/YYYY) for this status record.

State

Link

State of residence abbreviation and number as provided by SSA.

County

Output

County of residence abbreviation and number as provided by SSA.

Valid/Audit

Output

A 1-letter indicator to show that the record is valid or audited information.

V’ = Valid information.

A’ = Audited information/

Record Add Timestamp

Output

Date and time (MM/DD/YYYY HH:MM:SS) the record was added.

Record Update Timestamp

Output

Date and time (MM/DD/YYYY HH:MM:SS) the record was updated.

Record Audit Timestamp

Output

Date and time (MM/DD/YYYY HH:MM:SS) the record was audited. Only displays for records with a Valid/Audit status of ‘A’.

Premium Subsidy Level

Output

Level at which the premiums are subsidized. Values are:

  • 100

  • 75

  • 50

  • 25

Co-Payment Level

Output

The number to indicate the co-payment level assigned to the beneficiary.

0 – None, not low-income.

1 – High – Assigned to Full duals with income > 100% FPL, Partial Duals, and Recipients of SSI.

2 – Low – Assigned to Full Duals with income at or below 100% FPL.

3 – No Copay – Assigned to Full Duals who are institutionalized or receiving home and community-based services (HCBS).

4 – 15%.

5 – Unknown.

Space – Not applicable.

Subsidy Source

Output

A – Approved SSA or state applicant.

D – Deemed eligible by CMS.

Space – Not applicable.

Indicator

Output

NUNCMO indicator showing record type. Values are:

R = Reset

L = LIS

A = Aged 65 IEP

Number of Uncovered Months

Output

Number of Uncovered Months.

Total Number of Uncovered Months

Output

Total number of Uncovered Months based on the Indicator.

Primary Insurance Code

Output

A 2-digit code and description of the primary insurer.

Source Code

Output

A 5-digit code to identify the MSP source.

COB Contractor Code

Output

A 5-digit code to identify the Coordination of Benefits (COB) contractor.

Coverage Type Code

Output

A 1-letter code and description of the type of coverage.

Start Source

Output

Name of entity (contract or system) that provided notification that the NHC period began.

End Source

Output

Name of entity (contract or system) that provided notification that the NHC period stopped.

Earliest Bill Date

Output

First date (MM/DD/YYYY) that HHC billed.

Latest Bill Date

Output

Last date (MM/DD/YYYY) that HHC billed.

Contractor Number

Output

A 5-digit number to identify the HHC contractor.

Status Code

Output

A 2-digit code and description to identify the status code for the selected status category.

Provider Number

Output

A 7-character alphanumeric code to identify the HHC provider.

Medicaid Source

Output

The source of Medicaid.

State

Output

Current state of residence abbreviation and number as provided by SSA.

Premiums Payer Code

Output

A 3-digit code to identify the premium payer.

Dual Status Code

Output

A 2-digit code and description to identify the dual element status.

Revocation Code

Output

A 1-character code and description to identify Hospice revoked.

XREF Date

Output

Date (MM/DD/YYYY) that the cross-reference event occurred.

XREF Claim #

Output

Claim number related to the cross-reference event.

Change/Merge

Output

Identifies the cross-reference event as either a change or a record merge.

Status Switch

Output

A 1-character code to identify a status switch event for the status detail category.

Y’ = Status switch occurred.

N’ = Status switch did not occur.

Coverage Year

Input

Defaults to the current year. Optionally, select the desired Long-Term Institutional (LTI) year.

Status Month

Output

Name of the month for which the LTI status is being reported.

Entitlement Start Date

Output

Date (MM/DD/YYYY) entitlement began for this status record.

Entitlement End Date

Output

Date (MM/DD/YYYY) entitlement ended for this status record.

Enrollment Reason

Output

A 1-character code and description to identify the reason for enrollment.

Non‑Entitlement Reason

Output

A 1-character code and description to identify the reason a beneficiary was not entitled to enrollment.

Entitlement Status

Output

A 1-character code and description to identify the reason for entitlement.

Eligibility Start Date

Output

Date (MM/DD/YYYY) eligibility began for this status record.

Eligibility End Date

Output

Date (MM/DD/YYYY) eligibility stopped for this status record.

Eligibility Reason

Output

A 1-character code and description to identify the reason for eligibility.

Stop Reason

Output

A 1-character code and description to identify the reason that eligibility stopped.

Medicare Plan Ineligibility Start Date

Output

Date (MM/DD/YYYY) ineligibility began for this status record.

Medicare Plan Ineligibility End Date

Output

Date (MM/DD/YYYY) ineligibility ended for this status record.

SSA Benefit Suspension Start Date

Output

Date (MM/DD/YYYY) SSA benefit suspension began for this status record.

SSA Benefit Suspension End Date

Output

Date (MM/DD/YYYY) SSA benefit suspension ended for this status record.

Resumption Date Present

Output

A 1-character code to identify the presence of a resumption date for the status detail category. The presence of a resumption date indicates that the incarceration period was removed.

Y’ = Resumption date is present.

N’ = Resumption date is not present.



Table 2‑30: Status Detail (M257) Screen Messages

Status Detail (M257) Screen Messages

Message Type

Message Text

Suggested Action

No data

No status information found for <claim number>

No corresponding data is available for that contract number.

Software or Database Error

Error occurred retrieving beneficiary results

Contact the MAPD Help Desk to report the error.

Software or Database Error

Error occurred retrieving beneficiary status history

Contact the MAPD Help Desk to report the error.

Software or Database Error

Missing input on retrieval of the beneficiary status history

Contact the MAPD Help Desk to report the error.

Software or Database Error

Invalid screen ID

Contact the MAPD Help Desk to report the error.

Software or Database Error

Unexpected error code from database=<error code>

Contact the MAPD Help Desk to report the error.

Software or Database Error

Connection error

Contact the MAPD Help Desk to report the error.



      1. Logging Out of the Medicare Advantage and Part D Inquiry System

When the user is finished with all activities, the user should log out. If the user does not log completely out, the session eventually times out. Logging out as soon as the user is finished with the system is a more secure process to follow and is therefore recommended.

If the browser window is closed, the user is logged out automatically. To simplify logging out, the user may use the logout screen to close all windows in one step.

When the user logs on to the system, the logon screen is replaced with a logout screen as shown in Figure 2-19 and described in Table 2-31, with screen messages provided in Table 2-32. This logout screen is behind the MARx UI primary window and the user may access it at any time by selecting the window.

The user clicks on the [Logout] button; the browser asks if the user wants to close the window.

State User Logout Screen Figure 2‑19: State User Logout Screen

Table 2‑31: State User Logout Screen Field Descriptions and Actions

State User Logout Screen Field Descriptions and Actions

Item

Input/Output

Description

[Logout]

Button

The user clicks on this button to log out of the system, closing all windows.



Table 2‑32: State User Logout Screen Messages

State User Logout Screen Messages

Message Type

Message Text

Suggested Action

Process

The webpage you are viewing is trying to close the window. Do you want to close this window? [Yes] or [No]

The user clicks on the [Yes] button to close the window. The user clicks on the [No] button to keep the window open.



      1. Validation Messages

Table 2-33 lists validation messages that appear directly on the screen during data entry/processing in the status line (the line just below the title line, as in Figure 2-20)

Validation Message Placement on Screen

Figure 2‑20: Validation Message Placement on Screen

These are common validation messages, not specific to a single screen but related to the fields that appear on many screens. Note that screen/function-specific messages appear in the section related to the specific function and are associated with the specific screen.


Table 2‑33: Validation Messages

Validation Messages

Error Messages

Suggested Action

User must enter a contract number

Enter the field specified by the message.

A contract number must start with an ‘E’, ‘H’, ‘R’, ‘S’, ‘X,’ or ‘9’, followed by four characters

Re-enter the field and follow the format indicated in the message.

User must enter a sex

Enter the field specified by the message.

User must select a state

Enter the field specified by the message.

Invalid Contract/PBP combination

Check the combination and re-enter.

Invalid Contract/PBP/segment combination

Check the combination and re-enter.

<kind-of-date> is invalid. Must have the format (M)M/(D)D/YYYY

Re-enter the field and follow the format indicated in the message.

User must enter <kind of date>

Enter the field specified by the message.

PBP number must have three alphanumeric characters

Re-enter the field and follow the format indicated in the message.

Please enter at least one of the required fields

Make sure to enter all the required fields.

Please enter user ID or password

Make sure to enter one of the fields specified by the message.

Segment number must have three digits

Re-enter the field and follow the format indicated in the message.

The claim number is not a valid SSA or RRB number, or CMS Internal number

Re-enter the field in SSA, RRB, or CMS Internal format.

The last name contains invalid characters

Re-enter the field using only letters, apostrophes, hyphens, or blanks.

The user ID contains invalid characters

Re-enter the field and follow the format indicated in the message.



























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  1. Entitlement Status, Enrollment, and Disenrollment Reason Codes

The tables below list the codes for Part A and Part B Entitlement Status, Non-Entitlement Status, Enrollment, and Disenrollment Reasons.

Table 3‑1: Part A – Entitlement Status Codes

Part A Entitlement Status Codes

Code

Definition

Entitlement Date is Present and Termination Date is Blank

E

Free Part A Entitlement

G

Entitled due to good cause

Y

Currently entitled, premium is payable

Entitlement Date and Termination Date are Present

C

No longer entitled due to disability cessation

S

Terminated, no longer entitled under ESRD provision

T

Terminated for non-payment of premiums

W

Voluntary withdrawal from premium Part A coverage

X

Free Part A terminated because of Title II termination



Table 3‑2: Part A – Non-Entitlement Status Codes

Part A Non-Entitlement Status Codes

Code

Definition

Both Entitlement Date and Termination Date are Blank

D

Coverage denied

F

Terminated due to invalid enrollment or enrollment voided

H

Ineligible for free Part A, or did not enroll for premium Part A

N

Not valid SSA HIC, used by CMS 3rd party sys for potential PTA entitled date

R

Refused benefits



Table 3‑3: Part A – Enrollment Reason Codes

Part A – Enrollment Reason Codes

Code

Definition

A

Attainment of age 65.

B

Equitable relief.

D

Disability – Under age 65 entitlement.

G

General Enrollment Period.

I

Initial Enrollment Period.

J

MQGE entitlement.

K

Renal disease not reason for entitled prior to 65 or 25th month of disability.

L

Late filing.

M

Termination based on renal entitlement but disability based on entitlement continues.

N

Age 65 and uninsured.

P

Potentially insured beneficiary is enrolled for Medicare coverage only.

Q

Quarters of coverage requirements are involved.

R

Residency requirements are involved.

T

Disabled working individual.

U

Unknown blank = not applicable; e.g. Part A data is generated at age 64 years, 8 months.



Table 3‑4: Part B – Entitlement Status Codes

Part B Entitlement Status Codes

Code

Definition

Entitlement Date is Present and Termination Date is Blank

G

Entitled due to good cause

Y

Currently entitled, premium is payable

Entitlement Date and Termination Date is Present

C

No longer entitled due to cessation of disability

F

Terminated due to invalid enrollment or enrollment voided

S

Terminated, no longer entitled under ESRD provision

T

Terminated for non-payment of premiums

W

Voluntary withdrawal from coverage



Table 3‑5: Part B – Non-Entitlement Reason Codes

Part B Non-Entitlement Status Codes

Code

Definition

Both Entitlement Date and Termination Date are Blank

D

Coverage denied

N

No Foreign/Puerto Rican Beneficiary is not entitled to SMI or dually/Technically entitled Beneficiary ID not entitled to SMI.

R

Refused benefits




Table 3‑6: Part B - Enrollment Reason Codes

Part B - Enrollment Reason Codes

Code

Definition

B

Equitable relief.

C

Good cause.

D

Deemed date of birth.

F

Working aged.

G

General enrollment period.

H

Entitlement based on health hazard.

I

Initial enrollment period.

K

Renal disease was a reason for entitlement prior to age 65 or prior to the 25th month of disability.

M

Renal entitlement terminated, but disability-based entitlement continues.

P

Medicare Part B Immunosuppressive Drug (Part B-ID)

R

Residency requirements are involved.

S

State buy-in.

T

Disabled working individual *.

* = future – current CMS program edits do not create this code.

U

Unknown.



Table 3‑7: Disenrollment Reason Codes

Disenrollment Reason Codes

Code

Definition

01

Failure to pay Premiums

02

Relocation out of Plan Service Area (No special provisions)

03

Failure to convert to Risk Provisions

04

Fraud

05

Loss of Park B Entitlement

06

Loss of Part A Entitlement (Plan-specific)

07

For cause

08

Report of death

09

Termination of Contract (CMS-initiated)

10

Termination of Contract/Plan Benefit Package (PBP)/Segment (Plan withdrawal)

11

Voluntary disenrollment through Plan

12

Voluntary disenrollment through District Office

13

Disenrollment because of enrollment in another Plan

14

Retroactive

15

Terminated in error by CMS system

16

End of State and County Code (SCC) Conditional Enrollment Period

17

Beneficiary does not meet Age Criterion (Plan-specific)

18

Rollover

19

Terminated by Social Security Administration (SSA) District Office

20

Invalid enrollment with End-Stage Renal Disease (ESRD)

21

Cannot Travel/Poor Health/ to Health Maintenance Organization (HMO)/Plan Doctors

22

Spouse is no longer a Member of HMO/Plan

23

Couldn’t use Medicare Card to see other Plans

24

Did not know I joined this HMO

25

Difficulty reaching HMO/Plan Doctor by phone problem

26

Called HMO/Plan could not get help with the problem

27

Dissatisfied with Medical Care/Doctors or Hospital

28

Told by Plan Doctors or Staff I should disenroll

29

Prefer Traditional Medicare

30

Have other Health Insurance benefits available

31

Found HMO/Plan to be too confusing

32

My Claims/Bills were not paid

33

Had little or no choice of Specialist

34

Treated discourteously by Doctor/Nurse/Staff

35

Doctor could not improve my condition

36

HMO/Plan Medical Group was located too far away

37

Had limited or no choice of my Primary Doctor

41

You moved permanently out of area where Plan provides service

42

Your Doctor or the Plan told you to disenroll

43

Your Doctor did not give you good quality care

44

You used up the Prescription Allowance

45

The Plan cost you too much

46

You could not get care when you needed it

47

Your Doctor is not in the Plan

48

You did not know you signed up for this Plan

49

You did not like how the Plan worked

50

Rolled-over enrollment removed/audited

54

Part A or B start date change

56

Beneficiary Medicaid period received

57

Beneficiary Hospice period received

59

Invalid enrollment with Hospice

60

Beneficiary lives in the USA less than 183 days a year

61

Loss of Part D eligibility

62

Part D disenrollment due to failure to pay IRMAA

63

MMP (Medicare and Medicaid Plan) Opt-Out after enrolled

64

Loss of demonstration eligibility

65

Loss of Employer Group Plan eligibility

70

Confirmed Incarceration

71

Not Lawfully Present

72

Disenrollment due to Plan-submitted Rollover

88

Conversion

90

Enrollment cancelled due to Beneficiary Merge

91

Failure to Pay Premiums

92

Relocation out of Plan Service Area

93

Lost specific Plan eligibility; Special Needs Plan (SNP) only

99

Other (Not supplied by Beneficiary)

Y8

Report of a death date change


























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

Note: The state monthly file is often referred to as the MMA file, the State Phased-Down (SPD) file, or the Enrollment File. For purposes of consistency, the SUG uses the term MMA file.

    1. State Monthly MMA File Submission Requirements

Since 2005, states have been submitting files at least monthly to CMS to identify all dually eligible beneficiaries. This includes full-benefit dually eligible beneficiaries and partial-benefit dually eligible beneficiaries (i.e., those who get Medicaid help with Medicare premiums, and often for cost-sharing).


The file is called the “MMA file” (after the Medicare Prescription Drug, Improvement and Modernization Act of 2003), but is occasionally referred to as the “state phase-down file.” However, federal regulations at 42 CFR 423.910 now require states, effective April 1, 2022, to submit files daily. Territories do not participate in this data exchange with CMS.


CMS data collection according to MMA requirement implementation will be met by each of the fifty states and the District of Columbia Medicaid agencies (hereafter referred to as states) submitting at least one monthly file, including all known dually eligible beneficiaries and subsequent daily files that provide updates for changes in dual eligibility status (accretions, deletions, and changes).

Daily submission means every business day, but if a state has no new transactions to transmit, data would not need to be submitted on a given business day. Daily submission allows the states to provide current information on updated dual eligibility status and helps promote administrative efficiencies while also benefiting dually eligible beneficiaries and providers.

The MMA files address the following Medicare program needs based on dual-status:


    • Dual Eligible Enrollment

      • Parts A and B: QMB status and related protections

      • Part C: Plan risk adjustment

      • Part D: Auto-enrollment and LIS deeming

    • State Phased-Down Calculation

    • State Low-Income Subsidy (LIS) Applications



    1. Dual Eligible Enrollment

The MMA file submittals will include all full-benefit Medicare-Medicaid dually eligible beneficiaries in the state as well as those only eligible as:

  • Qualified Medicare Beneficiary (QMB)

  • Specified Low-Income Medicare Beneficiary (SLMB)

  • Qualifying Individual (QI) (partial-benefit dually eligible)

  • Retroactive (Retro) records, Prospective (PRO) records

  • State Low-Income Subsidy (LIS) applications for Part D subsidy processed since the last MMA file was created


This will allow CMS to establish the LIS status of dually eligible beneficiaries and to auto-assign beneficiaries to Medicare Part D plans. In addition, CMS uses QMB status to alert providers (via HETS provider eligibility query and via the Remittance Advice) as well as beneficiaries (via Medicare Summary Notice) of prohibitions on collecting cost-sharing for Medicare A/B services. Finally, CMS uses dual status to risk adjustment payments to Part C Medicare Advantage plans.

    1. State Phased-Down Calculation

CMS uses the state’s MMA file submission to calculate the State Phased-Down contribution payment. The Phased-Down process requires a monthly count of all full-benefit dually eligible beneficiaries with an active Part D plan enrollment in the month. CMS will make this selection of records using dual eligibility status codes contained in the person-month record to identify all full-benefit dually eligible beneficiaries (codes 02, 04, and 08).

For more information on the State Phased-Down contribution payment, click here.

In the case wherein a given month, multiple records were submitted for the same beneficiary in multiple file submittals, CMS uses the last record submitted for that beneficiary to determine the final effect on the Phased-Down count.

    1. State Low-Income Subsidy (LIS) Applications

The file may also include records for those beneficiaries for whom the state has made a low-income subsidy determination for an individual applying to the state, i.e., since the last file was created. A record for each Medicare Part D LIS application processed during the month by the state must be included in the file.

CMS strongly encourages states to use the SSA subsidy application (SSA-1020) for subsidy applicants unless a beneficiary specifically requests the state make the subsidy determination using a state application form.

  • States should ask applicants if they have already applied for the subsidy with SSA and if so, urge them to wait for a decision from SSA. However, if the applicant insists on filing with the state prior to an SSA decision, the state must comply.


If a beneficiary requests a state determination or refuses to use the SSA application, the state must use its application and process the case using federal LIS income, family size, and resource rules. Refer to 42 CFR § 423.904 (c). The state follows its process for taking applications. The state is then responsible for notices, appeals, and redeterminations for subsidy cases it has determined using a state application form. For more information, please refer to section 10.3.3, The State Application in the CMS Guidance to States on the Low-Income Subsidy.

  1. State MMA Request File Timing and Content

Sections 5 through 11 pertain to the fifty states and the District of Columbia process of exchanging data with CMS. Section 12 provides information specific to the process for Puerto Rico to exchange data with CMS.

    1. MMA Request File Timing

Each state will send at least one comprehensive MMA Request file to CMS between the start and the end of the enrollment month including all known dually eligible beneficiaries and subsequent daily files that include only file accretions, deletions, and changes in dual eligibility status. Daily means every business day, but if no new transactions are available to transmit, data would not need to be submitted on a given business day.

By month’s end, all file submissions for the month will result in a complete representation of all dually eligible beneficiaries enrolled in the state for that month.

  • States submit a full monthly file and subsequent daily (accretions, deletions, and changes) MMA Request files during the month. Subsequent submissions in the same month will be treated as a unique submission and processed like the first file. For each state file accepted and processed successfully, CMS will send an MMA Response file within 24-48 hours.

    • Note: State MMA Request files submitted successfully between 6:00 a.m. – 5:30 p.m. (ET) will be processed the same day. MMA Response files are processed and sent to states between 9:00 a.m. -10:00 a.m. (ET) the following day.

    • Files received after 5:30 p.m. (ET) will be processed the following day and the response file sent the next day.

    • Example: The state submits an MMA request file to CMS and it is received at 6 pm on 6/21 after the cutoff processing time of 5:30 p.m. The file is processed on the next day 6/22 and the response file is sent on 6/23.

  • Unexpected system issues or planned outages will cause delays in states receiving the MMA Response File within the 24-48-hour window. CMS issues a notification to states via email advising of all delays. If you are not receiving the notifications, contact the MAPD Help Desk at 800-927-8069.

  • CMS will process all files nightly for the LIS deeming and auto-assignment process. The resulting enrollment transactions shall be sent daily (except for Sundays) to the Part D Plans.


  • Files that are rejected based on data quality validation must be resubmitted to CMS by the last day of the month if this is to be the sole submission of the month.

  • If a state submits a file on the last day of the month, and CMS receives it on or after the cutoff processing time, CMS will process the file on the first day of the subsequent month.

The cutoff processing times are:

State File Cutoff Processing Times

Last Day of Month

Cutoff Processing Time

Weekday (including holidays)

5:30 p.m. Eastern Time

Saturday or Sunday

1:00 p.m. Eastern Time



If a file is submitted to CMS on January 31, 2021, at 11:00 p.m. Eastern Standard Time (EST), it would not be processed until February 1, 2021, and all enrollment detail (DET) records submitted as ‘current’ for January 2021would now be treated as retroactive records, any future DET records would be processed as current records.

If no file is successfully submitted for the month, CMS will project enrollment from the prior month’s file and apply retroactive updates based on the subsequent months’ submittals for the Phased-Down calculation.

    1. MMA Request File Content

The Record Identification Code field will identify if the record is an enrollment detail record (DET) for a known dually eligible beneficiary or future Medicaid eligible (not to exceed one month into the future), a prospective full-benefit dually eligible beneficiary (PRO), or a Low-Income Subsidy (LIS) determination record. Medically-needy and other spend-down beneficiaries who have not met their incurred liability for the month and are in inactive enrollment status for the reporting month should not be included. Below are the types of records states should include in their file:

  • Current DET Records

  • Retro DET Records

  • Future DET Records

  • LIS Records

  • PRO Records

      1. Current DET Records

States must include a person-month record for each dually eligible beneficiary for the current reporting month. A person-month record is a full detail record per beneficiary for the current month.

      1. Retro DET Records

The retroactive detail record allows the state to report information on changes in beneficiaries’ circumstances that were effective in one or more prior months. Retroactive records will be identified in the MMA Request file by the effective month and year to which the retroactive record data are to be applied. CMS requires states to submit retroactive records in their files to cover any unreported prior-month changes in one or more of the following values as soon as possible:

  • Eligibility status (including Medicaid eligibility and dual status)

  • Institutional status indicator (including Home- and Community-Based Services (HCBS))

  • Federal Poverty Level (FPL) percentage indicator




The following are examples of the most common situations that would lead to retroactive changes. In each of these cases, the MMA Request file will include a complete person-month record for that beneficiary for the current month, if applicable, and a subsequent record (s) providing a replacement record for each effective month and year of the change.

  1. A state has reported a beneficiary as having eligibility status for the first time in February 2020. The state later determines that the first full month of eligibility was January 2020 and that no other data for January was different. The state sends a retroactive detail record showing this update; the record would change only the eligibility month/year field and maintain all other fields from the February 2020 record.

In the following illustration of this example, you will see that a state would identify the retroactive records in the MMA Request file by the effective month and year to which the retroactive record data are to be applied. The state would submit a detail record for the current month and a new record for the effective month(s) of change. The state corrects the “Elig M/Y,” which should be the only field that changes. All other data fields remain the same.

February File Submission for Current Month

Record ID Code

Elig M/Y

Elig Status

Bene ID

Gender

Date of Birth

Dual Status Code

FPL % Indicator

Institutional Status Indicator

DET

22020

Y

4K88L84HXXX

F

12011950

2

1

Y

March File Submission for Current Month

Record ID Code

Elig M/Y

Elig Status

Bene ID

Gender

Date of Birth

Dual Status Code

FPL % Indicator

Institutional Status Indicator

DET

32020

Y

4K88L84HXXX

F

12011950

2

1

Y

DET

12020

Y

4K88L84HXXX

F

12011950

2

1

Y

DET

22020

Y

4K88L84HXXX

F

12011950

2

1

Y

Abbreviated MMA Request file layout for demonstration purposes.



  1. A state has reported a beneficiary as having a dual-status code of 02 (QMB-plus) in February 2020. The state later determines that a change in the beneficiary’s dual status code occurred 2 months before the reporting month and their dual status code was 08 (Other full benefit dually eligible) beginning in December 2019. The state sends a retroactive detail record showing this update; the file would maintain all fields from December 2019 to February 2020 records and change only the dual status code field.

As you can see in the following graphic, a state would identify the retroactive records in the MMA Request file by the effective month and year to which the retroactive record data are to be applied. The state would submit a detail record for the current month, if applicable, and a new record for the effective months of change (i.e., December 2019 to February 2020). The state would correct the “Elig M/Y” and “Dual-Status Code” fields, while all other fields would remain the same.

February File Submission for Current Month

Record ID Code

Elig M/Y

Elig Status

Bene ID

Gender

Date of Birth

Dual Status Code

FPL % Indicator

Institutional Status Indicator

DET

22020

Y

4K88L84HXXX

F

12011950

2

1

Y

March File Submission for Current Month

Record ID Code

Elig M/Y

Elig Status

Bene ID

Gender

Date of Birth

Dual Status Code

FPL % Indicator

Institutional Status Indicator

DET

32020

Y

4K88L84HXXX

F

12011950

8

1

Y

DET

22020

Y

4K88L84HXXX

F

12011950

8

1

Y

DET

12020

Y

4K88L84HXXX

F

12011950

8

1

Y

DET

122019

Y

4K88L84HXXX

F

12011950

8

1

Y



  1. A state has reported a beneficiary as having eligibility in March but was discovered in February to be deceased during the full month of March would have a change record for March showing an eligibility status of ‘N’ for the March enrollment month.

A state would identify the retroactive records in the MMA Request file by the effective month and year to which the retroactive record data are to be applied. The state would submit a detail record for the current month, if applicable, and a new record for the effective month(s) of change (i.e., March). The state corrects the “Elig M/Y,” which should be the only field that changes. All other data fields remain the same.

  1. If a beneficiary was submitted as a current DET record in a previous submission during the current reporting month as a ‘Y’, but the state discovered the beneficiary was not Medicaid eligible, the state may correct the eligibility status by resubmitting the beneficiary’s record with an ‘N’ in the Medicaid Eligibility Status field for the current reporting month within the same month.

A state would identify the retroactive records in the MMA Request file by the effective month and year to which the retroactive record data are to be applied. The state would submit a detail record for the current month and a new record for the effective month(s) of change. The state corrects the Eligibility Status field which should be the only field that changes. All other data fields remain the same.



NOTE: CMS can automatically process records up to 36 months of retroactivity from the current reporting month. On an exceptional basis, states are allowed to correct information submitted on the MMA file with eligibility months prior to 36 months and not exceeding 120 months. All state submissions meeting these criteria will require prior approval by the Medicare-Medicaid Coordination Office (MMCO) via a request to [email protected].

      1. Future DET Records

The file(s) may also include Medicare beneficiaries who will be identified as Medicaid beneficiaries one month into the future.

      1. LIS Records

The MMA Request file submittal may also include all state LIS applications for Part D subsidy processed since the last file was created.

      1. PRO Records

States should include beneficiaries in state Medicaid programs who are not known to be full-benefit dually eligible but are Medicaid eligible and approaching an age (64 and seven months or older in the reporting month) or disability status that is likely to lead to a future determination of full dually eligibility. See Sections 5.3 – 5.6 for detailed information on PRO Records.



    1. Prospective Full-Benefit Dually Eligible Individuals

One of the concerns related to the monthly MMA reporting cycle is the effect on Medicaid-only beneficiaries who transition to dually eligible status and the difficulty in ensuring a seamless transition in drug coverage. This section will clarify a few key elements that are part of the submission, as well as processing, of these prospective records.

The state should only submit prospective records for beneficiaries with full Medicaid benefits, i.e., beneficiaries who, if they have Medicare coverage, would be full-benefit dually eligible. Do not include beneficiaries who would only be partial-benefit dually eligible, i.e., QMB-only, SLMB-only, or QI. In the dual status code field in the PRO record, include the full-benefit dually eligible status code 08 which best describes the dual status assuming that the beneficiary is Medicare eligible.

    1. PRO Enrollment Process

By including these prospective beneficiaries on the MMA Request file(s), CMS will be able to return information to the states in the MMA Response files for beneficiaries already in Medicare and those projected to receive Medicare coverage within two months prior to the enrollment effective date. CMS will also be able to set up LIS status and auto-enroll beneficiaries into a Part D plan so their coverage will be in place when they become Part D eligible.

This process will help minimize the transitional drug coverage issues for beneficiaries becoming eligible for Part D. This process also provides an opportunity to better synchronize state information on Medicare enrollment.

    1. Submission of PRO Records

For CMS to successfully process a PRO record the following field requirement must be met in the MMA Request Detail Record (See Section 6.4):

  • Record Identification Code (item 1, positions 1-3) must contain ‘PRO’.

  • Eligibility Month/Year (item 2, positions 4-9) of submission must be the CURRENT PROCESSING MONTH/YEAR. CMS will reject past or future dates.

  • A record must contain a ‘Y’ in the Eligibility Status field (item 3, position 10)

  • A record must contain a valid Social Security Number (item 6, positions 27-35). This field cannot be 9-filled or blank.

  • A record must contain a valid Date of Birth (item 13, positions 108-115). If the date of birth is unknown, enter the best available data. This policy applies to DET records as well. CMS will reject records containing no date of birth or an incorrect birth date format.

  • A record must contain a valid Dual Status Code (item 14, positions 116-117) of ‘02’, ’04’ or ‘08’. CMS will reject dual-status codes 01, 03, 05, and 06.

Based on this coding, these records will be subjected to special processing. This processing will bypass counting for the Phased-Down state contribution but will allow CMS to prospectively auto-enroll these beneficiaries and to establish an appropriate Part D LIS level. These records will also be excluded from the file acceptance threshold for a 90-percent Medicare match rate.

PRO records may be submitted in any order within the MMA Request file(s). They may be intermingled with the monthly DET records or separated. CMS will sort the file upon receipt and process each record per the Record Identification Code, item 1 (DET, PRO, LIS).

The information on Medicare status (for Medicare Parts A, B, C, and D) will be returned to the State in the normal response file format. For records that do not match Medicare records, the Medicare enrollment information will be blank. For records having current Medicare enrollment, all available enrollment information will be returned on the response file, including any prospective enrollment dates derived from the SSA prospective enrollment information.

NOTE: Medicare enrollment systems can only return auto-enrollment information for prospective periods two months prior to the enrollment effective date.

Once a beneficiary is identified as a prospective full dual, the beneficiary should be submitted with a Record Identification Code of ‘DET’ in the first month Medicare eligibility is effective. If a beneficiary is identified on the response file as having current or retroactive Medicare coverage, submit retroactive ‘DET’ records covering the missed months of dual eligibility status. Full duals submitted as ‘DET’ records should not be submitted as ‘PRO’ records for the same eligibility month.

    1. Processing of Returned PRO Records

Once the state has submitted its PRO records to CMS for processing, CMS will respond by returning a PRO record for each PRO record submitted, regardless if found on CMS Medicare Beneficiary Database (MBD). A state will receive PRO statistics in the Summary Record, Section 7.6. The layout has been changed to accommodate PRO processing.

Record Return Summary Codes 000009 – 000012 apply to PRO records only. See Record Return Summary Code (item 55, positions 229-234) in Section 7.5 for descriptions.

Valid PRO records that have been matched to the database will contain the same information as matched DET records: Part A/B/C Entitlement dates, Beneficiary Identifier (MBI), Health Insurance Claim Number (HICN), SSNs, End-Stage Renal Disease (ESRD), Part C, Part D, etc.

For matched PRO records, a state should submit a DET record once the period of current dual eligibility has been reached. This information is contained in the Eligibility Information for Parts A/B and D in the MMA Response File. If, for example, a PRO record is returned in the December Response File as matched (Record Return Code = ‘000000’ or ‘000001’) and the Part A/B/D Entitlement Start Date is 01/01/2021, it is anticipated that a DET record will be submitted for this beneficiary in the January 2021 file.

Valid PRO records which were matched and are found to be Part A and/or B entitled within two months of submission will be auto-assigned to a PDP. Auto-assignment may only occur up to two months into the future.

For example, if a beneficiary PRO record was submitted in a December 2020 state request file and was found to be Part A and/or B entitled effective 03/01/2021, the beneficiary would be submitted to the LIS deeming process the evening of file submission, and be returned in the MMA Response file within 24-48 hours with a deeming onset date of 03/01/2021.

If the eligibility date is more than two months into the future, CMS will not auto-assign them until the appropriate time frame has been reached (for this example, any record with a future entitlement date beyond March 2021).

Deeming, however, will occur when the record is received for the appropriate period, regardless of the onset being more than two months into the future.

Already existing Medicare eligibility/enrollment may be returned for beneficiaries submitted by a state on a PRO record of which a state was otherwise not aware. When that occurs, the state should submit retroactive monthly DET records covering the newly-identified period of dual eligibility in the following month’s MMA Request file submission.

    1. Dual Status Codes

Dually eligible beneficiaries include beneficiaries enrolled in Medicare Part A and/or Part B and getting full Medicaid benefits and/or assistance with Medicare premiums or cost-sharing through the Medicare Savings Program (MSP). For each beneficiary, the state includes a dual-status code, and for full-benefit dually eligible beneficiaries, whether their income is over or under 100% FPL, and whether they are institutionalized or qualify for certain home and community-based services (HCBS).

Full-benefit dually eligible beneficiaries are Medicare beneficiaries who qualify for the full package of Medicaid benefits. They often separately qualify for assistance with Medicare premiums and cost-sharing through the MSPs. Full-benefit dually eligible beneficiaries are dual-status codes: 02, 04, and 08.

Partial-benefit dually eligible beneficiaries are enrolled only in Medicare and an MSP. Partial-benefit dually eligible beneficiaries are dual-status codes: 01, 03, 05, and 06.

The following chart summarizes the dual status codes for the seven eligibility categories for dually eligible beneficiaries, including each category’s benefits and basic qualifications. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/MMCO_DualEligibleDefinition.pdf

Dual status codes 09/99 (unknown) are not valid codes to submit on the MMA Request file. 09/99 codes existed for a processing need long ago but no longer serve a purpose for this file today and may be eliminated as a value in the future. A record should always contain a valid dual-status code (01, 02, 03, 04, 05, 06, and 08).

    1. Part B Immunosuppressive Drug (Part B-ID)

Starting January 1, 2023, certain individuals who lose End-Stage Renal Disease (ESRD) Medicare coverage after a successful kidney transplant are eligible for a limited benefit that covers immunosuppressive drug therapy under Medicare Part B (Part B-ID), as required by section 402 of the Consolidated Appropriations Act, 2021.

The Part B-ID benefit solely covers immunosuppressive drugs and no other Medicare items, services, or prescription drugs.

Individuals enrolled in Part B-ID are now considered QMBs, SLMBs and QIs (not just those enrolled in regular Part A and B) if they otherwise meet the eligibility requirements of QMB, SLMB and QI. States would report them with the appropriate dual status codes for QMB-only, SLMB-only, and QI apply per section 5.7.

Individuals are charged a monthly premium for Part B-ID through direct billing by CMS. Individuals eligible for the MSP QMB, SLMB or QI eligibility groups can receive coverage for the Medicare Part B-ID premium and, for QMBs, Part B-ID cost sharing, including the deductible and coinsurance.

On or after January 1, 2023, individuals are eligible for Part B-ID if they:

  • Lose Medicare entitlement on the basis of ESRD 36 months after a successful kidney transplant;

  • Are not otherwise eligible for Medicare; and

  • Complete an attestation through SSA certifying that they do not have or expect to obtain certain other forms of health coverage, including, but not limited to, employer coverage, Medicaid that includes immunosuppressive drugs, and marketplace coverage.

For more information about the Part B-ID benefit, see chapter 2, section 40.9 of the Medicare General Information, Eligibility and Entitlement Manual (IOM 100-01).





  1. MMA Request File

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

      1. Beneficiary Matching Criteria

Key beneficiary fields are used to perform a match between the state’s incoming beneficiary records to the CMS Medicare Beneficiary Database (MBD).

Primary Match Routine

The Primary Match routine uses the values for the following demographic fields from the beneficiary’s MMA Request record to find a match for the beneficiary in the Medicare database:

  • Beneficiary Identifier (HICN, RRB, or MBI)

  • Individual SSN

  • Date of Birth

  • Sex code


After searching to find a match for the beneficiary, the primary match routine returns a response to the MBD State Phased-Down process indicating the outcome of the search.

Secondary Match Routine

The secondary match routine uses the values for the following demographic fields from the beneficiary’s MMA Request file record to find a match for the beneficiary in the Medicare database:

  • Beneficiary Identifier (HICN, RRB, or MBI)

  • Individual SSN

  • First six (6) characters of the Individual Last Name

  • First character of the Individual First Name

  • Sex code

After searching to find a match for the beneficiary, the secondary match routine returns a response to the MBD State Phased-Down process indicating the outcome of the search.

An unsuccessful beneficiary match prevents CMS from sending beneficiary information back to the state in the MMA Response File.

      1. Institutional Status Indicator

The indicator represents a full-benefit dually eligible beneficiary who receives Medicaid-covered nursing facility, inpatient psychiatric hospital, or certain HCBS care. This field, located at item 17 on the MMA Request File, establishes which full-benefit dually eligible beneficiaries (dual status codes 02, 04, 08) qualify for $0 Part D co-payments.

Most non-institutionalized dually eligible beneficiaries pay small co-payments for prescription drugs covered under Medicare Part D. However, section 1860D-14 (a)(1)(D)(i) of the Social Security Act eliminates Medicare Part D co-payments for full-benefit dual eligible beneficiaries who would be institutionalized if they were not receiving services under a home and community-based waiver authorized by a state under section 1115, or subsections (c) or (d) of section 1915, or under a state plan amendment under section 1915(i), or if such services are provided through enrollment in a Medicaid managed care organization with a contract under section 1903(m) or under section 1932.

Since January 1, 2012, states have identified their full-benefit dually eligible beneficiaries (dual status codes 02, 04, 08) who are receiving certain home- and community-based services (HCBS) and coded these beneficiary’s “H” for HCBS in the Institutional Indicator field on the MMA file.

  • Y – Indicates that a full-benefit dually eligible beneficiary is enrolled in a Medicaid-paid institution for the full reporting month, or is projected by the state to be in the institution for the remainder of the month.

  • H (HCBS) – Indicates that a full-benefit dually eligible beneficiary receives HCBS.

States need to submit not only accurate current-month institutional status but retroactive records reflecting institutional status changes (including H codes) in prior months. This is important so beneficiaries are charged the correct Part D copay amount. Errors in coding this field can have significant financial impacts on beneficiaries. This is also necessary to ensure that there is closure on the Part D Plan’s responsibility for copay amounts during the span of coverage.

For example, if a state has reported a beneficiary for the first time as having institutional status in February, even though the first full month in the institution was January, a retroactive enrollment record is needed showing this update. For more information on submitting retro DET records, refer to section 5.2.2, Retro DET records.



    1. MMA Request File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

180

PRN

(States can send multiple files in a day)

This file includes the following records:

    1. MMA Request File Header Record Layout

MMA Request File Header Record

Item

Field

Size

Position

Format

Valid Values

1

Record Identification Code

3

1-3

CHAR

MMA.

2

State Code

2

4-5

CHAR

US Postal Service State Abbreviation.

Example = MD.

See Table 15-3, State Codes.

3

Create Month

2

6-7

NUM

Month the file is created.

4

Create Year

4

8-11

NUM

Year the file is created.

5

Filler

169

12-180

CHAR

Spaces



    1. MMA Request File Detail Record Layout

      MMA Request File Detail Record

      Item

      Field

      Size

      Position

      Format

      Valid Values

      1

      Record Identification Code

      3

      1-3

      CHAR

      DET – Beneficiary is eligible for Medicare and is currently eligible for Medicaid or will be eligible for Medicaid within the next month.

      PRO – Beneficiary is eligible for full Medicaid benefits and although not known to the state as dually eligible is at least 64 years and seven months old or has a disability-related condition.

      LIS – Beneficiary has undergone a low-income subsidy determination within the current month.

      2

      Eligibility Month/Year

      6

      4-9

      NUM

      Calendar month/year for applicable Medicaid eligibility for DET and PRO records; MMCCYY.

      Enter the effective month/year of the change for each retroactive record.

      Retroactive changes must be submitted to reflect prior month changes in one or more of the following fields:

      • Eligibility Status.

      • HICN/RRB/MBI.

      • Social Security Number.

      • Sex.

      • Date of Birth.

      • Dual Status Code.

      • Federal Poverty Level (FPL) % Indicator.

      • Institutional Status Indicator.

      Retroactive records must include replacement values for ALL fields for that record, NOT just for the fields that have changed.

      3

      Eligibility Status

      1

      10

      CHAR

      For DET and PRO records

      Y – Beneficiary is eligible for Medicaid for that eligibility Month/Year.

      N – Beneficiary is not eligible for Medicaid for that eligibility Month/Year.

      CMS will reject a PRO record with ‘N’ in this field.

      4

      Beneficiary’s Identifier

      15

      11-25

      CHAR

      • Health Insurance Claim Number (HICN)

      • Railroad Retirement Board (RRB) Number

      • Medicare Beneficiary Identifier (MBI)

      Whichever the State has active and available for the beneficiary.

      5

      Beneficiary Identifier Indicator Code

      1

      26

      CHAR

      A code that indicates the type of identifier used for the beneficiary. The value should be one of the following.

      • H (HICN).

      • R (RRB Number).

      • M (MBI).

      • Space (Unknown).

      6

      Social Security Number

      9

      27-35

      NUM

      Beneficiary’s SSN.

      CMS will reject a record with no SSN if there is no Beneficiary Identifier (Field 4) reported.

      7

      State Medicaid Agency (SMA) Identifier

      20

      36-55

      CHAR

      Beneficiary’s State Medicaid Agency Enrollee Identifier.

      This field is optional as CMS does not use it.

      8

      Beneficiary’s First Name

      12

      56-67

      CHAR

      Beneficiary’s first name (first 12 letters). This entry is used only for a beneficiary secondary match.

      9

      Beneficiary’s Last Name

      20

      68-87

      CHAR

      Beneficiary’s last name (first 20 letters). This entry is used only for a beneficiary secondary match.

      10

      Beneficiary’s Middle Name

      15

      88-102

      CHAR

      Beneficiary’s middle name (first 15 letters).

      11

      Beneficiary’s Suffix Name

      4

      103-106

      CHAR

      Beneficiary’s suffix name (first four letters). Examples – ‘JR’, ‘III’.

      12

      Beneficiary’s Gender

      1

      107

      CHAR

      Beneficiary’s gender:

      M = Male.

      F = Female.

      U = Unknown.

      9 = Unknown.

      Note: U and 9 can be used interchangeably.

      This entry is used for a beneficiary match.

      13

      Beneficiary’s Date of Birth

      8

      108-115

      NUM

      Enter the beneficiary’s date of birth; MMDDCCYY.

      CMS will reject a detail record without a date of birth or with an invalid date of birth.

      14

      Beneficiary’s Dual Status Code

      2

      116-117

      NUM

      Enter one of the following values for DET records:

      01 – Eligible is entitled to Medicare – QMB only. 02 – Eligible is entitled to Medicare – QMB and full Medicaid coverage.

      03 – Eligible is entitled to Medicare – SLMB only.

      04 – Eligible is entitled to Medicare – SLMB and full Medicaid coverage.

      1. Eligible is entitled to Medicare – QDWI.

      2. Eligible is entitled to Medicare – Qualifying beneficiaries.

      1. Eligible is entitled to Medicare –Other Full Dually Eligibles with full Medicaid coverage.

      States should submit a PRO record only for a beneficiary with full Medicaid benefits, that is, a beneficiary who if he /she had Medicare would qualify for a full dual-status code of ‘08’.


      CMS will reject PRO records with any other dual codes.

      15

      Federal Poverty Level Percentage Indicator

      1

      118

      NUM

      Enter one of the following values for DET and PRO record types:

      1 – Beneficiary’s income at or below 100% FPL.

      2 – Beneficiary’s income above 100% FPL.

      9 – Unknown.

      Do not derive this value from the Dual Status Code.

      16

      Drug Coverage Indicator

      1

      119

      NUM

      Enter ‘9’ in this field.

      This field is not used by CMS.

      17

      Institutional Status Indicator

      1

      120

      CHAR

      Enter one of the following values for DET and PRO records:

      Y – Beneficiary is institutionalized in a nursing facility, intermediate care facility, or inpatient psychiatric hospital for the entire span of eligibility for the month. Only full-benefit dual eligibles will receive the $0 co-pay.

      N – Beneficiary is not institutionalized in a nursing facility, intermediate care facility, or inpatient psychiatric hospital for the entire span of eligibility for the month.

      H (Home and Community Based) – Beneficiary is receiving home and community-based services at any period during the month (‘H’ can be used for Eligibility Month/Year of January 2012 and later.)

      9 – Unknown.

      18

      LIS Application Approval Code

      1

      121

      CHAR

      For LIS records

      Y – Beneficiary’s subsidy application is approved.

      N – Beneficiary’s subsidy application is not approved.

      19

      LIS Approved/

      Disapproved Date

      8

      122-129

      NUM

      MMDDCCYY

      For LIS records, enter the date that state-approved or disapproved the low-income subsidy application.

      20

      LIS Start Date

      8

      130-137

      NUM

      MMDDCCYY

      For LIS records, enter the date that the subsidy begins.

      The day of this entry must be the first day of the month in which the State received the application.

      21

      LIS End Date

      8

      138-145

      NUM

      MMDDCCYY

      For LIS records, enter the date that the subsidy ends.

      The day of this entry must be the last day of the month in which the subsidy ends.

      This field is not required and should be left blank or filled with 9s unless the state has definite knowledge of when the subsidy award ends.

      22

      Income as % of FPL

      3

      146-148

      NUM

      For LIS records

      Enter the percentage of income to Federal Poverty Level (FPL) as defined by the Federal LIS income determination policy.

      23

      LIS Level

      3

      149-151

      NUM

      For LIS records

      Enter one of the following values to describe the portion of Part D premium subsidized, based on a sliding scale linked to FPL %:

      100 – under 136 % FPL,

      075 – 136%-140%,

      050 – 141%-145%, and

      025 – 146%-149%.

      24

      Income Used for Determination

      1

      152

      CHAR

      For LIS records

      1 – Income used for determination is based on the beneficiary.

      2 – Income used for determination is based on the couple.

      25

      Resource Level

      1

      153

      CHAR

      For LIS records

      1 – Beneficiary’s resource limit is over the limit.

      2 – Beneficiary’s resource limit is under the limit.

      26

      Basis of Part D Subsidy Denial

      1

      154

      CHAR

      For LIS records

      Enter the reason that the State denied the subsidy application:

      1 – Not enrolled in Medicare Part A or Part B (NAB).

      2 – Does not reside in the USA (NUS).

      3 – Failure to cooperate (FTC).

      4 – Resources too high (RES).

      5 – Income too high (INC).

      27

      Result of an Appeal

      1

      155

      CHAR

      For LIS records

      Y – This record is the result of an appeal.

      N – If a Y is not entered.

      28

      Change to Previous Determination

      1

      156

      CHAR

      For LIS records

      Y – This record changes a determination sent previously.

      N or 9 – This record does not change a determination sent previously.

      This is a future element.

      29

      Determination Cancelled

      1

      157

      CHAR

      For LIS records

      Y – This record cancels the previously sent record.

      N – If Y is not entered.

      30

      Filler

      23

      158-180

      CHAR

      Spaces

    2. MMA Request File Trailer Record Layout

MMA Request File Trailer Record

Item

Field

Size

Position

Format

Valid Values

1

Record Identification Code

3

1-3

CHAR

TRL

2

Record Count

8

4-11

NUM

Total number of DET, PRO, and LIS records in the file.

3

State Code

2

12-13

CHAR

US Postal Service State Abbreviation. Example = MD.

See Table 15-3, State Codes.

4

Create Month

2

14-15

NUM

Month the file is created.

5

Create Year

4

16-19

NUM

Year the file is created.

6

Filler

161

20-180

CHAR

Spaces.



























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  1. MMA Response File

    1. MMA Response File Specifications

This file will be automatically returned to the state upon the successful processing of an MMA Request File through the same electronic file transfer used to submit the file to CMS.

Unexpected system issues or planned outages will cause delays in states receiving the MMA Response File within the 24-48-hour window. CMS issues a notification to states via email advising of all delays. Notifications are posted on the State Data Resource Center website and can be found here: Medicare Data -> Data File Exchange-> MMA Information -> MMA Announcements or by clicking here.

The content of the MMA Response file will include the following:

  1. 7.4 – MMA Response File Header Record with identifying information, record count summaries, and a copy of the incoming MMA Request file header record, position 116-118.

  2. 7.5 – MMA Response File Detail Record:

    1. Copy of the incoming MMA Request file detail record, position 1-180.

    2. Series of edit error return codes, position 181-228.

    3. Data from the MBD, position 229-4000.

  3. 7.6 – MMA Response File Summary Record including record validation and matching outcomes, position 1-4000.

  4. 7.7 – MMA Response File Monthly Summary Record count by month for each month of enrollment information on the MMA Request file, position 1-4000.

  5. 7.8 – MMA Response File Trailer Record with identifying information and a copy of the incoming MMA Request file trailer record, position 1-4000.

    1. Special Key Fields/User Tips for the MMA Response File

      1. Medicare Part D Enrollment Indicator

The Medicare Part D Enrollment Indicator, item 57, position 236 on the MMA Response Detail record, can have the following values:

  • Value will be ‘0’ for dual beneficiaries who are enrolled in a Part D plan during eligibility month/year.

  • Value will be ‘1’ for dual beneficiaries who are not enrolled in a Part D Plan during eligibility month/year.

      1. Managed Care Organization (MCO) (10 Occurrences)

The MCO Occurrences, items 143-154 on the MMA Response Detail record contains both Medicare Advantage Plans, Program for All-Inclusive Care for the Elderly (PACE), and Demo enrollments offering and not offering Part D drug benefits. The information represents the overall contract/organization within which a beneficiary may have a choice of Plans (Plan Benefit Packages or PBPs). If a rollover from a non-drug covering plan into one that does occur, the enrollment effective date of the MCO would not change but the enrollment periods of the affected PBPs would be updated.

The first occurrence is the active (current or future) or most recent Medicare MCO coverage (i.e. plan enrollment). Presently, this section is populated with Medicare Part C and Medicare Part D organizations enrollments. The organizations can be distinguished by the first position of Beneficiary MCO Number (contract level) (field 145, positions 1479-1483):

H – Local Medicare Advantage (MA), local MAPD, MMP, or non-MA Plan

9 – Non-MA Plan (no longer assigned)

R – Regional MA or MAPD Plan

S – Regular standalone Prescription Drug Plan (PDP)

E – Employer direct PDP

X – Limited-Income Newly Eligible Transition (LiNET)

      1. Plan Benefit Package Enrollment (10 Occurrences)

The Plan Benefit Package Enrollment Occurrence, items 155-168, lists the various PBP enrollments within the given MCO periods mentioned above:

  • The most recent plan enrollment will reside in Occurrence 1, followed by historical enrollments.

  • Presently, this section is populated with Medicare Part C offering no drug coverage as well as offering drug coverage and Part D standalone plans.

  • A beneficiary can have two open enrollment periods, one signifying a managed care plan offering no drug coverage and a PDP standalone. In that case, the MCO contract numbers will be different.

  • Updated list of values for the PBP Coverage Type Code (item 159, positions 1700-1701):

NF – Pay bill option was not found for the contract.

03 – Coordinated Care Plan (CCP)

04 – Medicare Medical Savings Account (MSA)

05 – Private Fee-for-Service (PFFS)

06 – Program of All-Inclusive Care for the Elderly (PACE)

07 – Regional Plan

08 – Demonstration (DEMO)

10 – Health Care Prepayment Plan (HCPP)

11 – Part D Drug Plan Election (PDP)

12 – Chronic Care Demo

13 – Medicare Medical Savings Account Demonstration (MSA Demo)

      1. Part D Plan Benefit Package (10 Occurrences)

The Part D Plan Benefit Package Occurrences (items 207-220) will list the Part D Plans which also triggers the Medicare Part D Eligibility Indicator (item 56) to reflect a ‘0’, denoting ‘Part D Enrollment found’.

This area of the response file describes the various PBP enrollments within the given PDP only periods:

  • The most active plan enrollment will reside in Occurrence 1, followed by historical enrollments.

  • Presently, this section is populated with Medicare Part C plans offering drug coverage as well as Part D standalone plans

  • A beneficiary can have two open enrollment periods, one signifying a managed care plan offering no drug coverage and a PDP standalone. In that case, the MCO contract numbers will be different.



    1. MMA Response File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

4000

Response to MMA Request File.

This file includes the following records:

    1. MMA Response File Header Record Layout

      MMA Response File Header Record

      Item

      Field

      Size

      Position

      Format

      Description

      1

      Record Identification Code

      3

      1-3

      CHAR

      SRF

      2

      File Process Timestamp

      26

      4-29

      CHAR

      The exact time that the State file is processed.

      Format: CCYY-MM-DD-hh.mm.ss.nnnnnn.

      CCYY – Year.

      MM – Month.

      DD – Day.

      hh – Hour.

      mm – Minute.

      ss – Second.

      nnnnnn – Microsecond.

      3

      File Accept Indicator

      1

      30

      CHAR

      Y – The State file to CMS is accepted.

      4

      Filler

      1

      31

      CHAR


      5

      Total Records in State File

      8

      32-39

      NUM

      The total number of DET and LIS records in the file. Note: This count excludes PRO records.

      Total Records = Valid Records + Invalid Records.

      Total Records = Matched Records + Not Matched Records

      6

      Duplicate Records in State File

      8

      40-47

      NUM

      The total number of duplicate DET and LIS records in the State file.

      This count excludes PRO records.

      7

      Non-Duplicate Records in State File

      8

      48-55

      NUM

      The total number of non-duplicate DET and LIS detail records in the State file.

      This count excludes PRO records.

      8

      Valid Records in State File

      8

      56-63

      NUM

      The total number of valid DET and LIS records in the State file.

      This count excludes PRO records.

      9

      Invalid Records in State File

      8

      64-71

      NUM

      The total number of invalid DET and LIS records in the State file.

      This count excludes PRO records.

      10

      Matched Records in State File

      8

      72-79

      NUM

      The total number of DET and LIS records in the files that are successfully matched to a beneficiary on the Active Medicare Beneficiary Database.

      This count excludes PRO records.

      11

      Not Matched Records in State File

      8

      80-87

      NUM

      The total number of DET and LIS records in the files that are not matched to a beneficiary on the Active Medicare Beneficiary Database.

      This count excludes PRO records.

      12

      File Create Month

      2

      88-89

      NUM

      Month the file is created.

      13

      File Create Year

      4

      90-93

      NUM

      Year the file is created.

      14

      Filler

      22

      94-115

      CHAR


      Start of Original MMA Request File Header Record

      15

      Record Identification Code

      3

      116-118

      CHAR

      A copy of the header record in the incoming file is displayed in positions 116-295.

      16

      State Code

      2

      119-120

      CHAR


      17

      Create Month

      2

      121-122

      NUM


      18

      Create Year

      4

      123-126

      NUM


      19

      Filler

      169

      127-295

      CHAR


      End of Original MMA Request File Header Record

      20

      Filler

      3705

      296-4000

      CHAR


    2. MMA Response File Detail Record Layout

Note: The Medicare Beneficiary Identifier (MBI), items 312 – 321, will not be populated until February 2018.

MMA Response File Detail Record

Item

Field

Size

Position

Format

Description

Start of Original MMA Request File Detail Record

1

Record Identification Code

3

1-3

CHAR

A copy of the detail record in the incoming file is displayed in positions 1-180.

2

Eligibility Month/Year

6

4-9

NUM

MMCCYY

3

Eligibility Status

1

10

CHAR


4

Beneficiary’s Identifier

15

11-25

CHAR


5

Beneficiary Identifier Indicator Code

1

26

CHAR


6

Beneficiary’s Social Security Number

9

27-35

NUM


7

SMA Identifier

20

36-55

CHAR


8

Beneficiary’s First Name

12

56-67

CHAR


9

Beneficiary’s Last Name

20

68-87

CHAR


10

Beneficiary’s Middle Name

15

88-102

CHAR


11

Beneficiary’s Suffix Name

04

103-106

CHAR


12

Beneficiary’s Gender

01

107

CHAR


13

Beneficiary’s Date of Birth

8

108-115

NUM

MMDDCCYY

14

Dual Status Code

2

116-117

NUM


15

FPL Percentage Indicator

1

118

NUM


16

Drug Coverage Indicator

1

119

NUM


17

Institutional Status Indicator

1

120

CHAR


18

LIS Application Approval Code

1

121

CHAR


19

LIS Approved/Disapproved Date

8

122-129

NUM

MMDDCCYY

20

LIS Start Date

8

130-137

NUM

MMDDCCYY

21

LIS End Date

8

138-145

NUM

MMDDCCYY

22

Income as % of FPL

3

146-148

NUM


23

LIS Level

3

149-151

NUM


24

Income used for Determination

1

152

CHAR


25

Resource Level

1

153

CHAR


26

Basis of LIS Denial

1

154

CHAR


27

Result of an Appeal

1

155

CHAR


28

Change to Previous Determination

1

156

CHAR


29

Determination Cancelled

1

157

CHAR


30

Filler

23

158-180

CHAR


End of Original MMA Request File Detail Record

Start of Error Return Codes (ERC)

31

Record Identification Code ERC

2

181-182

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

Note: Detail record is valid if ERC = 00.

32

Eligibility Month/Year ERC

2

183-184

CHAR

00 – Value is valid.

02 – Value is not numeric.

04 – Date is unknown.

05 – Eligibility Month/Year combination for PRO record, not current month/year.

10 – Value is future.

11 – Month value is not within the range of 01-12.

20 – Year < 2004.

37 – Month/year combination > 36 months.

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00 or 99.

33

Eligibility Status ERC

2

185-186

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

06 – PRO record Eligibility Status ≠ ‘Y’.

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00 or 99.

34

Beneficiary’s Identifier ERC

2

187-188

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

03 – Field is empty.

Note: Detail record is valid if ERC = 00.

Detail record is also valid if ERC = 01 or 03 and Social Security ERC = 00.

35

Beneficiary Identifier Indicator Code ERC

2

189-190

CHAR

CMS does not use Beneficiary Identifier Indicator Code.

36

Beneficiary’s SSN ERC

2

191-192

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

02 – Value is not numeric.

03 – Value is missing.

Note: Detail record is valid if ERC = 00.

Detail record is also valid if ERC = 01, 02 or 03 and Beneficiary’s Identifier ERC = 00.

37

Beneficiary’s Gender ERC

2

193-194

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

Note: Detail record is valid if ERC = 00.

38

Beneficiary’s Date of Birth ERC

2

195-196

CHAR

00 – Value is valid.

02 – Value is not numeric.

04 – Date is unknown.

10 – Value is future.

11 – Month value is not within the range of 01-12.

12 – Day value is out of range.

21 – Year < 1899.

Note: Detail record is valid if ERC = 00 or 21.

39

Dual Status Code ERC

2

197-198

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

07 – PRO record with Dual Status Code ≠ 02, 04 or 08

40 – DET record has dual status code of 99

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00, 40 or 99.

40

FPL % Indicator ERC

2

199-200

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00 or 99.

41

Drug Coverage Indicator ERC

2

201-202

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00 or 99.

42

Institutional Status Indicator ERC

2

203-204

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

99 – LIS record not scanned.

Note: Detail record is valid if ERC = 00 or 99.

43

LIS Application Approval Code ERC

2

205-206

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

44

LIS Approved/Disapproved Date ERC

2

207-208

CHAR

00 – Value is valid.

02 – Value is not numeric.

04 – Date is unknown.

10 – Value is future.

11 – Month value is not within the range of 01-12.

12 – Day value is out of range.

31 – Value is later than Low-Income Subsidy End Date.

98 – DET or PRO record not scanned.

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

45

LIS Start Date ERC

2

209-210

CHAR

00 – Value is valid.

02 – Value is not numeric.

04 – Date is unknown.

11 – Month value is not within the range of 01-12.

12 – Day value is out of range.

31 – Value is later than Low-Income Subsidy End Date.

36 – Value is earlier than January 1, 2006.

37 – Day value is not the first day of the month.

98 – DET or PRO record not scanned.

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

46

Part D End Date ERC

2

211-212

CHAR

00 – Value is valid.

02 – Value is not numeric.

04 – Date is unknown.

11 – Month value is not within the range of 01-12.

12 – Day value is out of range.

33 – Value is earlier than Low-Income Subsidy Approved/Disapproved Date.

34 – Value is earlier than Low-Income Subsidy Effective Date.

35 – Value is earlier than Low-Income Subsidy Approved/Disapproved Date and Low-Income Subsidy Effective Date

98 – DET or PRO record not scanned.

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

47

Income as % of FPL ERC

2

213-214

CHAR

00 – Value is valid.

02 – Value is not numeric

98 – DET or PRO record not scanned.

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

48

LIS Level ERC

2

215-216

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

49

Income Used for Determination ERC

2

217-218

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

50

Resource Level ERC

2

219-220

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

51

Basis of Part D Subsidy Denial ERC

2

221-222

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

52

Result of an Appeal ERC

2

223-224

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

53

Change to Previous Determination ERC

2

225-226

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned

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

54

Determination Cancelled ERC

2

227-228

CHAR

00 – Value is valid.

01 – Value is not in the Valid Value Set.

98 – DET or PRO record not scanned.

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

End of Error Return Codes (ERC)

Start of CMS Response fields from MBD

55

Record Return Summary Code

6

229-234

CHAR

This field is an assessment of the detail record.

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

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

000002: Detail record is rejected because Record Identification Code is not DET, PRO, or LIS.

000003: DET, PRO, or LIS record is rejected because it was not matched.

(May indicate a mismatch on the submitted date of birth.)

000004: DET record is rejected: record has no entry in required field or has an entry that does not pass validation edits.

000005: LIS record is rejected: record has no entry in required field or has an entry that does not pass validation edits.

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

000007: LIS record is rejected: record is a duplicate of another LIS record.

000009: PRO record is rejected: record has no entry in required field or has an entry that does not pass validation edits.

000010: PRO record is rejected: record is a duplicate of another PRO record.


55 Cont.

Record Return Summary Code

Cont.




000011: PRO Record is rejected: record is a duplicate of a DET record in the same file.

000012: PRO record is rejected: record is a duplicate of a DET record in the previous file.

56

Medicare Part D Eligibility Indicator

1

235

CHAR

Values:

0 – Beneficiary is eligible for Medicare Part D.

1 – Beneficiary is not eligible for Medicare Part D.

For DET and PRO records, this field indicates the presence of Medicare Part D eligibility during the Eligibility Month/Year.

57

Medicare Part D Enrollment Indicator

1

236

CHAR

Values:

0 – Beneficiary is enrolled in a Medicare Part D plan.

1 – Beneficiary is not enrolled in a Medicare Part D plan.

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

Beneficiary Identification – The remainder of this record is filled if the beneficiary is found in the active MBD. The remainder of the record is filled with spaces (alpha-numeric fields) and zeroes (numeric fields) if the beneficiary is not found in the active MBD. Additionally, the Archive Indicator is set to ‘A’ if the beneficiary is found in the Archived Database.

58

Beneficiary’s Claim Account Number

9

237-245

CHAR

The number identifying the primary Medicare beneficiary under the SSA or RRB programs. This number along with the Beneficiary Identification Code uniquely identifies a Medicare beneficiary.

59

Beneficiary’s Identification Code (BIC)

2

246-247

CHAR

A code that is used in conjunction with the Beneficiary CAN to uniquely identify a Medicare beneficiary.

The BIC Code establishes the beneficiary’s relationship to a primary SSA or RRB wage earner and is used to justify entitlement to Medicare benefits.

60

Beneficiary’s Birth Date

8

248-255

NUM

MMDDCCYY

61

Beneficiary’s Death Date

8

256-263

NUM

MMDDCCYY

62

Beneficiary’s Gender

1

264

CHAR

Values:

0 – Unknown

1 – Male

2 – Female

63

Beneficiary’s First Name

30

265-294

CHAR

First name of the Medicare beneficiary

64

Beneficiary’s Middle Name

1

295

CHAR

Middle initial of the Medicare beneficiary

65

Beneficiary’s Last Name

40

296-335

CHAR

Last name of the Medicare beneficiary including any titles or suffixes.

Cross Reference Numbers (10 occurrences). The first occurrence is the active/most recent cross-reference Medicare number.

66

Cross-Reference Beneficiary Claim Account Number (Occurrence 1)

9

336-344

CHAR

An additional beneficiary claim account number associated with the Medicare beneficiary. The beneficiary’s entitlement has been cross-referenced from this number to the beneficiary’s active claim account number.

67

Cross-Reference Beneficiary Identification Code

(Occurrence 1)

2

345-346

CHAR

The beneficiary’s identification code associated with the Medicare beneficiary’s cross-referenced claim account number.

68

Cross-Reference Beneficiary Claim Account Number (Occurrence 2)

9

347-355

See item 66.


69

Cross-Reference Beneficiary Identification Code

(Occurrence 2)

2

356-357

See item 67.


70

Cross-Reference Beneficiary Claim Account Number (Occurrence 3)

9

358-366

See item 66.


71

Cross-Reference Beneficiary Identification Code

(Occurrence 3)

2

367-368

See item 67.


72

Cross-Reference Beneficiary Claim Account Number (Occurrence 4)

9

369-377

See item 66.


73

Cross-Reference Beneficiary Identification Code

(Occurrence 4)

2

378-379

See item 67.


74

Cross-Reference Beneficiary Claim Account Number (Occurrence 5)

9

380-388

See item 66.


75

Cross-Reference Beneficiary Identification Code

(Occurrence 5)

2

389-390

See item 67.


76

Cross-Reference Beneficiary Claim Account Number (Occurrence 6)

9

391-399

See item 66.


77

Cross-Reference Beneficiary Identification Code

(Occurrence 6)

2

400-401

See item 67.


78

Cross-Reference Beneficiary Claim Account Number (Occurrence 7)

9

402-410

See item 66.


79

Cross-Reference Beneficiary Identification Code

(Occurrence 7)

2

411-412

See item 67.


80

Cross-Reference Beneficiary Claim Account Number (Occurrence 8)

9

413-421

See item 66.


81

Cross-Reference Beneficiary Identification Code

(Occurrence 8)

2

422-423

See item 67.


82

Cross-Reference Beneficiary Claim Account Number (Occurrence 9)

9

424-432

See item 66.


83

Cross-Reference Beneficiary Identification Code

(Occurrence 9)

2

433-434

See item 67.


84

Cross-Reference Beneficiary Claim Account Number (Occurrence 10)

9

435-443

See item 66.


85

Cross-Reference Beneficiary Identification Code

(Occurrence 10)

2

444-445

See item 67.


Social Security Numbers (5 most recent occurrences)

86

Beneficiary Social Security Number (Occurrence 1)

9

446-454

NUM

The beneficiary’s identification number was assigned by SSA.

87

Beneficiary Social Security Number (Occurrence 2)

9

455-463

See item 86.


88

Beneficiary Social Security Number (Occurrence 3)

9

464-472

See item 86.


89

Beneficiary Social Security Number (Occurrence 4)

9

473-481

See item 86.


90

Beneficiary Social Security Number (Occurrence 5)

9

482-490

See item 86.


Mailing Address – This may be the mailing address of the beneficiary or the mailing address of his/her representative payee.

91

Mailing Address Line 1

40

491-530

CHAR

1st line of address

92

Mailing Address Line 2

40

531-570

CHAR

2nd line of address

93

Mailing Address Line 3

40

571-610

CHAR

3rd line of address

94

Mailing Address Line 4

40

611-650

CHAR

4th line of address

95

Mailing Address Line 5

40

651-690

CHAR

5th line of address

96

Mailing Address Line 6

40

691-730

CHAR

6th line of address

97

Mailing Address City Name

40

731-770

CHAR

City name

98

Mailing Address State Code

2

771-772

CHAR

Postal state code

99

Mailing Address Zip Code

9

773-781

CHAR

ZIP

100

Mailing Address Change Date

8

782-789

NUM

MMDDCCYY

The date a new or corrected address becomes effective for a Medicare beneficiary.

Residence Address The beneficiary’s most recent residence address

101

Residence Address Line 1

60

790-849

CHAR


102

Filler

180

850-1029

CHAR

Spaces

103

Residence Address City Name

40

1030-1069

CHAR


104

Residence Address State Code

2

1070-1071

CHAR


105

Residence Address Zip code

9

1072-1080

CHAR


106

Residence Address Change Date

8

1081-1088

NUM

MMDDCCYY

107

Beneficiary Representative Payee Switch

1

1089

CHAR

A switch indicating whether the beneficiary has a representative payee according to SSA.

Values are:

Y – Beneficiary has a designated representative payee.

N or space – beneficiary has no designated representative payee.

108

Part A Non-Entitlement Status Code

1

1090

CHAR

Indicator/reason for the beneficiary’s current non-entitlement status to Part A Medicare benefits.

Values are:

D – Coverage was denied.

F – Terminated due to invalid enrollment or enrollment voided.

H – Not eligible for free Part A, or did not enroll for premium Part A.

N – 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.

109

Part B Non-Entitlement Status Code

1

1091

CHAR

Indicator/reason for a beneficiary’s current non-entitlement status to Part B Medicare benefits.

Values are:

D – Coverage was denied.

N – Not entitled.

R – Refused benefits.

Space – No non-entitlement reason applies to the beneficiary.

Entitlement Reason (five most recent occurrences)

110

Beneficiary Entitlement Reason Code Change Date

(Occurrence 1)

8

1092-1099

NUM

MMDDCCYY

111

Beneficiary’ Entitlement Reason Code

(Occurrence 1)

4

1100-1103

CHAR


112

Beneficiary Entitlement Reason

(Occurrence 2)

12

1104-1115

See items 110 and 111


113

Beneficiary Entitlement Reason

(Occurrence 3)

12

1116-1127

See items 110 and 111


114

Beneficiary Entitlement Reason

(Occurrence 4)

12

1128-1139

See items 110 and 111


115

Beneficiary Entitlement Reason

(Occurrence 5)

12

1140-1151

See items 110 and 111


Part A Entitlement (five most recent occurrences)

116

Beneficiary Part A Entitlement Start Date (Occurrence 1)

8

1152-1159

NUM

MMDDCCYY.

The date beneficiary became entitled to Medicare benefits.

This field is filled with zeroes if no Part A Entitlement Start Date is found.

117

Beneficiary Part A Entitlement End Date (Occurrence 1)

8

1160-1167

NUM

MMDDCCYY.

The last day that beneficiary is entitled to Medicare benefits.

If both the Part A Entitlement Start and End Dates are filled with zeroes, then no entitlement period was found.

If the Part A Entitlement Start Date is a valid date and the Part A Entitlement End Date is filled with 9s, then the entitlement has not ended.

118

Beneficiary Part A Entitlement Reason Code (Occurrence 1)

1

1168

CHAR

Values:

A – Attainment of age 65.

B – Equitable relief.

D – Disability.

G – General enrollment period.

H – Entitled based on health hazards.

I – Initial enrollment period.

J – MQGE entitlement.

K – Renal disease is or was a reason for entitlement prior to age 65 or 25th month of disability.

L – Late filing.

M – Termination based on renal entitlement but entitlement based on disability continues.

N – Age 65 and uninsured.

P – Potentially insured beneficiary is enrolled for Medicare coverage only.

Q – Quarters of coverage requirements are involved.

R – Residency requirements are involved.

S – State buy-in.

T – Disabled working individual.

U – Unknown.

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

119

Beneficiary Part A Entitlement Status Code (Occurrence 1)

1

1169

CHAR

Values:

E – Free Part A Entitlement.

G – Entitled due to good cause.

Y – Currently entitled, premium is payable.

Values when there is a termination date:

C – No longer entitled due to disability cessation.

S – Terminated, no longer entitled under ESRD provision.

T – Terminated for non-payment of premiums.

W – Voluntary withdrawal from premium coverage.

X – Free Part A terminated or refused HI.

This field is filled with a space if no entitlement period is found.

120

Part A Entitlement

(Occurrence 2)

18

1170-1187

See items 116 – 119

Same as Occurrence 1.

121

Part A Entitlement

(Occurrence 3)

18

1188-1205

See items 116 – 119

Same as Occurrence 1.

122

Part A Entitlement

(Occurrence 4)

18

1206-1223

See items 116 – 119

Same as Occurrence 1.

123

Part A Entitlement

(Occurrence 5)

18

1224-1241

See items 116 – 119

Same as Occurrence 1.

Part B Entitlement (five occurrences)

124

Beneficiary Part B Enrollment Start Date

(Occurrence 1)

8

1242-1249

NUM

MMDDCCYY

This field is filled with zeroes if no Part B enrollment period is found.

125

Beneficiary Part B Enrollment End Date

(Occurrence 1)

8

1250-1257

NUM

MMDDCCYY

When no Part B enrollment period is found, this field and the Part B Enrollment Start Date are filled with zeroes.

If there is a valid Part B Enrollment Start Date and the period is still active, then this field is filled with 9s.

126

Beneficiary Part B Enrollment Reason Code

(Occurrence 1)

1

1258

CHAR

Values:

B – Equitable relief.

C – Good cause.

D – Deemed date of birth.

F – Working aged.

G – General enrollment period.

I – Initial enrollment period.

H – Health hazard.

K – Renal disease is or was a reason for enrollment prior to age 65 or 25th month of disability.

M –Termination based on renal enrollment but enrollment based on disability continues.

P -Medicare Part B Immunosuppressive Drug (Part B-ID)

R – Residency requirements are involved.

S – State buy-in.

T – Disabled working beneficiary.

U –Unknown.

This field is filled with a space if no enrollment is found.

127

Beneficiary Part B Enrollment Status Code

(Occurrence 1)

1

1259

CHAR

Values when there is a Part B Enrollment Start Date and no Part B Enrollment End Date:

G – Enrolled due to good cause.

Y – Currently enrolled, premium is payable.

Values when Part B Enrollment End Date is present:

C – No longer entitled due to disability cessation.

F – Terminated due to invalid enrollment or enrollment voided.

S – Terminated, no longer entitled under ESRD provision.

T – Terminated for non-payment of premiums.

W – Voluntary withdrawal from premium coverage.

This field is filled with a space if no enrollment is found.

128

Part B Enrollment

(Occurrence 2)

18

1260-1277

See items 124 – 127.

Same as Occurrence 1.

129

Part B Enrollment
(Occurrence 3)

18

1278-1295

See items 124 – 127.

Same as Occurrence 1.

130

Part B Enrollment

(Occurrence 4)

18

1296-1313

See items 124 – 127.

Same as Occurrence 1.

131

Part B Enrollment
(Occurrence 5)

18

1314-1331

See items 124 – 127.

Same as Occurrence 1.

Hospice Coverage (five most recent occurrences)

132

Beneficiary Hospice Coverage Start Date

(Occurrence 1)

8

1332-1339

NUM

MMCCDDYY.

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

133

Beneficiary Hospice Coverage End Date

(Occurrence 1)

8

1340-1347

NUM

MMDDCCYY

If hospice coverage has a valid Hospice Start Date and no Hospice End Date, then this field is filled with 9s.

If there is no Hospice Start Date, then this field is filled with zeroes.

134

Beneficiary Hospice Coverage

(Occurrence 2)

16

1348-1363

See items 132 – 133.

Same as Occurrence 1.

135

Beneficiary Hospice Coverage

(Occurrence 3)

16

1364-1379

See items 132 – 133.

Same as Occurrence 1.

136

Beneficiary Hospice Coverage

(Occurrence 4)

16

1380-1395

See items 132 – 133.

Same as Occurrence 1.

137

Beneficiary Hospice Coverage

(Occurrence 5)

16

1396-1411

See items 132 – 133.

Same as Occurrence 1.

Disability Insurance Benefits (3 most recent occurrences)

138

Beneficiary Disability Insurance Benefits (DIB) Entitlement Start Date

(Occurrence 1)

8

1412-1419

NUM

MMDDCCYY.

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

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

139

Beneficiary DIB Entitlement End Date

(Occurrence 1)

8

1420-1427

NUM

MMDDCCYY

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

If there is a valid DIB Entitlement Start Date and no DIB Entitlement End Date, then this field is filled with 9s.

If there is no DIB Entitlement Start Date and no DIB Entitlement End Date, then this field is filled with zeroes.

140

Beneficiary DIB Entitlement Date Justification Code

(Occurrence 1)

1

1428

CHAR

The justification code for a beneficiary’s Part A and /or Part B Medicare benefit dates based upon the beneficiary’s DIB status.

Values:

1 – Beneficiary is entitled to Medicare coverage due to prior periods of SSA disability entitlement.

A – Beneficiary is entitled to Medicare based upon SSA disability and the 24-month waiting period has been waived.

H – Beneficiary is entitled to Medicare due to health hazards.

This field will have a space if no DIB is found.

141

Beneficiary DIB Entitlement

(Occurrence 2)

17

1429-1445

See items 138 – 140.

Same as Occurrence 1.

142

Beneficiary DIB Entitlement

(Occurrence 3)

17

1446-1462

See items 138 – 140.

Same as Occurrence 1.

Managed Care Organization (10 most recent occurrences)

143

Beneficiary Managed Care Organization (MCO) Enrollment Start Date

(Occurrence 1)

8

1463-1470

NUM

MMDDCCYY.

This field is filled with zeroes if no managed care organization enrollment is found.

144

Beneficiary MCO Enrollment End Date

(Occurrence 1)

8

1471-1478

NUM

MMDDCCYY.

This field is filled with zeroes if there is no managed care organization enrollment found.

This field is filled with 9s if there is an MCO Contract Enrollment Start Date and no MCO Contract Enrollment End Date.

145

Beneficiary MCO Number (contract level)

(Occurrence 1)

5

1479-1483

CHAR

Unique identification for an agreement between CMS and an MCO. The organizations can be distinguished by the first position:

H – Local MA, local MAPD, or non-MA Plan.

9 – Non-MA Plan (no longer assigned).

R – Regional MA or MAPD Plan.

S – Regular standalone Prescription Drug Plan (PDP).

E – Employer direct PDP.

X – Limited-Income Newly Eligible Transition (LiNET).

Note: Stand-alone plans are not included in this section. This field is filled with spaces if no enrollment is found.

146

Beneficiary MCO

(Occurrence 2)

21

1484-1504

See items 143 – 145.

Same as Occurrence 1.

147

Beneficiary MCO

(Occurrence 3)

21

1505-1525

See items 143 – 145.

Same as Occurrence 1.

148

Beneficiary MCO

(Occurrence 4)

21

1526-1546

See items 143 – 145.

Same as Occurrence 1.

149

Beneficiary MCO

(Occurrence 5)

21

1547-1567

See items 143 – 145.

Same as Occurrence 1.

150

Beneficiary MCO

(Occurrence 6)

21

1568-1588

See items 143 – 145.

Same as Occurrence 1.

151

Beneficiary MCO

(Occurrence 7)

21

1589-1609

See items 143 – 145.

Same as Occurrence 1.

152

Beneficiary MCO

(Occurrence 8)

21

1610-1630

See items 143 – 145.

Same as Occurrence 1.

153

Beneficiary MCO

(Occurrence 9)

21

1631-1651

See items 143 – 145.

Same as Occurrence 1.

154

Beneficiary MCO

(Occurrence 10)

21

1652-1672


See items 143 – 145.


Same as Occurrence 1.

Plan Benefits Package Election (10 most recent occurrences)

155

Group Health Plan Enrollment Start Date (Occurrence 1)

8

1673-1680

NUM

MMDDCCYY.

The date of the beneficiary’s enrollment at the contract level.

This field is filled with zeroes if there is no enrollment found.

156

Plan Benefit Package (PBP) Enrollment Start Date (Occurrence 1)

8

1681-1688

NUM

MMDDCCYY.

The date of the beneficiary’s enrollment at the PBP level.

This field is filled with zeroes if the beneficiary has no PBP enrollment.

157

Plan Benefit Package Enrollment End Date

(Occurrence 1)

8

1689-1696

NUM

MMDDCCYY.

The date the beneficiary’s PBP enrollment ends.

This field is filled with zeroes if there is no PBP Start Date.

This field is filled with 9s if there is a PBP Start Date and no PBP End Date.

158

Plan Benefit Package Number
(Occurrence 1)

3

1697-1699

CHAR

A unique identifier for the managed care plan benefit package.

This field contains spaces if the managed care plan has no PBP. If a Cost Plan has no PBP, the field contains ‘999’.

159

Plan Benefit Package Coverage Type Code

(Occurrence 1)

2

1700-1701

CHAR

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

Values:

NF – Pay bill option not found for this contract.

03 – CCP (Coordinated Care Plan).

04 – MSA (Medicare Medical Savings Account).

05 – PFFS (Private Fee for Service).

06 – PACE (Program of All-Inclusive Care for the Elderly).

07 – Regional.

08 – Demo (Demonstration).

09 – FFS (Fee for Service).

10 – Cost / HCPP (Health Care Prepayment Plan).

11 – PDP (Part D Drug Plan) Election).

12– Chronic Care Demo.

13 – MSA (Medicare Medical Savings Account) Demonstration.

14 – MMP (Medicare/Medicaid Plan).

This field is filled with spaces if no PBP enrollment is found.

160

PBP Enrollment

(Occurrence 2)

29

1702-1730

See items 155 – 159.

Same as Occurrence 1.

161

PBP Enrollment

(Occurrence 3)

29

1731-1759

See items 155 – 159.

Same as Occurrence 1.

162

PBP Enrollment

(Occurrence 4)

29

1760-1788

See items 155 – 159.

Same as Occurrence 1.

163

PBP Enrollment

(Occurrence 5)

29

1789-1817

See items 155 – 159.

Same as Occurrence 1.

164

PBP Enrollment

(Occurrence 6)

29

1818-1846

See items 155 – 159.

Same as Occurrence 1.

165

PBP Enrollment

(Occurrence 7)

29

1847-1875

See items 155 – 159.

Same as Occurrence 1.

166

PBP Enrollment

(Occurrence 8)

29

1876-1904

See items 155 – 159.

Same as Occurrence 1.

167

PBP Enrollment

(Occurrence 9)

29

1905-1933

See items 155 – 159.

Same as Occurrence 1.

168

PBP Enrollment

(Occurrence 10)

29

1934-1962

See items 155 – 159.

Same as Occurrence 1.

End-Stage Renal Disease Coverage

169

Beneficiary ESRD Coverage Start Date

8

1963-1970

NUM

MMDDCCYY.

The date on which the beneficiary is entitled to Medicare in some part because of a diagnosis of End-Stage Renal Disease.

This field is filled with zeroes if the beneficiary has no ESRD coverage.

170

Beneficiary ESRD Coverage End Date

8

1971-1978

MMDDCCYY

MMDDCCYY.

The date on which the beneficiary is no longer entitled to Medicare under ESRD provision.

This field is filled with zeroes if the beneficiary has no ESRD coverage.

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

171

Beneficiary ESRD Termination Reason Code

1

1979

CHAR

The reason Medicare ESRD coverage was terminated.

Values:

A – Month of transplant plus 36 months,

B – Last month of chronic dialysis,

C – Part A termination,

D – Death, and

E – ESRD ended.

This field is filled with spaces if the beneficiary has no ESRD coverage or if there is no ESRD Coverage End Date.

End-Stage Renal Disease Clinical Dialysis Dates. See items 267 – 271 (positions 3114 through 3193) for occurrences 2 – 6, sorted in descending order by Start Date.

172

Beneficiary ESRD Clinical Dialysis Start Date

(Occurrence 1)

Occurrence 1 is the latest dialysis period if multiple periods exist.

8

1980-1987

NUM

MMDDCCYY.

The date when ESRD dialysis starts.

This field is filled with zeroes if the beneficiary has no ESRD Dialysis Start Date.

173

Beneficiary ESRD Clinical Dialysis End Date

(Occurrence 1)

8

1988-1995

NUM

MMDDCCYY.

The date when ESRD dialysis ends.

This field is filled with zeroes if the beneficiary has no ESRD Dialysis Start Date.

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

End-Stage Renal Disease Transplant

174

Beneficiary ESRD Transplant Start Date

8

1996-2003

NUM

MMDDCCYY.

The date that a kidney transplant operation occurred. This field is filled with zeroes when no ESRD Transplant Start Date is found.

175

Beneficiary ESRD Transplant End Date

8

2004-2011

NUM

MMDDCCYY.

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

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

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

Third-Party Part A History (5 most recent occurrences)

176

Beneficiary Part A Third-Party Start Date

(Occurrence 1)

8

2012-2019

NUM

MMDDCCYY.

The start date of a private third-party group’s or State’s liability for a beneficiary’s Part A premium.

This field is filled with zeroes if there is no Part A Third-Party Start Date.

177

Beneficiary Part A Third-Party Premium Payer Code (Occurrence 1)

3

2020-2022

CHAR

The identifier for a third-party agency (either a private group or State buy-in agency) responsible for paying a beneficiary’s Medicare Part A premium.

Values:

S01 thru S99 – State Billing and

T01 thru Z98 – Private Third-Party Billing

178

Beneficiary Part A Third-Party End Date

(Occurrence 1)

8

2023-2030

NUM

MMDDCCYY.

The end date of a private third-party group’s or State’s liability for a beneficiary’s Part A premium.

This field is filled with zeroes if no Part A Third-Party Start Date was found.

This field is filled with 9s if there is a Third-Party Start Date and no Third-Party End Date.

179

Beneficiary Part A Third-Party Buy-in Eligibility Code (Occurrence 1)

1

2031

CHAR

This data element is obsolete.

180

Third-Party Part A History (Occurrence 2)

20

2032-2051

See items 176 – 179.

Same as Occurrence 1.

181

Third-Party Part A History (Occurrence 3)

20

2052-2071

See items 176 – 179.

Same as Occurrence 1.

182

Third-Party Part A History (Occurrence 4)

20

2072-2091

See items 176 – 179.

Same as Occurrence 1.

183

Third-Party Part A History (Occurrence 5)

20

2092-2111

See items 176 – 179.

Same as Occurrence 1.

Third-Party Part B History (5 most recent occurrences)

184

Beneficiary Part B Third-Party Start Date

(Occurrence 1)

8

2112-2119

NUM

MMDDCCYY.

The start date of a private third-party group’s or State’s liability for a Part B premium.

This field is filled with zeroes if no Part B Third-Party benefit is found for the beneficiary.

185

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

3

2120-2122

CHAR

The identifier for a third-party agency (either a private group, state buy-in agency or the Office of Personnel Management (OPM)) is responsible for paying a beneficiary’s Medicare Part B premium.

Values:

000 – Beneficiary is having Part B premium deducted from Title II check,

001 – Uninsured beneficiary,

005 – Insured beneficiary,

006 – Program Service Center control, no bill,

007 – Special age 72 enrollee,

008 – PSC annual billing,

010 – 650 – State billing,

700 – Office of Personnel Management (OPM), and

A01 – R99 – Group payers for Part B premiums.

186

Beneficiary Part B Third-Party Termination Date

(Occurrence 1)

8

2123-2130

NUM

MMDDCCYY.

The end date of a private third-party group’s or state’s liability for a beneficiary’s Part B premium.

This field is filled with zeroes if no Part B Third-Party Start Date is found.

This field is filled with 9s if there is a Third-Party Start Date and no Third-Party End Date.

187

Beneficiary Part B Third-Party Buy-in Eligibility Code (Occurrence 1)

1

2131

CHAR

Reason for Part B State buy-in eligibility. Values:

A – Aged recipient of SSI payments (CMS to State).

B – Blind recipient of SSI payments (CMS to State).

C – Entitled to Part A of Title IV (TANF) (State to CMS).

D – Disabled recipient of SSI payments (CMS to State).

E – Aged recipient of supplemental payment administered by SSA (CMS to State).

F – Blind recipient of supplemental payment administered by SSA (CMS to State).

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

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

L – Specified Low-Income Beneficiary (SLMB).

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

P – Qualified Medicare Beneficiary (QMB).

U – Qualified Individual One (QI-1).

Z – Deemed categorically needy (State to CMS).

Note: States can use any other alphabetic character.

188

Third-Party Part B History (Occurrence 2)

20

2132-2151

See items 184 – 187.

Same as Occurrence 1.

189

Third-Party Part B History (Occurrence 3)

20

2152-2171

See items 184 – 187.

Same as Occurrence 1.

190

Third-Party Part B History (Occurrence 4)

20

2172-2191

See items 184 – 187.

Same as Occurrence 1.

191

Third-Party Part B History (Occurrence 5)

20

2192-2211

See items 184 – 187.

Same as Occurrence 1.

Part D Data Elements

192

Beneficiary Part D Eligibility Start Date

8

2212-2219

NUM

MMDDCCYY.

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

This field is filled with zeroes if no Part D Start Date is found.

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

If there are multiple Part D eligibility periods, then this field will contain the earliest Part D Eligibility Start Date.

193

Beneficiary Part D Opt-Out Indicator

1

2220

CHAR

An indicator that the beneficiary chooses not to be automatically enrolled by CMS into a Part D plan.

Values:

Y – Yes.

N – No.

Space – No.

Beneficiary’s Co-Payment History (10 occurrences) The first occurrence is the active/most recent co-payment period.

194

Beneficiary Co-Payment Type

(Occurrence 1)

1

2221

CHAR

A code indicating whether the beneficiary was determined eligible for low-income subsidy (LIS) or deemed eligible.

Values:

L – Determined eligible.

D – Deemed.

195

Beneficiary Co-Payment Level

(Occurrence 1)

1

2222

CHAR

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

Values:

If bene co-pay type is ‘L’, then

1 – high.

4 – 15%.

If bene co-pay type is ‘D’, then:

1 – high.

2 – low.

3 – 0 (zero).

196

Beneficiary Co-Payment Start Date

(Occurrence 1)

8

2223-2230

NUM

MMDDCCYY.

The effective date of the co-payment period. This field is filled with zeroes if there is no Co-Payment Start Date.

197

Beneficiary Co-Payment End Date

(Occurrence 1)

8

2231-2238

NUM

MMDDCCYY.

The end date of the co-payment period.

This field is filled with zeroes if there is no Co-Payment Start Date.

This field is filled with 9s if there is a Co-Payment Start Date and no Co-Payment End Date.

198

Beneficiary Co-Payment History

(Occurrence 2)

18

2239-2256

See items 194 – 197.

Same as Occurrence 1.

199

Beneficiary Co-Payment History

(Occurrence 3)

18

2257-2274

See items 194 – 197.

Same as Occurrence 1.

200

Beneficiary Co-Payment History

(Occurrence 4)

18

2275-2292

See items 194 – 197.

Same as Occurrence 1.

201

Beneficiary’s Co-Payment History

(Occurrence 5)

18

2293-2310

See items 194 – 197.

Same as Occurrence 1.

202

Beneficiary’s Co-Payment History

(Occurrence 6)

18

2311-2328

See items 194 – 197.

Same as Occurrence 1.

203

Beneficiary’s Co-Payment History

(Occurrence 7)

18

2329-2346

See items 194 – 197.

Same as Occurrence 1.

204

Beneficiary’s Co-Payment History

(Occurrence 8)

18

2347-2364

See items 194 – 197.

Same as Occurrence 1.

205

Beneficiary’s Co-Payment History

(Occurrence 9)

18

2365-2382

See items 194 – 197.

Same as Occurrence 1.

206

Beneficiary’s Co-Payment History

(Occurrence 10)

18

2383-2400

See items 194 – 197.

Same as Occurrence 1.

Part D Plan Benefit Package (10 most recent occurrences)

207

Beneficiary Contract Number (Occurrence 1)

5

2401-2405

CHAR

Unique identification for an agreement between CMS and an MCO or PDP sponsor enabling the Plan to provide Medicare Part D prescription drug coverage.

208

Beneficiary Part D PBP Enrollment Start Date
(Occurrence 1)

8

2406-2413

NUM

MMDDCCYY.

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

This field is filled with zeroes if no MAPD or Part D PBP enrollment is found for the beneficiary

209

Beneficiary Part D PBP Enrollment End Date (Occurrence 1)

8

2414-2421

NUM

MMDDCCYY.

The end date of the beneficiary’s enrollment in the plan benefit package.

This field is filled with zeroes if there is no Part D PBP Enrollment Start Date.

This field is filled with 9s if there is a Part D PBP Enrollment Start Date and no Part D PBP Enrollment End Date.

210

Beneficiary Part D PBP Plan Number

(Occurrence 1)

3

2422-2424

CHAR

A unique identifier for the managed care benefit package.

211

Beneficiary Enrollment Type Code

(Occurrence 1)

1

2425

CHAR

An indicator providing the type of enrollment performed.

Values:

A: Auto enrolled by CMS.

B: Beneficiary election.

C: Facilitated enrollment by CMS.

D: CMS Annual Rollover.

E: Plan submitted auto-enrollments.

F: Plan submitted facilitated enrollments.

G: Point of Sale (POS) submitted enrollments.

H: CMS or plan submitted re- assignment enrollments.

I: Invalid Submitted Value.

J: State-submitted MMP passive enrollment.

K: CMS-submitted MMP passive enrollment.

L: Beneficiary MMP election.

M: Default for Financial Alignment Demo Plan enrollments submitted without an Enrollment Source Code (M is not submitted on an enrollment).

N: Rollover by plan transaction.

212

Part D Plan Benefit Package (Occurrence 2)

25

2426-2450

See items 207 – 211.

Same as Occurrence 1.

213

Part D Plan Benefit Package (Occurrence 3)

25

2451-2475

See items 207 – 211.

Same as Occurrence 1.

214

Part D Plan Benefit Package (Occurrence 4)

25

2476-2500

See items 207 – 211.

Same as Occurrence 1.

215

Part D Plan Benefit Package (Occurrence 5)

25

2501-2525

See items 207 – 211.

Same as Occurrence 1.

216

Part D Plan Benefit Package (Occurrence 6)

25

2526-2550

See items 207 – 211.

Same as Occurrence 1.

217

Part D Plan Benefit Package (Occurrence 7)

25

2551-2575

See items 207 – 211.

Same as Occurrence 1.

218

Part D Plan Benefit Package (Occurrence 8)

25

2576-2600

See items 207 – 211.

Same as Occurrence 1.

219

Part D Plan Benefit Package (Occurrence 9)

25

2601-2625

See items 207 – 211.

Same as Occurrence 1.

220

Part D Plan Benefit Package (Occurrence 10)

25

2626-2650

See items 207 – 211.

Same as Occurrence 1.

221

Part C Organization Name

(contract level)

55

2651-2705

CHAR

Relates to the first occurrence of the beneficiary’s MCO contract number in item 145 (positions 1479-1483).

222

Part C PBP Name

50

2706-2755

CHAR

Relates to the first occurrence of the beneficiary’s PBP in item 158 (positions 1697-1699).

223

Part D Organization Name

(contract level)

55

2756-2810

CHAR

Relates to the first occurrence of the beneficiary’s contract number in Part D PBP in item 207 (positions 2401-2405).

224

Part D PBP Name

50

2811-2860

CHAR

Relates to the first occurrence of the beneficiary’s PBP in item 210 (positions 2422-2424).

225

Part D Organization Plan Benefit

1

2861

CHAR

This field is filled with a space.

226

Beneficiary Language Indicator

1

2862

CHAR

A code that identifies the language that the beneficiary requested SSA to use for beneficiary notices.

Values:

Blank – English assumed for Non-Puerto Rican ZIP codes and Spanish assumed for Puerto Rican ZIP codes.

E – English requested (allowed only for Puerto Rican ZIP codes).

S – Spanish requested.

227

Special Needs Plan (SNP) Indicator

(Occurrence 1)

1

2863

CHAR

Indicates that the beneficiary is enrolled in a special needs plan.

Values:

Y – SNP, and

N – Not SNP.

Corresponds to the first occurrence of plan benefit package in item 159 (positions 1700-1701).

228

SNP Indicator

(Occurrence 2)

1

2864

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 2 of plan benefit package in item 160 (positions 1702-1730).

229

SNP Indicator

(Occurrence 3)

1

2865

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 3 of plan benefit package in item 161 (positions 1731-1759).

230

SNP Indicator

(Occurrence 4)

1

2866

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 4 of plan benefit package in item 162 (positions 1760-1788).

231

SNP Indicator

(Occurrence 5)

1

2867

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 5 of plan benefit package in item 163 (positions 1789-1817).

232

SNP Indicator

(Occurrence 6)

1

2868

See item 227.

Same as Occurrence 1. Corresponds to Occurrence 6 of plan benefit package in item 164 (positions 1818-1846).

233

SNP Indicator

(Occurrence 7)

1

2869

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 7 of plan benefit package in item 165 (positions 1847-1875).

234

SNP Indicator

(Occurrence 8)

1

2870

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 8 of plan benefit package in item 166 (positions 1876-1904).

235

SNP Indicator

(Occurrence 9)

1

2871

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 9 of plan benefit package in item 167 (positions 1905-1933).

236

SNP Indicator

(Occurrence 10)

1

2872

See item 227.

Same as Occurrence 1.

Corresponds to Occurrence 10 of plan benefit package in item 168 (positions 1934-1962).

Medicare Plan Ineligibility Due to Incarceration Periods, Ten Occurrences (sorted from latest to earliest based on Medicare Plan Ineligibility Due to Incarceration Start Date). See items 274 – 291 (positions 3196-3339) for occurrences 2-10.

237

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 1)

8

2873-2880

NUM

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 Start Date, then this field is filled with zeroes.

238

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 1)

8

2881-2888

NUM

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 Start Date and no Medicare Plan Ineligibility Due to Incarceration End Date, then this field is filled with zeroes.

If there is a Medicare Plan Ineligibility Due to Incarceration Start Date and no Medicare Plan Ineligibility Due to Incarceration End Date, then this field is filled with 9s.

239

Filler

11

2889-2899

CHAR

Spaces.

240

Previous Month SPD Calculation Code

1

2900

CHAR

Code that indicates how beneficiary was last classified in enrollment and disenrollment counts for the Eligibility Month/Year of this record.

Values:

E – Enrollment count,

D – Disenrollment count,

C – Carry forward enrollment count,

M –Missing state file (counted as enrollment),

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 Month/Year.

Special Codes

241

Secondary Match Indicator

1

2901

CHAR

This field indicates if the 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 from the beneficiary’s Detail record in the Request file:

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

  • First six characters of the Individual Last Name.

  • First letter of the Individual First Name.

  • Sex Code.

The process will return one of the following values:

  • Space – The process found a match for the beneficiary, but it did not use the Secondary Beneficiary Match algorithm to do so or the process did not find a match for the beneficiary.

  • S – The process used the Secondary Beneficiary Match algorithm to match the beneficiary).

Note: A matched detail record is indicated by the presence of alphanumeric values in the fields ‘Beneficiary Claim Account Number’ and ‘Beneficiary Identification Code’ (fields 58 and 59) and a Record Return Code (RRC) of ‘000000’ or ‘000001’.

242

Daily State Phase-Down Calculation Code

1

2902

CHAR

Code that indicates how the beneficiary is counted in enrollment and disenrollment counts for this record.

Values:

E – Enrollment count,

D – Disenrollment count,

C – Carry forward enrollment count,

M – Missing state file (counted as enrollment),

N – Not counted (This also includes future Medicaid DET records), and

P – Prospective Duals, not considered in Clawback counts.

Retiree Drug Subsidy (RDS) Coverage Periods (5 most recent occurrences)

243

RDS Start Date

(Occurrence 1)

8

2903-2910

NUM

MMDDCCYY.

The start date of the beneficiary’s enrollment in an employer plan.

If there is no RDS Start Date, then this field is filled with zeroes.

244

RDS Termination Date (Occurrence 1)

8

2911-2918

NUM

MMDDCCYY.

The end date of the beneficiary’s enrollment in an employer plan.

If there are multiple RDS coverage periods, overlapping dates are possible.

If there is no RDS Start Date, then this field is filled with zeroes.

If there is an RDS Start Date and no RDS End Date, then this field is filled with 9s.

245

RDS Coverage Period

(Occurrence 2)

16

2919-2934

See items 243 – 244.

Same as Occurrence 1.

246

RDS Coverage Period

(Occurrence 3)

16

2935-2950

See items 243 – 244.

Same as Occurrence 1.

247

RDS Coverage Period

(Occurrence 4)

16

2951-2966

See items 243 – 244.

Same as Occurrence 1.

248

RDS Coverage Period

(Occurrence 5)

16

2967-2982

See items 243 – 244.

Same as Occurrence 1.

249

Filler

1

2983

CHAR

Spaces.

Part D Eligibility (5 most recent occurrences)

250

Part D Eligibility Start Date (Occurrence 1)

8

2984-2991

NUM

MMDDCCYY.

Indicates the date that the beneficiary became eligible for Part D benefits.

This field is filled with zeroes if no Part 8D Eligibility Start Date is found.

251

Part D Eligibility End Date (Occurrence 1)

8

2992-2999

NUM

Indicates the date that the beneficiary is no longer eligible for Part D benefits.

This field is filled with zeroes if no Part D Eligibility Start Date is found.

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

252

Part D Eligibility Dates (Occurrence 2)

16

3000-3015

See items 250 – 251.

Same as Occurrence 1.

253

Part D Eligibility Dates (Occurrence 3)

16

3016-3031

See items 250 – 251.

Same as Occurrence 1.

254

Part D Eligibility Dates (Occurrence 4)

16

3032-3047

See items 250 – 251.

Same as Occurrence 1.

255

Part D Eligibility Dates (Occurrence 5)

16

3048-3063

See items 250 – 251.

Same as Occurrence 1.

Beneficiary Part D Low-Income Subsidy Information (10 most recent occurrences)

256

Subsidy Level

(Occurrence 1)

3

3064-3066

CHAR

Identifies the portion of the Part D Premium subsidized.

Values:

100

075

050

025

Relates to the numbered occurrences of the Beneficiary Co-Payment History, e.g. first occurrence here relates to the first occurrence of Co-Payment in item 195 (position 2222).

257

LIS/Deem Source code (Occurrence 1)

2

3067-3068

CHAR

Indicates the source of the LIS/Deeming action found in Co-Payment History Occurrence, item 194 (position 2221) and Subsidy Level, item 256 (position3064).

Values for D (Deemed):

01 – MBD Third Party.

02 – EEVS (State data baseline).

03 – SSA.

04 – State.

05 – Point of Sale.

06 – CMS User.

Values for L (LIS):

SS – SSA.

<ST> – Postal State Code Abbreviation.

258

Beneficiary LIS Premium Percentage and Source

(Occurrence 2)

5

3069-3073

See items 256 – 257.

Same as Occurrence 1.

259

Beneficiary LIS Premium Percentage and Source

(Occurrence 3)

5

3074-3078

See items 256 – 257.

Same as Occurrence 1.

260

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 4)

5

3079-3083

See items 256 – 257.

Same as Occurrence 1.

261

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 5)

5

3084-3068

See items 256 – 257.

Same as Occurrence 1.

262

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 6)

5

3069-3093

See items 256 – 257.

Same as Occurrence 1.

263

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 7)

5

3094-3098

See items 256 – 257.

Same as Occurrence 1.

264

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 8)

5

3099-3103

See items 256 – 257.

Same as Occurrence 1.

265

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 9)

5

3104-3108

See items 256 – 257.

Same as Occurrence 1.

266

Beneficiary Low-Income Subsidy Premium Percentage and Source

(Occurrence 10)

5

3109-3113

See items 256 – 257.

Same as Occurrence 1.

Beneficiary ESRD Clinical Dialysis Dates Occurrences 2 – 6, sorted from latest to earliest based on ESRD start date (refer to items 172-173, position 1980 for the first occurrence).

267

Beneficiary ESRD Clinical Dialysis Dates

(Occurrence 2)

16

3114-3129

See items 172 – 173.

Same as Occurrence 1.

268

Beneficiary ESRD Clinical Dialysis Dates

(Occurrence 3)

16

3130-3145

See items 172 – 173.

Same as Occurrence 1.

269

Beneficiary ESRD Clinical Dialysis Dates

(Occurrence 4)

16

3146-3161

See items 172 – 173.

Same as Occurrence 1.

270

Beneficiary ESRD Clinical Dialysis Dates

(Occurrence 5)

16

3162-3177

See items 172 – 173.

Same as Occurrence 1.

271

Beneficiary ESRD Clinical Dialysis Dates

(Occurrence 6)

16

3178-3193

See items 172 – 173.

Same as Occurrence 1.

272

Beneficiary Archive Indicator

1

3194

CHAR

Indicates that beneficiary is in Archived Medicare Beneficiary Database.

A – Archived

space – Not archived or not found in database

273

Medicare-Medicaid Plan (MMP) Opt-Out Indicator

1

3195

CHAR

Indicates that the beneficiary has opted out of an MMP

Y – Beneficiary has affirmatively opted out of the Financial Alignment Demonstration.

N – Beneficiary has not opted out of the Financial Alignment Demonstration.

Space – There is no opt-out information available (should be interpreted as the beneficiary has not opted out).

274

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 2)

8

3196-3203

See item 237.

MMDDCCYY.

275

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 2)

8

3204-3211

See item 238.

MMDDCCYY.

276

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 3)

8

3212-3219

See item 237.

MMDDCCYY.

277

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 3)

8

3220-3227

See item 238.

MMDDCCYY.

278

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 4)

8

3228-3235

See item 237.

MMDDCCYY.

279

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 4)

8

3236-3243

See item 238.

MMDDCCYY.

280

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 5)

8

3244-3251

See item 237.

MMDDCCYY.

281

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 5)

8

3252-3259

See item 238.

MMDDCCYY.

282

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 6)

8

3260-3267

See item 237.

MMDDCCYY.

283

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 6)

8

3268-3275

See item 238.

MMDDCCYY.

284

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 7)

8

3276-3283

See item 237.

MMDDCCYY.

285

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 7)

8

3284-3291

See item 238.

MMDDCCYY.

286

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 8)

8

3292-3299

See item 237.

MMDDCCYY.

287

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 8)

8

3300-3307

See item 238.

MMDDCCYY.

288

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 9)

8

3308-3315

See item 237.

MMDDCCYY.

289

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 9)

8

3316-3323

See item 238.

MMDDCCYY.

290

Medicare Plan Ineligibility Due to Incarceration Start Date

(Occurrence 10)

8

3324-3331

See item 237.

MMDDCCYY.

291

Medicare Plan Ineligibility Due to Incarceration End Date

(Occurrence 10)

8

3332-3339

See item 238.

MMDDCCYY.

292

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 1)

8

3340-3347

NUM

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 Not Lawful Presence Start Date and no Medicare Plan Ineligibility Due to Not Lawful Presence End Date, then this field is filled with zeroes.

If there is a Medicare Plan Ineligibility Due to Not Lawful Presence Start Date and no Medicare Plan Ineligibility Due to Not Lawful Presence End Date, then this field is filled with nines.

293

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 1)

8

3348-3355

NUM

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 Not Lawful Presence Start Date and no Medicare Plan Ineligibility Due to Not Lawful Presence End Date, then this field is filled with zeroes.

If there is a Medicare Plan Ineligibility Due to Not Lawful Presence End Date, then this field is filled with nines.

294

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 2)

8

3356-3363

See item 292.

MMDDCCYY

295

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 2)

8

3364-3371

See item 293.

MMDDCCYY

296

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 3)

8

3372-3379

See item 292.

MMDDCCYY

297

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 3)

8

3380-3387

See item 293.

MMDDCCYY

298

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 4)

8

3388-3395

See item 292.

MMDDCCYY

299

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 4)

8

3396-3403

See item 293.

MMDDCCYY

300

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 5)

8

3404-3411

See item 292.

MMDDCCYY

301

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 5)

8

3412-3419

See item 293.

MMDDCCYY

302

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 6)

8

3420-3427

See item 292.

MMDDCCYY

303

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 6)

8

3428-3435

See item 293.

MMDDCCYY

304

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 7)

8

3436-3443

See item 292.

MMDDCCYY

305

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 7)

8

3444-3451

See item 293.

MMDDCCYY

306

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 8)

8

3452-3459

See item 292.

MMDDCCYY

307

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 8)

8

3460-3467

See item 293.

MMDDCCYY

308

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 9)

8

3468-3475

See item 292.

MMDDCCYY

309

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 9)

8

3476-3483

See item 293.

MMDDCCYY

310

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date

(Occurrence 10)

8

3484-3491

See item 292.

MMDDCCYY

311

Medicare Plan Ineligibility Due to Not Lawful Presence End Date

(Occurrence 10)

8

3492-3499

See item 293.

MMDDCCYY

Medicare Beneficiary Identifier (MBI) Data (6 most recent occurrences). Note: These fields will not be populated until February 2018.

312

Beneficiary’s MBI

(Occurrence 1)

11

3500-3510

CHAR

The MBI from the beneficiary’s most recent Beneficiary MBI period. The value is a system-generated identifier used by CMS to uniquely identify the beneficiary in the Medicare database.

313

Beneficiary’s MBI Effective Date

(Occurrence 1)

8

3511-3518

NUM

MMDDCCYY.

The Effective Date of the beneficiary’s most recent Beneficiary MBI period.

314

Beneficiary’s MBI Effective Reason Code

(Occurrence 1)

5

3519-3523

CHAR

The Effective Reason Code from the beneficiary’s most recent Beneficiary MBI period. The value indicates the reason an MBI was assigned to the beneficiary.

Values:

A – Accretion.

I – Initial bulk MBI assignment.

BA – Special authorized.

BB – Breach.

BP – Provider issue.

BR – Religious/cultural.

BT – Medical/Identity theft.

BZ – Other.

CA – Special authorized.

CB – CMS breach.

CE – Entitlement and casework issues.

CF – Confirmed fraud.

CT – Medical/Identity theft.

CZ’ – Other.

315

Beneficiary’s MBI End Date

(Occurrence 1)

8

3524-3531

NUM

MMDDCCYY.

The End Date of the beneficiary’s most recent Beneficiary MBI period.

The field is populated with the End Date from the beneficiary’s record if a date exists.

The field is filled with nines if no value exists for the End Date in the beneficiary’s record.

316

Beneficiary’s MBI End Reason Code

(Occurrence 1)

5

3532-3536

CHAR

The End Reason Code from the beneficiary’s most recent Beneficiary MBI period. The value indicates the reason an MBI was deactivated for the beneficiary.

Values:

X – Cross-Reference merge.

BA – Special authorized.

BB – Breach.

BP – Provider issue.

BR – Religious/cultural.

BT – Medical/Identity theft.

BZ – Other.

CA – Special authorized.

CB – CMS breach.

CE – Entitlement and casework issues.

CF – Confirmed fraud.

CT – Medical/Identity theft.

CZ – Other.

317

Beneficiary MBI

(Occurrence 2)

37

3537-3573

See items 312 – 316

Same as Occurrence 1.

318

Beneficiary MBI

(Occurrence 3)

37

3574-3610

See items 312 – 316

Same as Occurrence 1.

319

Beneficiary MBI

(Occurrence 4)

37

3611-3647

See items 312 – 316

Same as Occurrence 1.

320

Beneficiary MBI

(Occurrence 5)

37

3648-3684

See items 312 – 316

Same as Occurrence 1.

321

Beneficiary MBI

(Occurrence 6)

37

3685-3721

See items 312 – 316

Same as Occurrence 1.

322

CARA Status Start Date (1)

8

3722-3729

NUM

MMDDCCYY

323

CARA Status End Date (1)

8

3730-3737

NUM

MMDDCCYY

324

CARA Status Start Date (2)

8

3738-3745

NUM

MMDDCCYY

325

CARA Status End Date (2)

8

3746-3753

NUM

MMDDCCYY

326

CARA Status Start Date (3)

8

3754-3761

NUM

MMDDCCYY

327

CARA Status End Date (3)

8

3762-3769

NUM

MMDDCCYY

328

CARA Status Start Date (4)

8

3770-3777

NUM

MMDDCCYY

329

CARA Status End Date (4)

8

3778-3785

NUM

MMDDCCYY

330

CARA Status Start Date (5)

8

3786-3793

NUM

MMDDCCYY

331

CARA Status End Date (5)

8

3794-3801

NUM

MMDDCCYY

332

CARA Status Start Date (6)

8

3802-3809

NUM

MMDDCCYY

333

CARA Status End Date (6)

8

3810-3817

NUM

MMDDCCYY

334

CARA Status Start Date (7)

8

3818-3825

NUM

MMDDCCYY

335

CARA Status End Date (7)

8

3826-3833

NUM

MMDDCCYY

336

CARA Status Start Date (8)

8

3834-3841

NUM

MMDDCCYY

337

CARA Status End Date (8)

8

3842-3849

NUM

MMDDCCYY

338

CARA Status Start Date (9)

8

3850-3857

NUM

MMDDCCYY

339

CARA Status End Date (9)

8

3858-3865

NUM

MMDDCCYY

340

CARA Status Start Date (10)

8

3866-3873

NUM

MMDDCCYY

341

CARA Status End Date (10)

8

3874-3881

NUM

MMDDCCYY

342

Date Beneficiary Last Used the Dual/LIS Special Election Period (Election Type “L”)

8

3882-3889

NUM

Format is MMDDCCYY

If the beneficiary has not used the DUAL/LIS SEP, then this field is filled with zeroes (00000000).

343

Filler

111

3890-4000

CHAR

Spaces



    1. MMA Response File Summary Record Layout

MMA Response File Summary Record

Item

Field

Size

Position

Format

Description

1

Record Identification Code

3

1-3

CHAR

FSM’.

2

State Code

2

4-5

CHAR

US Postal Service State Abbreviation.

See Table 15-3, State Codes.

3

File Process Timestamp

26

6-31

CHAR

The exact time that the MMA Request file is processed.

Format: CCYY-MM-DD-hh.mm.ss.nnnnnn.

CCYY – Year.

MM – Month.

DD – Day.

hh – Hour.

mm – Minute.

ss – Second.

nnnnnn – Microsecond.

4

File Create Month

2

32-33

NUM

The month that the MMA Request file is created

5

File Create Year

4

34-37

NUM

The year that the MMA Request file is created

6

Total Number of Records

8

38-45

NUM

The total number of DET records in the MMA Request file.

This count does not include PRO records.

7

Total Number of Duplicate Records

8

46-53

NUM

The total number of duplicate DET records in the MMA Request file.

This count does not include PRO records.

8

Total Number of Non-Duplicate Records

8

54-61

NUM

The total number of non-duplicate valid DET records in the MMA Request file.

This count does not include PRO records.

9

Total Number of Valid Records

8

62-69

NUM

The total number of valid DET records in the MMA Request file.

This count does not include PRO records.

10

Total Number of Invalid Records

8

70-77

NUM

The total number of invalid DET records in the MMA Request file.

This count does not include PRO records.

11

Total Number of Matched Records

8

78-85

NUM

The total number of DET records that could be matched to a beneficiary on the Active Medicare Beneficiary Database.

This count does not include PRO records.

12

Total Number of Unmatched Records

8

86-93

NUM

The total number of DET records that could not be matched to a beneficiary on the Active Medicare Beneficiary Database.

This count includes invalid records because a match is not attempted on invalid records.

This count does not include PRO records.

13

Filler

47

94-140

CHAR


14

Total Number of Valid Dual Records

8

141-148

NUM

The total number of valid DET records in the file.

This count does not include PRO records.

15

Total Number of Valid Dual Matches

8

149-156

NUM

The total number of DET records that are matched to a beneficiary on the Medicare Active Beneficiary Database.

This count does not include PRO records.

16

Total Number of Valid Dual Non-Matches

8

157-164

NUM

The total number of valid DET records that are not matched to a beneficiary on the Active Medicare Beneficiary Database.

This count does not include PRO records.

17

Total Number of Valid LIS Records

8

165-172

NUM

The total number of valid LIS records.

18

Total Number of Valid Current Duals

8

173-180

NUM

The total number of valid DET records with Eligibility Month/Year = File Create Month/Year.

This count does not include PRO records.

19

Total Number of Valid Retro Duals

8

181-188

NUM

The total number of valid DET records with Eligibility Month/Year < File Create Month/Year.

This count does not include PRO records.

20

Total Eligibility Months

2

189-190

NUM

The total number of Eligibility Months in the file.

This count does not include PRO records.

21

Total Valid PRO Records

8

191-198

NUM

The total number of valid PRO records in the file.

22

Total Invalid PRO Records

8

199-206

NUM

The total number of invalid PRO records in the file.

23

Total Matched PRO Records

8

207-214

NUM

The total number of valid PRO records that are matched to a beneficiary on the Active Medicare Beneficiary Database.

24

Filler

3786

215-4000

CHAR

Spaces.





    1. MMA Response File Monthly Summary Record Layout

MMA Response File Monthly Summary Record

Item

Field

Size

Position

Format

Description

1

Record Identification Code

3

1-3

CHAR

MSM.

2

State Code

2

4-5

CHAR

US Postal Service State Abbreviation.

See Table 15-3, State Codes.

3

File Process Timestamp

26

6-31

CHAR

The exact time that the MMA Request file is processed.

Format: CCYY-MM-DD-hh.mm.ss.nnnnnn.

CCYY – Year.

MM – Month.

DD – Day.

hh – Hour.

mm – Minute.

ss – Second.

nnnnnn – Microsecond.

4

File Create Month

2

32-33

NUM

The month that the MMA Request file is created.

5

File Create Year

4

34-37

NUM

The year that the MMA Request file is created.

6

Eligibility Month

2

38-39

NUM

Month for applicable Medicaid eligibility.

7

Eligibility Year

4

40-43

NUM

Year for applicable Medicaid eligibility.

8

Calculation Switch

1

44

CHAR

Y – The enrollment and disenrollment count for this Eligibility Month/Year have been included in the clawback counts.

Note: Eligibility Month/Year less than 1/1/2006 was never included in clawback count. Records older than 36 months are now rejected so entry will always be ‘Y’.

9

Total Valid Records

8

45-52

NUM

The total number of valid DET records for this Eligibility Month/Year.

This count does not include PRO records.

10

Total Valid Full Dual Records

8

53-60

NUM

The total number of valid full dual beneficiary records.

This count does not include PRO records.

11

Total Valid Non-Full Dual Records

8

61-68

NUM

The total number of valid non-full dual beneficiary records.

This count does not include PRO records.

12

Net Total Valid Full Dual Enrollments

8

69-76

NUM

The net total number of valid Full Dual Eligible enrollments counted for this Eligibility Month/Year.

This count does not include PRO records.

13

Net Total Valid Full Dual Disenrollments

8

77-84

NUM

The net total number of valid Full Dual Eligible disenrollments counted for this Eligibility Month/Year.

This count does not include PRO records.

14

Filler

3916

85-4000

CHAR

Spaces.





    1. MMA Response File Trailer Record Layout

MMA Response File Trailer Record

Item

Data Element Name

Size

Position

Format

Description

1

Record Identification Code

3

1-3

CHAR

TRL.

2

File Process Timestamp

26

4-29

CHAR

The exact time that the State file is processed.

Format: CCYY-MM-DD-hh.mm.ss.nnnnnn.

CCYY – Year.

MM – Month.

DD – Day.

hh – Hour.

mm – Minute.

ss – Second.

nnnnnn – Microsecond.

3

File Create Month

2

30-31

NUM

Month that the MMA Request file is created.

4

File Create Year

4

32-35

NUM

Year that MMA Request file is created.

5

File Accept Indicator

1

36

CHAR

Y – The MMA Request file is accepted.

6

Filler

7

37-43

CHAR


7

Record Identification Code

3

44-46

CHAR

A copy of the trailer record in the incoming file is displayed in items 7 – 12 (positions 44-223).

8

Beneficiary Record Count

8

47-54

NUM


9

State Code

2

55-56

CHAR


10

File Create Month

2

57-58

NUM


11

File Create Year

4

59-62

NUM


12

Filler

161

63-223

CHAR


13

Filler

3377

224-4000

CHAR


























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  1. Batch Eligibility Query (BEQ) Request File

The BEQ Request File includes transactions submitted by states to request eligibility information for beneficiaries. The file is used to conduct initial eligibility checks against the CMS MBD system to verify the beneficiary is Part A / B eligible.

Note: The date in the file name defaults to “01” denoting the first day of the CCM.

    1. BEQ Request File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

750

PRN

(states can send multiple files in a day)

This file includes the following records:


See Section 8.5 for a sample of the BEQ Request File Pass and Fail Acknowledgements.

    1. BEQ Request File Header Record Layout

BEQ Request File Header Record

Item

Field

Size

Position

Format

Valid Values

Description

1

File ID Name














8

1- 8

CHAR

MMABEQRH

Critical Field: This code identifies the file as a BEQ Request File and this record as the Header Record of the file.

2

Sending Entity: CMS










8

9-16

CHAR

Sending Organization (left-justified space filled)

Acceptable Values:

5-position Contract. (3 Spaces are for Future use)

Critical Field: This field provides CMS with the identification of the entity that is sending the BEQ Request File. The value for this field is provided to CMS and used in connection with CMS electronic routing and mailbox functions. The value in this field should agree with the corresponding value in the Trailer Record.

The Sending Entity may participate in Part D.

3

File Creation Date

8

17-24

CHAR

YYYYMMDD

Critical Field: The date that the Sending Entity created the BEQ Request File. For example, January 3 2010 is the value 20100103. This value should agree with the corresponding value in the Trailer Record. CMS returns this information to the Sending Entity on all Transactions (Detail Records) of a BEQ Response File.

4

File Control Number

9

25-33

CHAR

Assigned by Sending Entity

Critical Field

The specific Control Number assigned by the Sending Entity to the BEQ Request File. CMS returns this information to the Sending Entity on all Transactions (Detail Records) of a BEQ Response File. This value should agree with the corresponding value in the Trailer Record.

5

Filler

717

34-750

CHAR

Spaces




    1. BEQ Request File Detail Record Layout

BEQ Request File Detail Record

Item

Field

Size

Position

Format

Valid Values

Description

1

Record Type

5

1-5

CHAR

DTL01 = BEQ Transaction

Note: The value above is DTL-zero-one.

Critical Field

This code identifies the record as a detail record for processing specifically for BEQ Service.

2

Beneficiary ID

12

6-17

CHAR

Beneficiary ID, HICN, or RRB

Critical Field

  • Before the Medicare Beneficiary Identifier (MBI) Transition period, the acceptable values are the Health Insurance Claim Number (HICN), and the Railroad Retirement Board (RRB) Number.

  • During the MBI Transition period, the acceptable values are the HICN, RRB Number, and MBI.

  • When the MBI Transition period ends, the acceptable value is the MBI.

The last position may be a space.

3

Filler

9

18-26

CHAR

Spaces

4

DOB

8

27-34

CHAR

YYYYMMDD

Critical Field

The date of the beneficiary’s birth. The value should not include dashes, decimals, or commas. The value should include only numbers.

5

Gender Code

1

35

CHAR

0 – Unknown

1 – Male

2 – Female

Not Critical Field

The gender of the beneficiary.

6

Detail Record Sequence Number

7

36-42

NUM

Seven-byte number unique within the BEQ Request File

Critical Field

A unique number assigned by the Sending Entity to the Transaction (Detail Record). This number should uniquely identify the Transactions (Detail Record) within the BEQ Request File.

7

Filler

708

43-750

CHAR

Spaces




    1. BEQ Request File Trailer Record Layout

BEQ Request File Trailer Record

Item

Field

Size

Position

Format

Valid Values

Description

1

File ID Name

8

1-8

CHAR

MMABEQRT

Critical Field

This code identifies the record as the Trailer Record of a BEQ Request File.

2

Sending Entity (CMS)

8

9-16

CHAR

Sending Organization (left-justified space filled)

Acceptable Values:

5-position Contract Identifier + 3 Spaces

(3 Spaces for Future use)

Critical Field

This field provides CMS with the identification of the entity that is sending the BEQ Request File. The value for this field is provided to CMS and used in connection with CMS electronic routing and mailbox functions. The value in this field should agree with the corresponding value in the Header Record.

The Sending Entity may participate in Part D.

3

File Creation Date

8

17-24

CHAR

YYYYMMDD

Critical Field

The date when the Sending Entity created the BEQ Request File. For example, January 3, 2010, is the value 20100103. This value should agree with the corresponding value in the Header Record. CMS will pass this information back to the Sending Entity on all Transactions (Detail Records) of a BEQ Response File.

4

File Control Number

9

25-33

CHAR

Assigned by Sending Entity

Critical Field

The specific Control Number assigned by the Sending Entity to the BEQ Request File. CMS will return this information to the Sending Entity on all Transactions (Detail Records) of a BEQ Response File. This value should agree with the corresponding value in the Header Record.

5

Record Count

7

34-40

NUM

Numeric value greater than Zero, with leading zeroes.

Critical Field

The total number of Transactions (Detail Records) supplied on the BEQ Request File.

6

Filler

710

41-750

CHAR

Spaces




    1. Sample BEQ Request File E-mail Acknowledgments

The Medicare enrollment system issues an e-mail acknowledgment of receipt and status to the state. If the status is accepted, the file is processed. If the status is rejected, the e-mail informs the state of the first File Error Condition that caused the BEQ Request File’s rejection. A rejected file is not returned.

Sample e-mail of a Pass and Fail Acknowledgement appear below:

Example of BEQ Request File “Pass” Acknowledgment

TO: Jim.Doe@xxs.net

TO: Chris.Doe@dxxx.org

TO: Falcon.Doe@xxxx.org

FROM: MBD#BQ94.HCFJES@cms.hhs.gov

Subject: CMS MMA DATA EXCHANGE FOR MMABTCH



MMABTCH file has been received and passed surface edits by CMS.

QUESTIONS? Contact 1-800-927-8069 or E-mail [email protected]



INPUT HEADER RECORD

MMABEQRHS0094 20070306F20070306



INPUT TRAILER RECORD

MMABEQRTS0094 20070306F200703060000074



Example of BEQ Request File “Fail” Acknowledgment

TO: Jim.Doe@xxs.net

TO: Chris.Doe@dxxx.org

TO: Falcon.Doe@xxxx.org

FROM: MBD#BQ30.HCFJES@cms.hhs.gov

Subject: CMS MMA DATA EXCHANGE FOR MMABTCH

MMABTCH file has been received and failed surface edits by CMS.

QUESTIONS? Contact 1-800-927-8069 or E-mail [email protected]



INPUT HEADER RECORD

MMABEQRHH0030 20070228 84433346

INPUT TRAILER RECORD

MMABEQRTH0030 20070221 844333460074065

THE TRAILER RECORD IS INVALID

  1. Batch Eligibility Query (BEQ) Response File

The BEQ Response File contains records produced from processing the transactions of accepted BEQ Request files. Detail records for all submitted records that are successfully processed contain Processed Flag = Y. Detail records for all submitted records that are not successfully processed contain Processed Flag = N.

    1. BEQ Response File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

2000

Response to BEQ Request File.

The following records are included in this file:

    1. BEQ Response File Header Record Layout

BEQ Response File Header Record

Item

Field

Size

Position

Format

Valid Values

1

Header Code

8

1 – 8

CHAR

CMSBEQRH

2

Sending Entity

8

9 – 16

CHAR

MBD (MBD + five spaces)

3

File Creation Date

8

17 – 24

CHAR

CCYYMMDD

4

File Control Number

9

25 – 33

CHAR

 

5

Filler

1967

34 - 2000

CHAR

Spaces



    1. BEQ Response File Detail Record Layout

BEQ Response File Detail Record

Item

Field

Size

Position

Format

Valid Values

1

Record Type

3

1 – 3

CHAR

DTL

Start of Original Detail Record

2

Record Type

5

4 – 8

CHAR


3

Beneficiary ID

12

9 – 20

CHAR

This field will contain exactly what is received in the same field of the beneficiary’s Detail record in the related BEQ Request file.

4

Filler

9

21 –29

CHAR


5

Beneficiary’s Date of Birth

8

30 – 37

CHAR


6

Beneficiary’s Gender Code

1

38

CHAR


7

Detail Record Sequence Number

7

39 – 45

NUM


End of Original Detail Record

8

Processed Flag

1

46

CHAR

Y or N

9

Beneficiary Match Flag

1

47

CHAR

Y or N

Medicare Part A Entitlement Dates (2nd occurrence in Positions 1735 – 1750)

16

48 – 63

NUM

N/A

10

Medicare Part A Entitlement Start Date

8

48 – 55

CHAR

CCYYMMDD

11

Medicare Part A Entitlement End Date

8

56 – 63

CHAR

CCYYMMDD

Medicare Part B Entitlement Dates (2nd occurrence in Positions 1751 – 1766)

16

64 – 79

NUM

N/A

12

Medicare Part B Entitlement Start Date

8

64 – 71

CHAR

CCYYMMDD

13

Medicare Part B Entitlement End Date

8

72 – 79

CHAR

CCYYMMDD

14

Medicaid Indicator

1

80

CHAR

0 or 1

15

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 1)

8

81 – 88

CHAR

CCYYMMDD

16

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 1)

8

89 – 96

CHAR

CCYYMMDD

17

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 2)

8

97 – 104

See item 15

CCYYMMDD

18

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 2)

8

105 – 112

See item 16

CCYYMMDD

19

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 3)

8

113 – 120

See item 15

CCYYMMDD

20

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 3)

8

121 – 128

See item 16

CCYYMMDD

21

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 4)

8

129 – 136

See item 15

CCYYMMDD

22

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 4)

8

137 – 144

See item 16

CCYYMMDD

23

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 5)

8

145 – 152

See item 15

CCYYMMDD

24

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 5)

8

153 – 160

See item 16

CCYYMMDD

25

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 6)

8

161 – 168

See item 15

CCYYMMDD

26

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 6)

8

169 – 176

See item 16

CCYYMMDD

27

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 7)

8

177 – 184

See item 15

CCYYMMDD

28

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 7)

8

185 – 192

See item 16

CCYYMMDD

29

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 8)

8

193 – 200

See item 15

CCYYMMDD

30

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 8)

8

201 – 208

See item 16

CCYYMMDD

31

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 9)

8

209 – 216

See item 15

CCYYMMDD

32

Part D Disenrollment Date or Employer Subsidy End Date

(Occurrence 9)

8

217 – 224

See item 16

CCYYMMDD

33

Part D Enrollment Effective Date or Employer Subsidy Start Date

(Occurrence 10)

8

225 – 232

See item 15

CCYYMMDD

34

Part D Disenrollment Date or Employer Subsidy End Date

(occurrence 10)

8

233 – 240

See item 16

CCYYMMDD

35

Sending Entity

8

241 – 248

CHAR


36

File Control Number

9

249 – 257

CHAR


37

File Creation Date

8

258 – 265

CHAR

CCYYMMDD

38

Part D Eligibility Start Date

8

266 – 273

CHAR


39

Deemed / Low-Income Subsidy Effective Date

(Occurrence 1)

8

274 – 281

CHAR

CCYYMMDD

40

Deemed / Low-Income Subsidy End Date

(Occurrence 1)

8

282 – 289

CHAR

CCYYMMDD

41

Co-Payment Level Identifier

(Occurrence 1)

1

290

CHAR

1, 2, 3, 4 or 5

42

Part D Premium Subsidy Percent

(Occurrence 1)

3

291 – 293

CHAR

100, 075, 050, or 025

43

Deemed / Low-Income Subsidy Effective Date

(Occurrence 2)

8

294 – 301

See item 39

CCYYMMDD

44

Deemed / Low-Income Subsidy End Date

(Occurrence 2)

8

302 – 309

See item 40

CCYYMMDD

45

Co-Payment Level Identifier

(Occurrence 2)

1

310

See item 41

1, 2, 3, 4 or 5

46

Part D Premium Subsidy Percent

(Occurrence 2)

3

311 – 313

See item 42

100, 075, 050, or 025

Part D/RDS Indicator (10 occurrences)

47

RDS/Part D Indicator (Occurrence 1)

1

314

CHAR

D or R

48

RDS/Part D Indicator (Occurrence 2)

1

315

CHAR

D or R

49

RDS/Part D Indicator (Occurrence 3)

1

316

CHAR

D or R

50

RDS/Part D Indicator (Occurrence 4)

1

317

CHAR

D or R

51

RDS/Part D Indicator (Occurrence 5)

1

318

CHAR

D or R

52

RDS/Part D Indicator (Occurrence 6)

1

319

CHAR

D or R

53

RDS/Part D Indicator (Occurrence 7)

1

320

CHAR

D or R

54

RDS/Part D Indicator (Occurrence 8)

1

321

CHAR

D or R

55

RDS/Part D Indicator (Occurrence 9)

1

322

CHAR

D or R

56

RDS/Part D Indicator (Occurrence 10)

1

323

CHAR

D or R

Uncovered Months Data (20 occurrences)

57

Start Date

(Occurrence 1)

8

324 – 331

CHAR

CCYYMMDD

58

Number of Uncovered Months

(Occurrence 1)

3

332 – 334

NUM


59

Number of Uncovered Months Status Indicator

(Occurrence 1)

1

335

CHAR


60

Total Number of Uncovered Months

(Occurrence 1)

3

336 – 338

NUM


61

Uncovered Months

(Occurrence 2)

15

339 – 353

See items 57 – 60


62

Uncovered Months

(Occurrence 3)

15

354 – 368

See items 57 – 60


63

Uncovered Months

(Occurrence 4)

15

369 – 383

See items 57 – 60


64

Uncovered Months

(Occurrence 5)

15

384 – 398

See items 57 – 60


65

Uncovered Months

(Occurrence 6)

15

399 – 413

See items 57 – 60


66

Uncovered Months

(Occurrence 7)

15

414 – 428

See items 57 – 60


67

Uncovered Months

(Occurrence 8)

15

429 – 443

See items 57 – 60


68

Uncovered Months

(Occurrence 9)

15

444 – 458

See items 57 – 60


69

Uncovered Months

(Occurrence 10)

15

459 – 473

See items 57 – 60


70

Uncovered Months

(Occurrence 11)

15

474 – 488

See items 57 – 60


71

Uncovered Months

(Occurrence 12)

15

489 – 503

See items 57 – 60


72

Uncovered Months

(Occurrence 13)

15

504 – 518

See items 57 – 60


73

Uncovered Months

(Occurrence 14)

15

519 – 533

See items 57 – 60


74

Uncovered Months

(Occurrence 15)

15

534 – 548

See items 57 – 60


75

Uncovered Months

(Occurrence 16)

15

549 – 563

See items 57 – 60


76

Uncovered Months

(Occurrence 17)

15

564 – 578

See items 57 – 60


77

Uncovered Months

(Occurrence 18)

15

579 – 593

See items 57 – 60


78

Uncovered Months

(Occurrence 19)

15

594 – 608

See items 57 – 60


79

Uncovered Months

(Occurrence 20)

15

609 – 623

See items 57 – 60


80

Beneficiary’s Retrieved Date of Birth

(as retrieved from CMS database for matching beneficiary)

8

624 – 631

CHAR

CCYYMMDD

81

Beneficiary’s Retrieved Gender Code
(as retrieved from CMS database for matching beneficiary)

1

632

CHAR

0 – Unknown

1 – Male

2 – Female

82

Last Name

40

633 – 672

CHAR


83

First Name

30

673 – 702

CHAR


84

Middle Initial

1

703

CHAR


85

Current State Code

2

704 – 705

CHAR


86

Current County Code

3

706 – 708

CHAR


87

Date of Death

8

709 – 716

CHAR

CCYYMMDD

88

Part C/D Contract Number (if available)

5

717 – 721

CHAR


89

Part C/D Enrollment Start Date (if available)

8

722 – 729

CHAR

CCYYMMDD

90

Part D Indicator (if available)

1

730

CHAR

Y – Yes

N – No

Space

91

Part C Contract Number (if available)

5

731 – 735

CHAR


92

Part C Enrollment Start Date (if available)

8

736 – 743

CHAR


93

Part D Indicator (if available)

1

744

CHAR

N – No

Space

94

ESRD Indicator

1

745

CHAR

End-Stage Renal Disease Indicator

0 – No ESRD

1 – ESRD

95

PBP Number (associated with contract number in item 88, positions 717 – 721)

3

746 – 748

CHAR

Plan Benefit Package number

96

Plan Type Code

(associated with PBP number in item 95, positions 746 – 748)

2

749 – 750

CHAR

Type of plan

01 – HMO

02 – HMOPOS

04 – Local PPO

05 – PSO (State License)

07 – MSA

08 – RFB PFFS

09 – PFFS

18 – 1876 Cost

19 – HCPP 1833 Cost

20 – National PACE

28 – Chronic Care

29 – Medicare Prescription Drug Plan

30 – Employer/ Union Only Direct Contract PDP

31 – Regional PPO

40 – Employer/ Union Only Direct Contract PFFS

42 – RFB HMO

43 – RFB HMOPOS

44 – RFB Local PPO

45 – RFB PSO (State License)

46 – Point-of-Sale Contractor

47 – Employer/ Union Only Direct Contract PPO

48 – Medicare-Medicaid Plan HMO

49 – Medicare-Medicaid Plan HMOPOS

50 – Medicare-Medicaid Plan PPO

99 – Undefined Historical Data

97

EGHP Indicator

(associated with PBP number in item 95, positions 746 – 748)

1

751

CHAR

EGHP Switch

Y – EGHP

N – not EGHP

98

PBP Number

(associated with contract number in item 91, positions 731 – 735)

3

752 – 754

CHAR

Plan Benefit Package number

99

Plan Type Code

(associated with PBP number in item 98, positions 752 – 754)

2

755 – 756

CHAR

See values in item 96, positions 749 – 750.

100

EGHP Indicator

(associated with PBP number in item 98, positions 752 – 754)

1

757

CHAR

Employer Group Health Plan Switch

Y – EGHP

N – not EGHP

101

Mailing Address Line 1

40

758 – 797

CHAR


102

Mailing Address Line 2

40

798 – 837

CHAR


103

Mailing Address Line 3

40

838 – 877

CHAR


104

Mailing Address Line 4

40

878 – 917

CHAR


105

Mailing Address Line 5

40

918 – 957

CHAR


106

Mailing Address Line 6

40

958 – 997

CHAR


107

Mailing Address City

40

998 – 1037

CHAR


108

Mailing Address Postal State Code

2

1038-1039

CHAR


109

Mailing Address ZIP Code

9

1040–1048

CHAR


110

Mailing Address Start Date

8

1049–1056

CHAR

CCYYMMDD

111

Residence Address Line 1

60

1057–1116

CHAR


112

Residence Address City

40

1117–1156

CHAR


113

Residence Address Postal State Code

2

1157–1158

CHAR


114

Residence Address ZIP Code

9

1159–1167

CHAR


115

Residence Address Start Date

8

1168- 175

CHAR

CCYYMMDD

116

Medicare Plan Ineligibility Due to Incarceration Start Date (1)

8

1176–1183

CHAR

CCYYMMDD

117

Medicare Plan Ineligibility Due to Incarceration End Date (1)

8

1184–1191

CHAR

CCYYMMDD

118

Medicare Plan Ineligibility Due to Incarceration Start Date (2)

8

1192–1199

CHAR

CCYYMMDD

119

Medicare Plan Ineligibility Due to Incarceration End Date (2)

8

1200–1207

CHAR

CCYYMMDD

120

Medicare Plan Ineligibility Due to Incarceration Start Date (3)

8

1208–1215

CHAR

CCYYMMDD

121

Medicare Plan Ineligibility Due to Incarceration End Date (3)

8

1216–1223

CHAR

CCYYMMDD

122

Medicare Plan Ineligibility Due to Incarceration Start Date (4)

8

1224–1231

CHAR

CCYYMMDD

123

Medicare Plan Ineligibility Due to Incarceration End Date (4)

8

1232–1239

CHAR

CCYYMMDD

124

Medicare Plan Ineligibility Due to Incarceration Start Date (5)

8

1240–1247

CHAR

CCYYMMDD

125

Medicare Plan Ineligibility Due to Incarceration End Date (5)

8

1248–1255

CHAR

CCYYMMDD

126

Medicare Plan Ineligibility Due to Incarceration Start Date (6)

8

1256–1263

CHAR

CCYYMMDD

127

Medicare Plan Ineligibility Due to Incarceration End Date (6)

8

1264–1271

CHAR

CCYYMMDD

128

Medicare Plan Ineligibility Due to Incarceration Start Date (7)

8

1272–1279

CHAR

CCYYMMDD

129

Medicare Plan Ineligibility Due to Incarceration End Date (7)

8

1280–1287

CHAR

CCYYMMDD

130

Medicare Plan Ineligibility Due to Incarceration Start Date (8)

8

1288–1295

CHAR

CCYYMMDD

131

Medicare Plan Ineligibility Due to Incarceration End Date (8)

8

1296–1303

CHAR

CCYYMMDD

132

Medicare Plan Ineligibility Due to Incarceration Start Date (9)

8

1304–1311

CHAR

CCYYMMDD

133

Medicare Plan Ineligibility Due to Incarceration End Date (9)

8

1312–1319

CHAR

CCYYMMDD

134

Medicare Plan Ineligibility Due to Incarceration Start Date (10)

8

1320–1327

CHAR

CCYYMMDD

135

Medicare Plan Ineligibility Due to Incarceration End Date (10)

8

1328–1335

CHAR

CCYYMMDD

136

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (1)

8

1336-1343

CHAR

CCYYMMDD

137

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (1)

8

1344-1351

CHAR

CCYYMMDD

138

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (2)

8

1352-1359

CHAR

CCYYMMDD

139

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (2)

8

1360-1367

CHAR

CCYYMMDD

140

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (3)

8

1368-1375

CHAR

CCYYMMDD

141

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (3)

8

1376-1383

CHAR

CCYYMMDD

142

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (4)

8

1384-1391

CHAR

CCYYMMDD

143

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (4)

8

1392-1399

CHAR

CCYYMMDD

144

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (5)

8

1400-1407

CHAR

CCYYMMDD

145

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (5)

8

1408-1415

CHAR

CCYYMMDD

146

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (6)

8

1416-1423

CHAR

CCYYMMDD

147

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (6)

8

1424-1431

CHAR

CCYYMMDD

148

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (7)

8

1432-1439

CHAR

CCYYMMDD

149

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (7)

8

1440-1447

CHAR

CCYYMMDD

150

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (8)

8

1448-1455

CHAR

CCYYMMDD

151

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (8)

8

1456-1463

CHAR

CCYYMMDD

152

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (9)

8

1464-1471

CHAR

CCYYMMDD

153

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (9)

8

1472-1479

CHAR

CCYYMMDD

154

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (10)

8

1480-1487

CHAR

CCYYMMDD

155

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (10)

8

1488-1495

CHAR

CCYYMMDD

156

Current Enrollment Source Type Code

(associated with PBP number in item 95, positions 746 – 748)

1

1496

CHAR

An indicator providing the type of enrollment performed.


Values:

A: Auto enrolled by CMS.

B: Beneficiary election.

C: Facilitated enrollment by CMS.

D: CMS Annual Rollover.

E: Plan submitted auto-enrollments.

F: Plan submitted facilitated enrollments.

G: Point of Sale (POS) submitted enrollments.

H: CMS or plan submitted re- assignment enrollments.

I: Invalid Submitted Value.

J: State-submitted MMP passive enrollment.

K: CMS-submitted MMP passive enrollment.

L: Beneficiary MMP election.

M: Default for Financial Alignment Demo Plan enrollments submitted without an Enrollment Source Code (M is not submitted on an enrollment).

N: Rollover by plan transaction.

157

Current Enrollment Source Type Code (associated with PBP number in item 98, positions 752– 754)

1

1497

CHAR

See values in item 156, position 1496.

158

Prior Part C/D Contract Number

5

1498-1502

CHAR


159

Prior Part C/D Enrollment Start Date

(associated with PBP Number in item 162, positions 1520-1522)

8

1503-1510

CHAR

CCYYMMDD

160

Prior Part C/D Disenrollment Date

(associated with PBP Number in item 162, positions 1520-1522)

8

1511-1518

CHAR

CCYYMMDD

161

Prior Part D Indicator

(associated with PBP Number in item 162, positions 1520-1522)

1

1519

CHAR

Y – Yes

N – No

Space

162

Prior PBP Number

(associated with Contract Number in item 158, positions 1498-1502)

3

1520-1522

CHAR

Plan Benefit Package number

163

Prior Plan Type Code

(associated with PBP Number in item 162, positions 1520-1522)

2

1523-1524

CHAR

See values in item 96 (positions 749-750).

164

Prior EGHP Indicator

(associated with PBP Number in item 162, positions 1520-1522)

1

1525

CHAR

Employer Group Health Plan Switch

Y – EGHP

N – not EGHP

165

Prior Enrollment Source Type Code

(associated with PBP Number in positions 1520-1522)

1

1526

CHAR

See values in item 156 (position 1496).

166

Prior Part C Contract Number

5

1527-1531

CHAR


167

Prior Part C Enrollment Start Date

(associated with PBP Number in item 170, positions 1549-1551)

8

1532-1539

CHAR

CCYYMMDD

168

Prior Part C Disenrollment Date

(associated with PBP Number in item 170, positions 1549-1551)

8

1540-1547

CHAR

CCYYMMDD

169

Prior Part D Indicator

(associated with PBP Number in item 170, positions 1549-1551)

1

1548

CHAR

N – No

Space

170

Prior PBP Number

(associated with Contract Number in item 166, positions 1527-1531)

3

1549-1551

CHAR

Plan Benefit Package number

171

Prior Plan Type Code

(associated with PBP Number in item 170, positions 1549-1551)

2

1552-1553

CHAR

See values in item 96 (positions 749-750).

172

Prior EGHP Indicator

(associated with PBP Number in item 170, positions 1549-1551)

1

1554

CHAR

Employer Group Health Plan Switch

Y – EGHP

N – not EGHP

173

Prior Enrollment Source Type Code

(associated with PBP Number in item 170, positions 1549-1551)

1

1555

CHAR

See values in item 156 (position 1496).

174

Active MBI

11

1556-1566

CHAR

The MBI field will be populated during and after MBI Transition.

175

Most Recent Duals SEP Use Date

8

1567-1574

NUM

CCYYMMDD

176

CARA Status Start Date (1)

8

1575-1582

NUM

CCYYMMDD

177

CARA Status End Date (1)

8

1583-1590

NUM

CCYYMMDD

178

CARA Status Start Date (2)

8

1591-1598

NUM

CCYYMMDD

179

CARA Status End Date (2)

8

1599-1606

NUM

CCYYMMDD

180

CARA Status Start Date (3)

8

1607-1614

NUM

CCYYMMDD

181

CARA Status End Date (3)

8

1615-1622

NUM

CCYYMMDD

182

CARA Status Start Date (4)

8

1623-1630

NUM

CCYYMMDD

183

CARA Status End Date (4)

8

1631-1638

NUM

CCYYMMDD

184

CARA Status Start Date (5)

8

1639-1646

NUM

CCYYMMDD

185

CARA Status End Date (5)

8

1647-1654

NUM

CCYYMMDD

186

CARA Status Start Date (6)

8

1655-1662

NUM

CCYYMMDD

187

CARA Status End Date (6)

8

1663-1670

NUM

CCYYMMDD

188

CARA Status Start Date (7)

8

1671-1678

NUM

CCYYMMDD

189

CARA Status End Date (7)

8

1679-1686

NUM

CCYYMMDD

190

CARA Status Start Date (8)

8

1687-1694

NUM

CCYYMMDD

191

CARA Status End Date (8)

8

1695-1702

NUM

CCYYMMDD

192

CARA Status Start Date (9)

8

1703-1710

NUM

CCYYMMDD

193

CARA Status End Date (9)

8

1711-1718

NUM

CCYYMMDD

194

CARA Status Start Date (10)

8

1719-1726

NUM

CCYYMMDD

195

CARA Status End Date (10)

8

1727-1734

NUM

CCYYMMDD

Medicare Part A Entitlement Dates (1st occurrence in Positions 48 – 63)

16

1735-1750

NUM

N/A

196

Medicare Part A Entitlement Start Date (occurrence two)

8

1735-1742

NUM

CCYYMMDD

197

Medicare Part A Entitlement End Date (occurrence two)

8

1743-1750

NUM

CCYYMMDD

Medicare Part B Entitlement Dates (1st occurrence in Positions 64 – 79)

16

1751-1766

NUM

N/A

198

Medicare Part B Entitlement Start Date (occurrence two)

8

1751-1758

NUM

CCYYMMDD

199

Medicare Part B Entitlement End Date (occurrence two)

8

1759-1766

NUM

CCYYMMDD

200

Filler

234

1767-2000

CHAR

Spaces



    1. BEQ Response File Trailer Record Layout

BEQ Response File Trailer Record

Item

Field

Size

Position

Format

Valid Values

1

Trailer Code

8

1 – 8

CHAR

CMSBEQRT

2

Sending Entity

8

9 – 16

CHAR

MBD ‘

(MBD + five spaces)

3

File Creation Date

8

17 – 24

CHAR

CCYYMMDD

4

File Control Number

9

25 – 33

CHAR


5

Record Count

7

34 – 40

NUM

Right justified

6

Filler

1960

41 – 2000

CHAR

Spaces



  1. Territory Beneficiary Query (TBQ) Request File

The TBQ is a data exchange between CMS and the states. To determine beneficiary entitlement and enrollment information as part of the process for Low-Income Subsidy (LIS) enrollment, participating States will request information from MBD. MBD will validate the incoming file and send an email to the state indicating acceptance or rejection of the file. If the file is rejected, no further action is taken. If the file is accepted, MBD will send a file containing the latest entitlement data for the matched beneficiaries.

    1. TBQ Request File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

100

PRN

(states can send multiple files in a day)

The following records are included in this file:



    1. TBQ Request File Header Record Layout

TBQ Request File Header Record

Item

Field

Size

Position

Format

Valid Values

1

Header Code

8

1 – 8

CHAR

MMATBQH

2

State Code

2

9 – 10

CHAR

See Table 15-3, State Codes.

3

Create Month

2

11 – 12

NUM

MM.

4

Create Year

4

13 – 16

NUM

CCYY.

5

Filler

84

17 – 100

CHAR

Spaces.



    1. TBQ Request File Detail Record Layout

      TBQ Request File Detail Record

      Item

      Field

      Size

      Position

      Format

      Valid Values

      1

      Record Type

      3

      1 – 3

      CHAR

      DTL.

      2

      Beneficiary’s Social Security Number

      9

      4 – 12

      NUM


      3

      Beneficiary’s First Name

      15

      13 – 27

      CHAR

      The value should not be blank and should be upper case only.

      4

      Beneficiary’s Last Name

      20

      28 – 47

      CHAR

      The value should not be blank and should be upper case only.

      5

      Beneficiary’s Middle Initial (Optional)

      1

      48

      CHAR

      The first character, upper case only, of the beneficiary’s middle name.

      6

      Beneficiary’s Date of Birth

      8

      49 – 56

      CHAR

      CCYYMMDD.

      7

      Beneficiary’s Gender Code

      1

      57

      CHAR

      M, F, or U.

      8

      Family ID

      11

      58 – 68

      CHAR

      The TBQ process does not require or evaluate any value it receives in this field.

      9

      Beneficiary Suffix

      2

      69 – 70

      CHAR

      The TBQ process does not require or evaluate any value it receives in this field.

      10

      MPI

      13

      71 – 83

      CHAR

      The TBQ process does not require or evaluate any value it receives in this field.

      11

      Filler

      17

      84 – 100

      CHAR

      Spaces.

    2. TBQ Request File Trailer Record Layout

TBQ Request File Trailer Record

Item

Field

Size

Position

Format

Valid Values

1

Trailer Code

8

1 – 8

CHAR

MMATBQT.

2

Detail Record Count

9

9 – 17

NUM


3

Filler

83

18 – 100

CHAR

Spaces.



  1. Territory Beneficiary Query (TBQ) Response File

The MBD creates a TBQ Response file for each corresponding TBQ Request file from a State. The TBQ Response file contains beneficiary entitlement information for each matched beneficiary TBQ Request file. The response file is transmitted to the State via CMS’ Enterprise File Transfer (EFT) process.

    1. TBQ Response File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

4000

Response to TBQ Request File.



The following records are included in this file:



    1. TBQ Response File Header Record Layout

TBQ Response File Header Record

Item

Field

Size

Position

Format

Valid Values

1

Header Code

8

1 – 8

CHAR

MMATBQRH.

2

File Creation Date

8

9 – 16

NUM

CCYYMMDD.

3

Filler

3984

17 – 4000

CHAR

Spaces.



    1. TBQ Response File Detail Record Layout


TBQ Response File Detail Record

Item

Field

Size

Position

Format

Valid Values

Start of Original Detail Record

1

Record Type

3

1 – 3

CHAR

DTL

2

Beneficiary’s Social Security Number

9

4 – 12

CHAR


3

Beneficiary’s First Name

15

13 – 27

CHAR


4

Beneficiary’s Last Name

20

28 – 47

CHAR


5

Beneficiary’s Middle Initial

1

48

CHAR


6

Beneficiary’s Date of Birth

8

49 – 56

CHAR

CCYYMMDD.

7

Beneficiary’s Gender Code

1

57

CHAR

M, F, or U.

8

Family ID

11

58 – 68

CHAR


9

Beneficiary Suffix

2

69 – 70

CHAR


10

MPI

13

71 – 83

CHAR


End of Original Detail Record

11

Processed Flag

2

84 – 85

CHAR

00 – Successfully Processed.

01 – Detail Record Identifier not DTL.

02 – SSN Missing.

03 – First Name Missing.

04 – Last Name Missing.

05 – Gender Code Missing.

06 – Date of Birth Missing.

07 – Beneficiary Not Found.

08 – Successfully processed, but beneficiary not entitled to Part A and/or Part B.

09 – More than One Beneficiary Found.

12

Filler

151

86 – 236

CHAR

Spaces.

Beneficiary Information

13

Beneficiary’s Claim Account Number

9

237 – 245

CHAR


14

Beneficiary’s Identification Code

2

246 – 247

CHAR


15

Beneficiary’s Date of Birth

8

248 – 255

NUM

MMDDCCYY.

16

Beneficiary’s Date of Death

8

256 – 263

NUM

MMDDCCYY.

17

Beneficiary’s Gender Code

1

264

CHAR

0, 1, or 2.

18

Beneficiary’s First Name

30

265 – 294

CHAR


19

Beneficiary’s Middle Initial

1

295

CHAR


20

Beneficiary’s Last Name

40

296 – 335

CHAR


Cross Reference Numbers (10 occurrences)

21

Cross Reference Beneficiary’s Claim Account Number

(Occurrence 1)

9

336 – 344

CHAR

Previous Claim Account Number Identifying Beneficiary

22

Cross Reference Beneficiary’s Identification Code

(Occurrence 1)

2

345 – 346

CHAR

Previous Beneficiary Identification Code Identifying Beneficiary

23

Cross Reference

(Occurrence 2)

11

347 – 357

See items

21 – 22


24

Cross Reference

(Occurrence 3)

11

358 – 568

See items

21 – 22


25

Cross Reference

(Occurrence 4)

11

369 – 379

See items

21 – 22


26

Cross Reference

(Occurrence 5)

11

380 – 390

See items

21 – 22


27

Cross Reference

(Occurrence 6)

11

391 – 401

See items

21 – 22


28

Cross Reference

(Occurrence 7)

11

402 – 412

See items

21 – 22


29

Cross Reference

(Occurrence 8)

11

413 – 423

See items

21 – 22


30

Cross Reference

(Occurrence 9)

11

424 – 434

See items

21 – 22


31

Cross Reference

(Occurrence 10)

11

435 – 445

See items

21 – 22


Social Security Numbers (5 occurrences)

32

Social Security Number (Occurrence 1)

9

446 – 454

CHAR


33

Social Security Number (Occurrence 2)

9

455 – 463

CHAR


34

Social Security Number (Occurrence 3)

9

464 – 472

CHAR


35

Social Security Number (Occurrence 4)

9

473 – 481

CHAR


36

Social Security Number (Occurrence 5)

9

482 – 490

CHAR


Mailing Address

37

Mailing Address Line 1

40

491 – 530

CHAR


38

Mailing Address Line 2

40

531 – 570

CHAR


39

Mailing Address Line 3

40

571 – 610

CHAR


40

Mailing Address Line 4

40

611 – 650

CHAR


41

Mailing Address Line 5

40

651 – 690

CHAR


42

Mailing Address Line 6

40

691 – 730

CHAR


43

Mailing Address City Name

40

731 – 770

CHAR


44

Mailing Address State Code

2

771 – 772

CHAR


45

Mailing Address Zone Improvement Plan (Zip) Code

9

773 – 781

CHAR


46

Mailing Address Change Date

8

782 – 789

NUM

MMDDCCYY.

Residence Address

47

Residence Address Line 1

60

790 – 849

CHAR


48

Filler

180

850–1029

CHAR


49

Residence Address City Name

40

1030 – 1069

CHAR


50

Residence Address State Code

2

1070 – 1071

CHAR


51

Residence Address Zip Code

9

1072 – 1080

CHAR


52

Residence Address Change Date

8

1081 – 1088

NUM

MMDDCCYY.

Representative Payee

53

Beneficiary’s Representative Payee Switch

1

1089

CHAR

Y, N, or space.

Non-Entitlement Status

54

Part A Non-Entitlement Status Code

1

1090

CHAR

D, F, H, N, R, or space.

55

Part B Non-Entitlement Status Code

1

1091

CHAR

D, N, R, or space.

Entitlement Reason (5 occurrences)

56

Beneficiary’s Entitlement Reason Code Change Date

(Occurrence 1)

8

1092 – 1099

NUM

Zeroes.

57

Beneficiary’s Entitlement Reason Code

(Occurrence 1)

4

1100 – 1103

CHAR

Spaces.

58

Entitlement Reason

(Occurrence 2)

12

1104 – 1115

See items

56 – 57


59

Entitlement Reason

(Occurrence 3)

12

1116 – 1127

See items

56 – 57


60

Entitlement Reason

(Occurrence 4)

12

1128 – 1139

See items

56 – 57


61

Entitlement Reason

(Occurrence 5)

12

1140 – 1151

See items

56 – 57


Part A Entitlement (5 occurrences)

62

Beneficiary’s Part A Entitlement Start Date

(Occurrence 1)

8

1152 – 1159

NUM

MMDDCCYY.

63

Beneficiary’s Part A Entitlement End Date

(Occurrence 1)

8

1160 – 1167

NUM

MMDDCCYY.

64

Beneficiary’s Part A Enrollment Reason Code

(Occurrence 1)

1

1168

CHAR

Values:

A – Attainment of age 65.

B – Equitable relief.

D – Disability (under age 65 entitlement).

G – General enrollment period.

H – Entitlement based on health hazards.

I – Initial enrollment period.

J – Medicare Qualified Government Employee entitlement.

K – Renal disease is or was a reason for entitlement prior to age 65 or prior to the 25th month of disability.

L – Late filing.

M – Entitlement based on ESRD is terminated, but entitlement based on disability continues.

N – Age 65 and uninsured.

P – Potentially insured beneficiary is enrolled for Medicare coverage only.

Q – Quarters of coverage requirements are involved.

R – Residency requirements are involved.

S – State buy-in.

T – Disabled working individual.

U – Unknown.

Space – No value exists.

65

Beneficiary’s Part A Enrollment Status Code

(Occurrence 1)

1

1169

CHAR

Values:

C – No longer entitled due to disability cessation.

E – Free Part A Entitlement.

G – Entitled due to good cause.

S – Terminated. No longer entitled under End-Stage Renal Disease provision.

T – Terminated for non-payment of premiums.

W – Voluntary withdrawal from premium coverage.

X – Free Part A terminated or refused Hospital Insurance.

Y – Currently entitled. Premium is payable.

Space – No value exists.

66

Part A Entitlement

(Occurrence 2)

18

1170 – 1187

See items

62 – 65


67

Part A Entitlement

(Occurrence 3)

18

1188 – 1205

See items

62 – 65


68

Part A Entitlement

(Occurrence 4)

18

1206 – 1223

See items

62 – 65


69

Part A Entitlement

(Occurrence 5)

18

1224 – 1241

See items

62 – 65


Part B Entitlement (5 occurrences)

70

Beneficiary’s Part B Entitlement Start Date

(Occurrence 1)

8

1242 – 1249

NUM

MMDDCCYY.

71

Beneficiary’s Part B Entitlement End Date

(Occurrence 1)

8

1250 – 1257

NUM

MMDDCCYY.

72

Beneficiary’s Part B Enrollment Reason Code

(Occurrence 1)

1

1258

CHAR

Values:

B – Equitable relief.

C – Good cause.

D – Deemed Date of Birth.

F – Working aged.

G – General enrollment period.

H – Entitlement based on health hazards.

I – Initial enrollment period.

K – Renal disease is or was a reason for entitlement prior to age 65 or prior to the 25th month of disability.

M – Entitlement based on ESRD is terminated, but entitlement based on disability continues.

P – Medicare Part B Immunosuppressive Drug (Part B-ID).

R – Residency requirements are involved.

S – State buy-in.

T – Disabled working individual.

U – Unknown.

Space – No value exists.

73

Beneficiary’s Part B Enrollment Status Code

(Occurrence 1)

1

1259

CHAR

Values:

C – No longer entitled due to disability cessation.

F – Terminated due to invalid enrollment or enrollment voided.

G – Entitled due to good cause.

S – Terminated. No longer entitled under ESRD provision.

T – Terminated for non-payment of premiums.

W – Voluntary withdrawal from premium coverage.

Y – Currently entitled. Premium is payable.

Space – No value exists.

74

Part B Entitlement

(Occurrence 2)

18

1260 – 1277

See items

70 – 73


75

Part B Entitlement

(Occurrence 3)

18

1278 – 1295

See items

70 – 73


76

Part B Entitlement

(Occurrence 4)

18

1296 – 1313

See items

70 – 73


77

Part B Entitlement

(Occurrence 5)

18

1314 – 1331

See items

70 – 73


Hospice Coverage (5 occurrences)

78

Beneficiary Hospice Coverage Start Date

(Occurrence 1)

8

1332 – 1339

NUM

MMDDCCYY.

79

Beneficiary Hospice Coverage End Date

(Occurrence 1)

8

1340 – 1347

NUM

MMDDCCYY.

80

Hospice Coverage

(Occurrence 2)

16

1348 – 1363

See items

78 – 79


81

Hospice Coverage

(Occurrence 3)

16

1364 – 1379

See items

78 – 79


82

Hospice Coverage

(Occurrence 4)

16

1380 – 1395

See items

78 – 79


83

Hospice Coverage

(Occurrence 5)

16

1396 – 1411

See items

78 – 79


84

Beneficiary Disability Insurance Benefits Entitlement Start Date

(Occurrence 1)

8

1412 – 1419

NUM

MMDDCCYY.

85

Beneficiary Disability Insurance Benefits Entitlement End Date

(Occurrence 1)

8

1420 – 1427

NUM

MMDDCCYY.

86

Beneficiary Disability Insurance Benefits Entitlement Justification Code

(Occurrence 1)

1

1428

CHAR

1, A, H, or space.

87

Disability Insurance Benefits

(Occurrence 2)

17

1429 – 1445

See items

84 – 86


88

Disability Insurance Benefits

(Occurrence 3)

17

1446 – 1462

See items

84 – 86


89

Beneficiary's Managed Care

Organization Enrollment Start Date

(Occurrence 1)

8

1463 – 1470

NUM

MMDDCCYY.

90

Beneficiary's Managed Care Organization Enrollment End Date

(Occurrence 1)

8

1471 – 1478

NUM

MMDDCCYY.

91

Beneficiary's Managed Care Organization Contract Number

(Occurrence 1)

5

1479 – 1483

CHAR


92

Managed Care Organization

(Occurrence 2)

21

1484 – 1504

See items

89 – 91


93

Managed Care Organization

(Occurrence 3)

21

1505 – 1525

See items

89 – 91


94

Managed Care Organization

(Occurrence 4)

21

1526 – 1546

See items

89 – 91


95

Managed Care Organization

(Occurrence 5)

21

1547 – 1567

See items

89 – 91


96

Managed Care Organization

(Occurrence 6)

21

1568 – 1588

See items

89 – 91


97

Managed Care Organization

(Occurrence 7)

21

1589 – 1609

See items

89 – 91


98

Managed Care Organization

(Occurrence 8)

21

1610 – 1630

See items

89 – 91


99

Managed Care Organization

(Occurrence 9)

21

1631 – 1651

See items

89 – 91


100

Managed Care Organization

(Occurrence 10)

21

1652 – 1672

See items

89 – 91


Plan Benefits Package Election (10 occurrences)

101

Group Health Plan Enrollment Effective Date

(Occurrence 1)

8

1673 – 1680

NUM

MMDDCCYY.

102

Plan Benefits Package Start Date

(Occurrence 1)

8

1681 – 1688

NUM

MMDDCCYY.

103

Plan Benefits Package End Date

(Occurrence 1)

8

1689 – 1696

NUM

MMDDCCYY.

104

Plan Benefits Package Number

(Occurrence 1)

3

1697 – 1699

CHAR


105

Plan Benefits Package Coverage Type Code

(Occurrence 1)

2

1700 – 1701

CHAR

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

Values:

NF – Pay bill option not found for this contract.

03 – CCP (Coordinated Care Plan).

04 – MSA (Medicare Medical Savings Account).

05 – PFFS (Private Fee for Service).

06 – PACE (Program of All-Inclusive Care for the Elderly).

07 – Regional.

08 – Demo (Demonstration).

09 – FFS (Fee for Service).

10 – Cost / HCPP (Health Care Prepayment Plan).

11 – PDP (Part D Drug Plan) Election).

12– Chronic Care Demo.

13 – MSA (Medicare Medical Savings Account) Demonstration.

14 – MMP (Medicare/Medicaid Plan).

This field is filled with spaces if no PBP enrollment is found.

106

PBP Election

(Occurrence 2)

29

1702 – 1730

See items

101 – 105


107

PBP Election

(Occurrence 3)

29

1731 – 1759

See items

101 – 105


108

PBP Election

(Occurrence 4)

29

1760 – 1788

See items

101 – 105


109

PBP Election

(Occurrence 5)

29

1789 – 1817

See items

101 – 105


110

PBP Election

(Occurrence 6)

29

1818 – 1846

See items

101 – 105


111

PBP Election

(Occurrence 7)

29

1847 – 1875

See items

101 – 105


112

PBP Election

(Occurrence 8)

29

1876 – 1904

See items

101 – 105


113

PBP Election

(Occurrence 9)

29

1905 – 1933

See items

101 – 105


114

PBP Election

(Occurrence 10)

29

1934 – 1962

See items

101 – 105


End-Stage Renal Disease Coverage

115

Beneficiary’s ESRD Coverage Start Date

8

1963 – 1970

NUM

MMDDCCYY.

116

Beneficiary’s ESRD Coverage End Date

8

1971 – 1978

NUM

MMDDCCYY.

117

Beneficiary’s ESRD Termination Reason Code

1

1979

CHAR

A, B, C, D, E, or space.

End-Stage Renal Disease Clinical Dialysis Dates Occurrence 1 (refer to items 211 – 215, position 3114 – 3193 for 5 remaining occurrences)

118

Beneficiary’s ESRD Clinical Dialysis Start Date

8

1980 – 1987

NUM

MMDDCCYY.

119

Beneficiary’s ESRD Clinical Dialysis End Date

8

1988 – 1995

NUM

MMDDCCYY.

End-Stage Renal Disease Transplant

120

Beneficiary’s ESRD Transplant Start Date

8

1996 – 2003

NUM

MMDDCCYY.

121

Beneficiary’s ESRD Transplant End Date

8

2004 – 2011

NUM

MMDDCCYY.

Third-Party Part A History (5 occurrences)

122

Beneficiary’s Part A Third-Party Start Date

(Occurrence 1)

8

2012 – 2019

NUM

MMDDCCYY.

123

Beneficiary’s Part A Third-Party Premium Payer Code

(Occurrence 1)

3

2020 – 2022

CHAR

S01 – S99 and T01 – Z98.

124

Beneficiary’s Part A Third-Party End Date

(Occurrence 1)

8

2023 – 2030

NUM

MMDDCCYY.

125

Beneficiary’s Part A Third-Party Buy-In Eligibility Code

(Occurrence 1)

1

2031

CHAR

Values:

A – Aged recipient of Supplemental Security Income (SSI) payments.

B – Blind recipient of SSI payments.

C – Entitled to Part A of Title IV (Aid to Families with Dependent Children (AFDC)).

D – Disabled recipient of SSI payments.

E – Aged recipient of supplemental payment administered by SSA.

F – Blind recipient of supplemental payment administered by SSA.

G – Disabled recipient of supplemental payment administered by SSA.

H – Aged, blind, or disabled recipient.

M – Entitled to Medical Assistance only (MAO), non-cash recipient.

Z – Deemed categorically needy.

Space – No eligibility reason exists.

126

Third-Party Part A History

(Occurrence 2)

20

2032 – 2051

See items

122 – 125


127

Third-Party Part A History

(Occurrence 3)

20

2052 – 2071

See items

122 – 125


128

Third-Party Part A History

(Occurrence 4)

20

2072 – 2091

See items

122 – 125


129

Third-Party Part A History

(Occurrence 5)

20

2092 – 2111

See items

122 – 125


Third-Party Part B History (5 occurrences)

130

Beneficiary’s Part B Third-Party Start Date

(Occurrence 1)

8

2112 – 2119

NUM

MMDDCCYY.

131

Beneficiary’s Part B Third-Party Premium Payer Code

(Occurrence 1)

3

2120 – 2122

CHAR

000, 001, 005, 006, 007, 008, 010 – 650, 700, A01 – R99 or spaces.

132

Beneficiary’s Part B Third-Party Termination Date

(Occurrence 1)

8

2123 – 2130

NUM

MMDDCCYY.

133

Beneficiary’s Part B Third-Party Buy-In Eligibility Code

(Occurrence 1)

1

2131

CHAR

Values:

A – Aged recipient of Supplemental Security Income (SSI) payments.

B – Blind recipient of SSI payments.

C – Entitled to Part A of Title IV (Aid to Families with Dependent Children (AFDC)).

D – Disabled recipient of SSI payments.

E – Aged recipient of supplemental payment administered by SSA.

F – Blind recipient of supplemental payment administered by SSA.

G – Disabled recipient of supplemental payment administered by SSA.

H – Aged, blind, or disabled recipient.

M – Entitled to Medical Assistance only (MAO), non-cash recipient.

Z – Deemed categorically needy.

Space – No eligibility reason exists.

134

Third-Party Part B History

(Occurrence 2)

20

2132 – 2151

See items

130 – 133


135

Third-Party Part B History

(Occurrence 3)

20

2152 – 2171

See items

130 – 133


136

Third-Party Part B History

(Occurrence 4)

20

2172 – 2191

See items

130 – 133


137

Third-Party Part B History

(Occurrence 5)

20

2192 – 2211

See items

130 – 133


Part D Data Elements

138

Beneficiary’s First Eligibility Part D Date

8

2212 – 2219

NUM

MMDDCCYY.

139

Beneficiary’s Affirmatively Decline Indicator

1

2220

CHAR

Y, N, or space.

Beneficiary’s Co-Payment History (10 occurrences)

140

Beneficiary’s LIS Type

(Occurrence 1)

1

2221

CHAR

L or D.

141

Beneficiary’s Co-Payment Level

(Occurrence 1)

1

2222

CHAR

1, 2, 3, or 4.

142

Beneficiary’s Co-Payment Start Date

(Occurrence 1)

8

2223 – 2230

NUM

MMDDCCYY.

143

Beneficiary’s Co-Payment End Date

(Occurrence 1)

8

2231 – 2238

NUM

MMDDCCYY.

144

Co-Payment History

(Occurrence 2)

18

2239 – 2256

See items

140 – 143


145

Co-Payment History

(Occurrence 3)

18

2257 – 2274

See items

140 – 143


146

Co-Payment History

(Occurrence 4)

18

2275 – 2292

See items

140 – 143


147

Co-Payment History

(Occurrence 5)

18

2293 – 2310

See items

140 – 143


148

Co-Payment History

(Occurrence 6)

18

2311 – 2328

See items

140 – 143


149

Co-Payment History

(Occurrence 7)

18

2329 – 2346

See items

140 – 143


150

Co-Payment History

(Occurrence 8)

18

2347 – 2364

See items

140 – 143


151

Co-Payment History

(Occurrence 9)

18

2365 – 2382

See items

140 – 143


152

Co-Payment History

(Occurrence 10)

18

2383 – 2400

See items

140 – 143


Part D Plan Benefit Package (10 occurrences)

153

Beneficiary’s Contract Number

(Occurrence 1)

5

2401 – 2405

CHAR


154

Beneficiary’s Part D Enrollment Start Date

(Occurrence 1)

8

2406 – 2413

NUM

MMDDCCYY.

155

Beneficiary’s Part D Enrollment End Date

(Occurrence 1)

8

2414 – 2421

NUM

MMDDCCYY.

156

Beneficiary’s Part D PBP Plan Number

(Occurrence 1)

3

2422 – 2424

CHAR


157

Beneficiary’s Enrollment Type Indicator

(Occurrence 1)

1

2425

CHAR

A, B, C, D, E, F, G, H, I, J, K, L, M or N

158

Part D Plan Benefit Package

(Occurrence 2)

25

2426 – 2450

See items

153 – 157


159

Part D Plan Benefit Package

(Occurrence 3)

25

2451 – 2475

See items

153 – 157


160

Part D Plan Benefit Package

(Occurrence 4)

25

2476 – 2500

See items

153 – 157


161

Part D Plan Benefit Package

(Occurrence 5)

25

2501 – 2525

See items

153 – 157


162

Part D Plan Benefit Package

(Occurrence 6)

25

2526 – 2550

See items

153 – 157


163

Part D Plan Benefit Package

(Occurrence 7)

25

2551 – 2575

See items

153 – 157


164

Part D Plan Benefit Package

(Occurrence 8)

25

2576 – 2600

See items

153 – 157


165

Part D Plan Benefit Package

(Occurrence 9)

25

2601 – 2625

See items

153 – 157


166

Part D Plan Benefit Package

(Occurrence 10)

25

2626 – 2650

See items

153 – 157


167

Part C Organization Name

55

2651 – 2705

CHAR


168

Part C Plan Name

50

2706 – 2755

CHAR


169

Part D Organization Name

55

2756 – 2810

CHAR


170

Part D Organization Plan Name

50

2811 – 2860

CHAR


171

Part D Organization Plan Benefit

1

2861

CHAR

future use

172

Beneficiary Language Indicator

1

2862

CHAR

C, D, E, F, G, I, J, N, P, R, S, V, W, or space.

173

Special Needs Plan Indicator (Occurrence 1)

1

2863

CHAR

Y or N or Space (not applicable).

174

Special Needs Plan Indicator (Occurrence 2)

1

2864

CHAR

Y or N or Space (not applicable).

175

Special Needs Plan Indicator (Occurrence 3)

1

2865

CHAR

Y or N or Space (not applicable).

176

Special Needs Plan Indicator (Occurrence 4)

1

2866

CHAR

Y or N or Space (not applicable).

177

Special Needs Plan Indicator (Occurrence 5)

1

2867

CHAR

Y or N or Space (not applicable).

178

Special Needs Plan Indicator (Occurrence 6)

1

2868

CHAR

Y or N or Space (not applicable).

179180

Special Needs Plan Indicator (Occurrence 7)

1

2869

CHAR

Y or N or Space (not applicable).

181

Special Needs Plan Indicator (Occurrence 8)

1

2870

CHAR

Y or N or Space (not applicable).

182

Special Needs Plan Indicator (Occurrence 9)

1

2871

CHAR

Y or N or Space (not applicable).

183

Special Needs Plan Indicator (Occurrence 10)

1

2872

CHAR

Y or N or Space (not applicable).

184

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 1)

8

2873 – 2880

NUM

MMDDCCYY.

185

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 1)

8

2881 – 2888

NUM

MMDDCCYY.

186

Filler

14

2889 – 2902

CHAR

Spaces.

RDS Coverage Periods (5 occurrences)

187

RDS Start Date

(Occurrence 1)

8

2903 – 2910

NUM

MMDDCCYY.

188

RDS Termination Date (Occurrence 1)

8

2911 – 2918

NUM

MMDDCCYY.

189

RDS Coverage Period (Occurrence 2)

16

2919 – 2934

See items

187 – 188


190

RDS Coverage Period (Occurrence 3)

16

2935 – 2950

See items

187 – 188


191

RDS Coverage Period (Occurrence 4)

16

2951 – 2966

See items

187 – 188


192

RDS Coverage Period (Occurrence 5)

16

2967 – 2982

See items

187 – 188


193

Filler

1

2983

CHAR

Spaces.

Part D Eligibility Dates (5 occurrences)

194

Part D Eligibility Start Date (Occurrence 1)

8

2984 – 2991

NUM

MMDDCCYY.

195

Part D Eligibility Termination Date

(Occurrence 1)

8

2992 – 2999

NUM

MMDDCCYY.

196

Part D Eligibility Dates (Occurrence 2)

16

3000 – 3015

See items

194 – 195


197

Part D Eligibility Dates (Occurrence 3)

16

3016 – 3031

See items

194 – 195


198

Part D Eligibility Dates (Occurrence 4)

16

3032 – 3047

See items

194 – 195


199

Part D Eligibility Dates (Occurrence 5)

16

3048 – 3063

See items

194 – 195


Beneficiary Subsidy Information (10 occurrences)

200

Subsidy Level

(Occurrence 1)

3

3064 – 3066

NUM

100, 075, 050, or 025.

201

LIS DEEM Source Code

(Occurrence 1)

2

3067 – 3068

CHAR

01, 02, 03, 04, 05, 06, SS or <ST> valid state code.

202

Beneficiary Subsidy Information (Occurrence 2)

5

3069 – 3073

See items

200 – 201


203

Beneficiary Subsidy Information (Occurrence 3)

5

3074 – 3078

See items

200 – 201


204

Beneficiary Subsidy Information (Occurrence 4)

5

3079 – 3083

See items

200 – 201


205

Beneficiary Subsidy Information (Occurrence 5)

5

3084 – 3088

See items

200 – 201


206

Beneficiary Subsidy Information (Occurrence 6)

5

3089 – 3093

See items

200 – 201


207

Beneficiary Subsidy Information (Occurrence 7)

5

3094 – 3098

See items

200 – 201


208

Beneficiary Subsidy Information (Occurrence 8)

5

3099 – 3103

See items

200 – 201


209

Beneficiary Subsidy Information (Occurrence 9)

5

3104 – 3108

See items

200 – 201


210

Beneficiary Subsidy Information (Occurrence 10)

5

3109 – 3113

See items

200 – 201


Beneficiary ESRD Clinical Dialysis Dates occurrences 2 through 6 (refer to items 118 – 119, position 1980 – 1995 for the first occurrence).

211

Beneficiary ESRD Clinical Dialysis Dates (Occurrence 2)

16

3114 – 3129

See items

118 – 119


212

Beneficiary ESRD Clinical Dialysis Dates (Occurrence 3)

16

3130 – 3145

See items

118 – 119


213

Beneficiary ESRD Clinical Dialysis Dates (Occurrence 4)

16

3146 – 3161

See items

118 – 119


214

Beneficiary ESRD Clinical Dialysis Dates (Occurrence 5)

16

3162-3177

See items

118 – 119


215

Beneficiary ESRD Clinical Dialysis Dates (Occurrence 6)

16

3178-3193

See items

118 – 119


216

Filler

1

3194-3194

CHAR

Spaces.

217

MMP Opt-Out Indicator

1

3195-3195

CHAR

Y, N, or space.

218

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 2)

8

3196-3203

NUM

MMDDCCYY.

219

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 2)

8

3204-3211

NUM

MMDDCCYY.

220

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 3)

8

3212-3219

NUM

MMDDCCYY.

221

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 3)

8

3220-3227

NUM

MMDDCCYY.

222

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 4)

8

3228-3235

NUM

MMDDCCYY.

223

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 4)

8

3236-3243

NUM

MMDDCCYY.

224

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 5)

8

3244-3251

NUM

MMDDCCYY.

225

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 5)

8

3252-3259

NUM

MMDDCCYY.

226

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 6)

8

3260-3267

NUM

MMDDCCYY.

227

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 6)

8

3268-3275

NUM

MMDDCCYY.

228

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 7)

8

3276-3283

NUM

MMDDCCYY.

229

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 7)

8

3284-3291

NUM

MMDDCCYY.

230

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 8)

8

3292-3299

NUM

MMDDCCYY.

231

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 8)

8

3300-3307

NUM

MMDDCCYY.

232

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 9)

8

3308-3315

NUM

MMDDCCYY.

233

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 9)

8

3316-3323

NUM

MMDDCCYY.

234

Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 10)

8

3324-3331

NUM

MMDDCCYY.

235

Medicare Plan Ineligibility Due to Incarceration End Date (Occurrence 10)

8

3332-3339

NUM

MMDDCCYY.

236

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 1)

8

3340-3347

NUM

MMDDCCYY.

237

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 1)

8

3348-3355

NUM

MMDDCCYY.

238

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 2)

8

3356-3363

NUM

MMDDCCYY.

239

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 2)

8

3364-3371

NUM

MMDDCCYY.

240

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 3)

8

3372-3379

NUM

MMDDCCYY.

241

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 3)

8

3380-3387

NUM

MMDDCCYY.

242

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 4)

8

3388-3395

NUM

MMDDCCYY.

243

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 4)

8

3396-3403

NUM

MMDDCCYY.

244

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 5)

8

3404-3411

NUM

MMDDCCYY.

245

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 5)

8

3412-3419

NUM

MMDDCCYY.

246

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 6)

8

3420-3427

NUM

MMDDCCYY.

247

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 6)

8

3428-3435

NUM

MMDDCCYY.

248

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 7)

8

3436-3443

NUM

MMDDCCYY.

249

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 7)

8

3444-3451

NUM

MMDDCCYY.

250

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 8)

8

3452-3459

NUM

MMDDCCYY.

251

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 8)

8

3460-3467

NUM

MMDDCCYY.

252

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 9)

8

3468-3475

NUM

MMDDCCYY.

253

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 9)

8

3476-3483

NUM

MMDDCCYY.

254

Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 10)

8

3484-3491

NUM

MMDDCCYY.

255

Medicare Plan Ineligibility Due to Not Lawful Presence End Date (Occurrence 10)

8

3492-3499

NUM

MMDDCCYY.

Beneficiary MBI: Up to six occurrences listed in descending order by the date the occurrence was added to the beneficiary’s record.

256

Beneficiary’s MBI

(Occurrence 1)

11

3500-3510

CHAR

The MBI from the beneficiary’s most recent Beneficiary MBI period. The value is a system-generated identifier used by CMS to uniquely identify the beneficiary in the Medicare database.

257

Beneficiary’s MBI Effective Date

(Occurrence 1)

8

3511-3518

NUM

The Effective Date of the beneficiary’s most recent Beneficiary MBI period. The format is MMDDCCYY.

258

Beneficiary’s MBI Effective Reason Code

(Occurrence 1)

5

3519-3523

CHAR

The Effective Reason Code from the beneficiary’s most recent Beneficiary MBI period. The value indicates the reason an MBI was assigned to the beneficiary. The valid values are the following.

A – Accretion.

I – Initial bulk MBI assignment.

BA – Special authorized.

BB – Breach.

BP – Provider issue.

BR – Religious/cultural.

BT – Medical/Identity theft.

BZ – Other.

CA – Special authorized.

CB – CMS breach.

CE – Entitlement and casework issues.

CF – Confirmed fraud.

CT – Medical/Identity theft.

CZ’ – Other.

259

Beneficiary’s MBI End Date

(Occurrence 1)

8

3524-3531

NUM

The End Date of the beneficiary’s most recent Beneficiary MBI period. The format is MMDDCCYY. The valid values are the following.

  • The field is populated with the End Date from the beneficiary’s record if a date exists; or

  • The field is filled with nines if no value exists for the End Date in the beneficiary’s record.

260

Beneficiary’s MBI End Reason Code

(Occurrence 1)

5

3532-3536

CHAR

The End Reason Code from the beneficiary’s most recent Beneficiary MBI period. The value indicates the reason an MBI was deactivated for the beneficiary. The valid values are the following.

X – Cross-Reference merge.

BA – Special authorized.

BB – Breach.

BP – Provider issue.

BR – Religious/cultural.

BT – Medical/Identity theft.

BZ – Other.

CA – Special authorized.

CB – CMS breach.

CE – Entitlement and casework issues.

CF – Confirmed fraud.

CT – Medical/Identity theft.

CZ – Other.

261

Beneficiary MBI

(Occurrence 2)

37

3537-3573

See items

256 – 260


262

Beneficiary MBI

(Occurrence 3)

37

3574-3610

See items

256 – 260


263

Beneficiary MBI

(Occurrence 4)

37

3611-3647

See items

256 – 260


264

Beneficiary MBI

(Occurrence 5)

37

3648-3684

See items

256 – 260


265

Beneficiary MBI

(Occurrence 6)

37

3685-3721

See items

256 – 260


266

CARA Status Start Date (1)

8

3722-3729

NUM

MMDDCCYY

267

CARA Status End Date (1)

8

3730-3737

NUM

MMDDCCYY

268

CARA Status Start Date (2)

8

3738-3745

NUM

MMDDCCYY

2695

CARA Status End Date (2)

8

3746-3753

NUM

MMDDCCYY

270

CARA Status Start Date (3)

8

3754-3761

NUM

MMDDCCYY

271

CARA Status End Date (3)

8

3762-3769

NUM

MMDDCCYY

272

CARA Status Start Date (4)

8

3770-3777

NUM

MMDDCCYY

273

CARA Status End Date (4)

8

3778-3785

NUM

MMDDCCYY

274

CARA Status Start Date (5)

8

3786-3793

NUM

MMDDCCYY

275

CARA Status End Date (5)

8

3794-3801

NUM

MMDDCCYY

276

CARA Status Start Date (6)

8

3802-3809

NUM

MMDDCCYY

277

CARA Status End Date (6)

8

3810-3817

NUM

MMDDCCYY

278

CARA Status Start Date (7)

8

3818-3825

NUM

MMDDCCYY

279

CARA Status End Date (7)

8

3826-3833

NUM

MMDDCCYY

280

CARA Status Start Date (8)

8

3834-3841

NUM

MMDDCCYY

281

CARA Status End Date (8)

8

3842-3849

NUM

MMDDCCYY

282

CARA Status Start Date (9)

8

3850-3857

NUM

MMDDCCYY

283

CARA Status End Date (9)

8

3858-3865

NUM

MMDDCCYY

284

CARA Status Start Date (10)

8

3866-3873

NUM

MMDDCCYY

285

CARA Status End Date (10)

8

3874-3881

NUM

MMDDCCYY

286

Date Beneficiary Last Used the Dual/LIS SEP (Election Type “L”)

8

3882-3889

NUM

Format is MMDDCCYY. If the beneficiary has not used the DUAL/LIS SEP, then this field is filled with zeroes (00000000).


287

Filler

111

3890-4000

CHAR

Spaces



    1. TBQ Response File Trailer Record Layout

      TBQ Response File Trailer Record

      Item

      Field

      Size

      Position

      Format

      Valid Values

      1

      Trailer Code

      8

      1 – 8

      CHAR

      MMATBQRT.

      2

      Detail Record Count

      9

      9 – 17

      NUM


      3

      Filler

      3983

      18 – 4000

      CHAR

      Spaces.

  1. Puerto Rico Dual Eligibles File Process

This section describes the Dual Eligible Beneficiaries data exchange between the Medical Assistance Program of Puerto Rico (known by its Spanish acronym, PAM) and CMS.

Medicare Beneficiary Database Suite of Systems (MBDSS) builds a risk adjustment period for a beneficiary living in Puerto Rico based on the beneficiary’s eligibility for Medicaid. Puerto Rico sends a Dual Eligibles File to CMS monthly that contains a record for each beneficiary who is eligible for Medicaid during the current month. Records for retroactive Medicaid eligibility may also be included in the file.

MBDSS creates a response file for each file received from Puerto Rico. The response file includes the original beneficiary record in addition to a processing indicator that describes the disposition of the record.

Section 12.1 through 12.4 covers the Request File layouts from Puerto Rico to CMS and Sections 12.5 through 12.9 covers the Response File layouts from CMS to Puerto Rico.

    1. Puerto Rico Dual Eligibles Request File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

129

Monthly

The following records are included in this file:

    1. Puerto Rico Dual Eligibles Request File Header Record Layout

Puerto Rico Dual Eligibles Request File Header Record

Item

Field

Size

Position

Format

Valid Values

1

File ID Name

8

1-8

CHAR

MMATMA1H

2

State Code

2

9-10

CHAR

PR

3

File Creation Month

2

11-12

NUM

MM

4

File Creation Year

4

13-16

NUM

CCYY

5

Filler

113

17-129

CHAR

Spaces



    1. Puerto Rico Dual Eligibles Request File Detail Record Layout

      Puerto Rico Dual Eligibles Request File Detail Record

      Item

      Field

      Size

      Position

      Format

      Valid Values

      1

      Record Type

      3

      1-3

      CHAR

      DTL

      2

      Eligibility Month

      2

      4-5

      NUM

      MM

      3

      Eligibility Year

      4

      6-9

      NUM

      CCYY

      4

      Eligibility Status

      1

      10-10

      CHAR

      Y – Eligible

      N – Not Eligible

      5

      Beneficiary’s Identifier

      12

      11-22

      CHAR

      The beneficiary’s identifier, which is used by CMS to identify the beneficiary in the Medicare database. The acceptable values are the following:

      • Health Insurance Claim Number (HICN);

      • Railroad Retirement Board (RRB) Number; or

      • Medicare Beneficiary Identifier (MBI).

      6

      Beneficiary’s Social Security Number

      9

      23-31

      CHAR


      7

      Medicaid Identifier

      24

      32-55

      CHAR


      8

      Beneficiary’s First Name

      15

      56-70

      CHAR


      9

      Beneficiary’s Last Name

      20

      71-90

      CHAR


      10

      Beneficiary’s Middle Name

      15

      91-105

      CHAR


      11

      Beneficiary’s Gender Code

      1

      106-106

      CHAR

      F – Female

      M – Male

      U – Unknown

      12

      Beneficiary’s Date of Birth

      8

      107-114

      CHAR

      CCYYMMDD

      13

      Filler

      15

      115-129

      CHAR

      Spaces

    2. Puerto Rico Dual Eligibles Request File Trailer Record Layout

Puerto Rico Dual Eligibles Request File Trailer Record

Item

Field

Size

Position

Format

Valid Values

1

Trailer Code

8

1-8

CHAR

MMATMA1T

2

Detail Record Count

9

9-17

NUM

Right justified

3

Filler

112

18-129

CHAR

Spaces





    1. Puerto Rico Dual Eligibles Response File Dataset Naming Conventions

System

Type

Size

Frequency

MBD

Data File

129

Monthly


The following records are included in this file:



    1. Puerto Rico Dual Eligibles Response File Header Record Layout

Puerto Rico Dual Eligibles Response File Header Record

Item

Field

Size

Position

Format

Valid Values

1

File ID Name

8

1-8

CHAR

MMATMA1H

2

File Creation Date

8

9-16

NUM

CCYYMMDD

3

Filler

113

17-129

CHAR

Spaces



    1. Puerto Rico Dual Eligibles Response File Detail Record Layout


Puerto Rico Dual Eligibles Response File Detail Record

Item

Field

Size

Position

Format

Valid Values

Start of Original Transaction Detail Record

1

Record Type

3

1-3

CHAR

DTL

2

Eligibility Month

2

4-5

NUM

MM

3

Eligibility Year

4

6-9

NUM

CCYY

4

Eligibility Status

1

10-10

CHAR

Y – Eligible

N – Not Eligible

5

Beneficiary’s Identifier

12

11-22

CHAR

The field is populated with the value for the same field from the related Puerto Rico to CMS Monthly Dual Eligibles file.

6

Beneficiary’s Social Security Number

9

23-31

CHAR


7

Medicaid Identifier

24

32-55

CHAR


8

Beneficiary’s First Name

15

56-70

CHAR


9

Beneficiary’s Last Name

20

71-90

CHAR


10

Beneficiary’s Middle Name

15

91-105

CHAR


11

Beneficiary’s Gender Code

1

106-106

CHAR

F – Female

M – Male

U – Unknown

12

Beneficiary’s Date of Birth

8

107-114

CHAR

CCYYMMDD

End of Original Transaction Detail Record

13

Processing Response Code

2

115-116

CHAR

00 – Record processed successfully.

01 – HICN/RRB/MBI number missing.

02 – Reserved.

03 – Eligibility Month Missing or Invalid.

04 – Eligibility Year Missing or Invalid.

05 – Beneficiary Not Found.

06 – Beneficiary Not Eligible for Part D.

07 – Future Eligibility Month/Year.

08 – Multiple Match.

09 – Eligibility Month/Year Earlier Than January 2006.

10 – Detail Record Identifier Not ‘DTL’.

14

Archive Indicator

1

117-117

CHAR

A – Archived

Space – Not Archived or not found in database.

15

Beneficiary’s MBI

11

118-128

CHAR

The MBI from the beneficiary’s most recent Beneficiary MBI period. The value is a system-generated identifier used internally and externally to uniquely identify the beneficiary in the Medicare database.

16

Filler

1

129-129

CHAR

Space





    1. Puerto Rico Dual Eligibles Response File Trailer Record Layout

      Puerto Rico Dual Eligibles Response File Trailer Record

      Item

      Field

      Size

      Position

      Format

      Valid Values

      1

      Trailer Code

      8

      1-8

      CHAR

      MMATMA1T

      2

      Detail Record Count

      9

      9-17

      NUM

      Right justified

      3

      Filler

      112

      18-129

      CHAR

      Spaces

    2. Puerto Rico Dual Eligibles File – E-mail Acknowledgement

If the incoming files pass all validation tests, an e-mail acknowledgment will be sent to Puerto Rico. A template of the e-mail text is as follows:

This e-mail is to confirm that CMS has received your recent file submission.

If the incoming file is rejected for file format errors, a file rejection will be sent to Puerto Rico. A template of the e-mail text is as follows:

This e-mail is to inform you that your recently submitted file was rejected.

This file must be corrected and resubmitted

If the incoming file is rejected because the error count has exceeded the allowable threshold limit a file rejection will be sent to Puerto Rico. A template of the e-mail text is as follows:

This e-mail is to inform you that your recently submitted file has exceeded the allowable threshold limit for edit errors.


Header name: MMATMA1HPR102014

Maximum Allowable Rejection Limit is 10.00%

Total Description

000000000 HIC/RRB# Missing

000000000 Invalid Eligibility Status

000000000 Eligibility Month Invalid

000000000 Eligibility Year Invalid

000000000 Beneficiary Not Found

000000000 Beneficiary Not Eligible for Part D

000000000 Future Eligibility Month/Year

000000000 Disposition of Record Pending

000000000 Eligibility Date Earlier 01/01/2006

000000000 Detail Record Identifier Not DTL

000000000 Total Records Read

000000000 Total Records Failed”



  1. Glossary, List of Acronyms, and State Codes

Table 13‑1: Glossary

Glossary

Term

Definition

Application Date

The date that the beneficiary applies to enroll in a Plan. Enrollments submitted by CMS or its contractors, such as the Medicare Beneficiary Contact Center, do not need application dates.

Beneficiary Identification Code (BIC)

The portion of the Medicare health insurance claim number that identifies a specific beneficiary.

Button

A rectangular icon on a screen that, when clicked, engages an action. The button is labeled with the word(s) that describe the action, such as Find or Update.

Checkbox

A field that is part of a group of options, for which the user may select any number of options. Each option is represented with a small box, where ‘x’ means “on” and an empty box means “off.” When a checkbox is clicked, an ‘x’ appears in the box. When the checkbox is clicked again, the ‘x’ is removed.

Correction

A record submitted by a Plan or CMS office to correct or update existing Beneficiary data.

Current Calendar Month (CCM)

Represents the calendar month and year at the time of transaction submission. For batch, the current month is derived from the batch file transmission date; for User Interface transactions, the current month is derived from the system data at the time of transaction submission.

Current Payment Month (CPM)

The month for which Plans receive payment from CMS, not the current calendar month.

Creditable Coverage

Prescription drug coverage, generally from an employer or union, that is equivalent to, or better than, Medicare standard prescription drug coverage.

Data entry field

A field that requires the user to enter information.

Disenrollment

A record submitted by a Plan, Social Security Administration District Office (SSA DO), Medicare Customer Service Center (MCSC), or CMS when a beneficiary discontinues membership in the Plan.

Dropdown list

A field that contains a list of values from which the user chooses. Clicking on the down arrow on the right of the field enables the user to view the list of values, and then click on a value to select it.

Dually Eligible

Beneficiaries entitled to both Medicare and Medicaid benefits.

Election Period

Periods during which a Beneficiary may elect to join, change, or leave Medicare Part C and/or Part D Plans. These periods are fully defined in CMS Enrollment and Disenrollment guidance for Part C and D Plans available on the CMS website at: http://www.cms.gov/home/medicare.asp under “Eligibility and Enrollment.”

Enrollment

A record is submitted when a Beneficiary joins an MCO or a Drug Plan.

Enrollment Process

A process in which a Plan submits a request to enroll in a Plan, change enrollment, or disenroll.

Hospice

A health facility for the terminally ill.

Logoff

The method of exiting an online system.

Logon

The method for gaining entry to an online system.

Lookup field

A field that provides a list of possible values. When the user clicks on the “binocular” button next to the field, a window pops up with a list of values for that field. Clicking on one of those values closes the pop-up window and the field is filled with the value chosen.

Managed Care Organization (MCO)

A type of Medicare Part C or D contract under which CMS pays for each beneficiary, based on demographic characteristics and health status; also referred to as Risk contract. In a Risk contract, the MCO accepts the risk if the payment does not cover the cost of services, but keeps the difference (subject to any risk corridors) if the payment is greater than the cost of services.

Medicaid

A jointly funded, Federal-State health insurance program for certain low-income people. It covers approximately 72.2 million beneficiaries.

Menu

A horizontal list of items at the top of a screen. Clicking on a menu item displays a screen and may display a submenu of items corresponding to the selected menu item.

Nursing Home Certifiable (NHC)

A code that reflects the relative frailty of a beneficiary. NHC beneficiaries are those whose condition would ordinarily require nursing home care. The code is only acceptable for certain social health maintenance organization (SHMO)-type Plans.

Online

An automated system approach that interactively processes data, normally

through computer input.

Program for All-Inclusive Care for the Elderly (PACE) Plans

PACE is a unique capitated managed care benefit for the frail elderly provided by an entity that offers a comprehensive medical and social service delivery system. It uses a multidisciplinary team approach in an adult day health center, supplemented by in-home and referral services in accordance with participants' needs.

Radio button

A field that is part of a group of options, of which the user may only select one option. A radio button is represented with a small circle; a filled circle indicates the button is selected, and an empty circle means it is not selected. Clicking a radio button selects that option and deselects the existing selection.

Required field

A field that the user must complete before a button is clicked to engage an action. If the button is clicked and the field is not filled in, an error message displays and the action does not occur.

There are two types of required fields:

  • Always required, which are marked with an asterisk (*)

  • Conditionally required, where the user must fill in at least one or only one of the conditionally required fields. These are marked with a plus sign (+).

Special Needs Plan

(SNP)

A certain type of MA Plan that serves a limited population of beneficiaries in CMS special-needs categories, as defined in CMS Part C Enrollment and Eligibility Guidance. This Plan is fully defined on the CMS website at: http://www.cms.gov/home/medicare.asp under “Health Plans.”

Submenu

A horizontal list of items below the screen’s menu. Clicking on a submenu item displays a screen.

User ID

Valid IDM user identification code used for accessing MARx.

User Interface

The screens, forms, and menus that display to a user logged on to an automated system.

Table 13‑2: Acronyms Used in this Document

Acronyms Used in this Document

Acronym

Definition

BEQ

Batch Eligibility Queries

BIC

Beneficiary Identification Code

BIN

Beneficiary Identification Number

BIPA

Benefits Improvement & Protection Act

CAN

Claim Account Number

CCM

Current Calendar Month

CMS

Centers for Medicare & Medicaid Services

COB

Coordination of Benefits

COM

Current Operation Month

CPM

Current Payment Month

DET

Detail Record

DOB

Date of Birth

DOD

Date of Death

DTL

Detail

EFT

Enterprise File Transfer

EGHP

Employer Group Health Plan

ESRD

End Stage Renal Disease

EUA

Enterprise User Administration

FFS

Fee-For-Service

GHP

Group Health Plan

GRP

Group

HCBS

Home and Community-Based Services

HICN

Health Insurance Claim Number

HMO

Health Maintenance Organization

HTML

Hypertext Markup Language

ID

Identification

IDM

Identity Management

LI

Low-Income

LIS

Low-Income Subsidy

LTI

Long-Term Institutional

MA

Medicare Advantage

MAPD

Medicare Advantage Prescription Drug

MARx

Medicare Advantage Prescription Drug System

MBD

Medicare Beneficiary Database

MBI

Medicare Beneficiary Identifier

MBR

Master Beneficiary Record

MCO

Managed Care Organization

MMA

Medicare Modernization Act

MMP

Medicare and Medicaid Plan

MSA

Medical Savings Account

MSP

Medicare Secondary Payer

NHC

Nursing Home Certifiable

NUNCMO

Number of Uncovered Months

PACE

Program of All-Inclusive Care for the Elderly

PAM

Medical Assistance Program of Puerto Rico

PBP

Plan Benefit Package

PCN

Processing Control Number

PDP

Prescription Drug Plan

PFFS

Private Fee-for-Service

POS

Point-of-Sale

PRO

PROspective Record

QI

Qualified Individual

QMB

Qualified Medicare Beneficiary Program

RACF

Resource Access Control Facility

RDS

Retiree Drug Subsidy

RRB

Railroad Retirement Board

SCC

State and County Code

SLMB

Specified Low-Income Medicare Beneficiary Program

SNP

Special Needs Plan

SPAP

State Pharmaceutical Assistance Program

SSA

Social Security Administration

SSN

Social Security Number

TBQ

Territory Beneficiary Query

UI

User Interface

XREF

Cross Reference



Table 13‑3: State Codes

State Codes

State Code

State

State Code

State

AL

Alabama

MT

Montana

AK

Alaska

NE

Nebraska

AZ

Arizona

NV

Nevada

AR

Arkansas

NH

New Hampshire

CA

California

NJ

New Jersey

CO

Colorado

NM

New Mexico

CT

Connecticut

NY

New York

DE

Delaware

NC

North Carolina

DC

District of Columbia

ND

North Dakota

FL

Florida

OH

Ohio

GA

Georgia

OK

Oklahoma

HI

Hawaii

OR

Oregon

ID

Idaho

PA

Pennsylvania

IL

Illinois

PR

Puerto Rico

IN

Indiana

RI

Rhode Island

IA

Iowa

SC

South Carolina

KS

Kansas

SD

South Dakota

KY

Kentucky

TN

Tennessee

LA

Louisiana

TX

Texas

ME

Maine

UT

Utah

MD

Maryland

VT

Vermont

MA

Massachusetts

VA

Virginia

MI

Michigan

WA

Washington

MN

Minnesota

WV

West Virginia

MS

Mississippi

WI

Wisconsin

MO

Missouri

WY

Wyoming



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