2012 Regional Technical Assistance Resource Guide. Wednesday, August 8, Enrollment

Transcription

1 Wednesday, August 8, 2012

2 RESOURCE GUIDE Purpose This is intended to help Medicare Advantage cost and prescription drug plans locate information specific to plan enrollment. The information listed in the is arranged in six sections: General Contact Information and Payment Acronyms and Terms Online Resources Reference Documents Links Best Available Evidence: Policy History and Document List s Summary General Contact Information Centers For Medicare & Medicaid Services (CMS) - MAPD Help Desk The MAPD Help Desk is the CMS contact for technical issues, and provides technical system support to CMS business partners for the operation of Medicare Parts C and D, assisting partners with connectivity, testing and data exchange with CMS. Contact Information: Phone: mapdhelp@cms.hhs.gov Hours of Operation: Monday-Friday 6 a.m. to 9 p.m. EST. HPMS Help Desk - The HPMS Help Desk is available to provide technical assistance to Plans on the use of HPMS and its software modules, such as the Complaints Tracking Module (CTM). The HPMS Help Desk also assists Plans on issues related to accessing and connecting to HPMS. Contact Information: Phone: HPMS@cms.hhs.gov For access, connectivity and user ID issues: HPMS_Access@cms.hhs.gov Retroactive Processing Contractor (RPC) - Contact Information: Client Services Department Phone: (402) clientservices@reedassociates.org Manager, Quality Assurance: Bob Hursh bhursh@reedassociates.org 1

3 and Payment Acronyms and Terms ACA...Affordable Care Act ACR...Adjusted Community Rate ADLs...Activities of Living AE...Automated AEP...Annual Period APPS...Automated Plan Payment System (Calculates payment using data provided by, HPMS, and PWS, and disperses payment to the U.S. Treasury ASUF...Age Sex Underwriting Factor BAE...Best Available Evidence BBA...Balanced Budget Act of 1997 BCSS...Batch Completion Status BEQ...Batch Eligibility Query BIC...Beneficiary Identification Code BIPA...Benefits Improvement & Protection Act of 2000 BPT...Bid Pricing Tool BSF...Benefit Stabilization Fund CAN...Claim Account Number CAP...Corrective Action Plan CCM...Current Calendar Month CCP...Coordinated Care Plan C: D...Connect: Direct CHF...Congestive Heart Failure CMB...Change Management Board (formerly Change Control Board) CMS...Centers for Medicare & Medicaid Services CMS-HCC...CMS-Hierarchical Condition Category CO...Central Office COB...Close of Business COB...Coordination of Benefits COBA...Coordination of Benefits Agreement CPM...Current Payment Month CPP...Covered D Plan Paid Amount CR...Change Request CSMM...Customer Support for Medicare Modernization CTM...Complaint Tracking Module CUI...Common User Interface CWF...Common Working database (CMS beneficiary database) DBC...Drug Benefit Calculator DCG...Diagnostic Cost Group DDPS...Drug Processing Systems DIR...Direct and Indirect Remuneration DMEC...Division of Medicare Coordination DO...District Office DOB...Date of Birth DOD...Date of Death DOE...Date of Entitlement DOS...Date of Service 2

4 DPO...Division of Payment Operations DSN... Set Name DTRR... Transaction Reply ECRS...Electronic Correspondence Referral System EDB... base EGHP...Employer Group Health Plan EGWP...Employer Group Waiver Plan ESRD...End Stage Renal Disease EOB...Explanation of Benefit EOM...End of Month EOY...End of Year EPOC...External Point of Contact ERC...Error Return Codes FAQ...Frequently Asked Questions FBDE...Full-Benefit Dual Eligible FE...Facilitated FEF...Full FFS...Fee-for-Service FIPS...Federal Information Processing Standard FIR...Financial Information ing FOIA...Freedom of Information Act FPL...Federal Poverty Level FTR...Failed Transaction FTP... Transfer Protocol GDCA...Gross Drug Cost Above the Out-of-Pocket Threshold GDCB...Gross Drug Cost Below the Out-of-Pocket Threshold GHP...Group Health Plan HCPP...Health Care Prepayment Plan HCC...Hierarchical Condition Category HIC...Health Insurance Claim HICN...Health Insurance Claim Number (a Medicare beneficiary s identification number) HMO...Health Maintenance Organization HPMS...Health Plan Management System (a CMS information system that contains health plan-level data) HTML...Hypertext Markup Language HTTPS...Hypertext Transfer Protocol Secure IACS...Individuals Authorized Access to CMS Computer Services ICEP...Initial Coverage Election Period ID...Identification IEP...Initial Period IRC...Information Request Code IRE...Independent Review Entity ISAR...Intra-Service Area Rate IT...Information Technology LEP...Late Penalty LICS...Low Income Cost-sharing Subsidy LIS...Low Income Subsidy LISHIST... Low Income Subsidy History LTC...Long Term Care LTI...Long-Term Institutionalized 3

5 MA...Medicare Advantage (formerly known as M+C) MA BSF...Medicare Advantage Benefit Stabilization Fund MAO...Medicare Advantage Organization (formerly known as M+CO) MA-PD...Medicare Advantage Prescription Drug Plan MA-PFFS...Medicare Advantage Private Fee-for-Service...Medicare Advantage and Prescription Drug System MBD...Medicare Beneficiary base MCO...Managed Care Organization MCSC...Medicare Customer Service Center (1-800-MEDICARE) MMA...Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Medicare Modernization Act) MMCM...Medicare Managed Care Manual MMR... Membership MMRD... Membership Detail MMSR... Membership Summary MPWR... Premium Withholding MSA...Medical Savings Account MSP...Medicare Secondary Payer NCDP...National Council of Prescription Drug Programs NDM...Network Mover NHC...Nursing Home Certifiable NPAR...Not Processed as Requested NUNCMO...Number of Uncovered Months OEPI...Open Period for Institutionalized Individuals OMB...Office of Management and Budget OOP...Out-of-Pocket OPM...Office of Personnel Management PACE...Program for All-Inclusive Care for the Elderly PAP...Patient Assistance Program PAR...Processed as Requested PBO...Payment Bill Option PBM...Pharmacy Benefit Manager PBP...Plan Benefit Package PCUG...Plan Communications User Guide PDE...Prescription Drug Event PDP...Prescription Drug Plan PFFS...Private Fee-for-Service PHI...Personal Health Information PIP-DCG...Principal Inpatient Diagnostic Cost Group PMPM...Per Member Per Month POS...Point of Sale PPO...Preferred Provider Organization PRS...Payment Reconciliation System PSO...Provider Sponsored Organization PW...Premium Withhold PWS...Premium Withhold System QI...Qualified Individuals QMB...Qualified Medicare Beneficiaries RACF...Resource Access Control Facility RAF...Risk Adjustment Factor 4

6 RAPS...Risk Adjustment Processing System RAS...Risk Adjustment System RDS...Retiree Drug Subsidy RPC...Retroactive Processing Contractor Rx BIN...Prescription Beneficiary Identification Number Rx GRP...Prescription Group Number Rx ID...Prescription Identification Number Rx PCN...Prescription Patient Control Number RxHCCs...Prescription Drug Hierarchical Condition Categories RO...CMS Regional Office RRB...Railroad Retirement Board SA...Service Area SCC...State and Country Code SEP...Special Election Period SFTP...Secure Shell Transfer Protocol SGMT...Segment Number SHMO...Social Health Maintenance Organization SLMB...Specified Low Income Medicare Beneficiary SNP...Special Needs Plan SOP...Standard Operation Procedure SSA...Social Security Administration SSA DO...Social Security Administration District Office SSA FO...Social Security Administration Field Office SSI...Supplemental Security Income SSN...Social Security Number TBT...TrOOP Balance Transfer TC...Transaction Code TPA...Third Party Administrator TRC...Transaction Reply Code TrOOP...True Out-of-Pocket Costs TRR...Transaction Reply UI...User Interface URL...Universal Resource Locator (worldwide web address) USPCC...United States Per Capita Cost VA...Veteran s Administration VDSA...Voluntary Sharing Agreement Online Resources online resources include: Centers for Medicare and Medicaid Services: HPMS CMS communications on a variety of topics: MAPD Help Desk, , mapdhelp@cms.hhs.gov, Technical Assistance and Registration Service Center (TARSC): Retroactive Processing Contractor (RPC): Social Security Administration: 5

7 Reference Documents Links Links to reference documents include: CMS and Disenrollment Guidance and manual chapters: select Eligibility and 2011 Technical Assistance presentation materials: e?opendocument&start=1&count=45&expand=1.1 Redesign and Modernization Handbook: Systems/CMS-Information- Technology/mapdhelpdesk/Downloads/_RM_HANDBOOK_Final_2010_12_16.pdf System Redesign & Modernization User Interface (UI) Handbook: Technology/mapdhelpdesk/Downloads/Plan_UI_RM_HANDBOOK_final.pdf Retroactive Processing Contractor (RPC) Toolkit and Standard Operating Procedures (SOPs): IACS User Guides: Technology/mapdhelpdesk/IACS.html Plan Schedules: Technology/mapdhelpdesk/ reports/trends: FAQ-Submitting Number of Uncovered Month to CMS: Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/Submitting-Number-of-Uncovered- Months-FAQ pdf Medicare Advantage/Part D Contract and : Final MA and Disenrollment Guidance Update for CY 2012: Medicare Managed Care Eligibility and Overview: PCUG Medicare Advantage (MA) Prescription Drug Plans Communications User Guide Plan Communications User Guide Appendices Systems/CMS-Information- Technology/mapdhelpdesk/Downloads/PCUG_v61_Appendices_Master_Copy_Final2_ pdf 6

8 Best Available Evidence (BAE): Policy History and Document List Medicare Prescription Drug Benefit Manual, Chapter 13, sections 70.5 through Call Letter - Announced a new requirement effective 2009 for sponsors to update their systems with hours of receipt of BAE. HPMS Notices DATE May 5, 2006 December 6, 2006 June 27, 2007 November 27, 2007 August 4, 2008 October 16, 2008 May 11, 2009 December 28, 2011 Established "best available data" policy. DESCRIPTION Discontinued the option for sponsors to "default" to a $2/$5 cost-sharing level without BAE". Established policies and procedures for the manual LIS status correction process. Instructed plans to send manual adjustments for deemed corrections to the Retroactive Processing Contractor. Outlined the requirement for BAE assistance process. Outlined which LIS award letters from SSA could be used for BAE. Clarified that only corrections for deemed individuals should be sent to the Retroactive Processing Contractor. Instructs plans to included documentation for the correction up front instead of upon request. Includes a sample of the SSI Award Letter as acceptable BAE evidence. References implementing the waiver of Part D cost sharing for Full Benefit Dual eligible beneficiaries who are receiving Home and Community Based Services (HCBS). Manual chapters are available at and memos are posted on HPMS. 7

9 s Summary All Transmissions Overview (Table K-1 from the PCUG Appendices) ID# Transmittal Description set naming conventions key: [GUID] = 7 character IACS User ID P = Production [.ZIP] = Appended if the file is compressed [directory] = optional directory specification from non-mainframe C:D clients (if present, may consist of up to 60 characters). If none exists, directory defaults to the constant EFTO. for Production files and "EFTT." for Test files. Plan Submittals to CMS pn = Processing number of varying length assigned to the file by Gentran ccccc = Contract number Pccccc = Plan Contract Number for C:D Uuuu-uuuuuuu = 4-7 character transmitter RACF ID xxxxx = 5 character Contract ID yyyymmdd = Calendar year, month & day yymmdd = two digit year, month, day zzzzzzzz = Plan-provided high level qualifier eeee = Year for which final yearly RAS file was produced vvvvv = Sequence counter for final yearly RAS files Responsible System Type Freq. set Naming Conventions Annnnn & Bnnnnn = batch transaction ID, nnnnnnnnnn split into two nodes A and B with leading zeroes as necessary to complete tencharacter batch ID hhmm = hour and minute ssssss= Sequentially assigned number mmyyyy = Calendar month & year hlq = High Level Qualifier or Directory per VSAM freq = Frequency code of file Batch Input Transaction 1 Header Record Transaction (Employer & Plan - 61 Detail Record Disenrollment Transaction (51/54) Detail Record Plan Elections (PBP Change) Transaction (71) Detail Record 4Rx Update (72) NUNCMO Update (73) Other record Update (74) Premium Withhold Option Update (75) Transaction file to CMS system requesting new enrollment, disenrollment, changes, etc. Only the Medicare group submits a Part D Opt-Out (41) transaction. Batch - PRN ** [GUID].[RACFID].MARX.D.xxxx x.future.[p/t][.zip] FUTURE is part of the filename and does not change. P#EFT.IN.uuuuuuu.MARXTR.DY YMMDD.THHMMSST DYYMMDD.THHMMSST must be coded as shown, as it is a literal PCUG Record Layout F.7 2 Batch Eligibility Query (BEQ) Request Header Record Detail Record Trailer Record PCUG Record Layout F.22 of transactions submitted by Plans to request eligibility information for prospective Plan enrollees. Used to do initial eligibility checks against CMS MBD system to verify member is Part A./B eligible MBD PRN (Plans can send Multiple files in a day) ** [GUID].[RACFID].MBD.D.xxxxx. BEQ.[P/T][.ZIP] P#EFT.IN.PLxxxxx.BEQ4RX.DY YMMDD.THHMMSST DYYMMDD.THHMMSST must be coded as shown, as it is a literal 3 Electronic Correspondence Referral System (ECRS) Batch Submittal used by Plans to submit other healthcare information (OHI) to CMS (rather than submittal through the ECRS online system) ECRS [GUID].[RACFID].ECRS.D.ccccc. FUTURE.[P/T] [.ZIP] TRANSMITTED TO GHI 4 Prescription Drug Event (PDE) Submittal of transactions submitted by the Plans with Prescription Drug Events. PDE Can be [GUID].[RACFID].PDE.D.ccccc.F UTURE.[P/T] [.ZIP] TRANSMITTED TO 8

10 ID# Transmittal Description Responsible System Type Freq. set Naming Conventions 5 RAPS Submittal of transactions submitted by the Plans with diagnoses for FFS Beneficiaries RAPS [GUID].[RACFID].RAPS.D.ccccc.F UTURE.[P/T] [.ZIP] TRANSMITTED TO 6 Electronic Services (EDS) Submittal CMS Transmittals to the Users (Submitters) of transactions submitted by the Plans with EDS. EDS [GUID].[RACF].EDS.D.xxxxx.FUT URE.[P/T][.ZIP] TRANSMITTED TO 7 Failed Transaction Header Record Failed Record This report is no longer generated as a result of the November 2009 software release. Failed Records are now reported on the BCSS data file. Response to transaction batch file Obsolete 8 Batch Completion Status Summary Summary Record Failed Records PCUG Record Layout F.3 file sent to the submitter once a batch of submitted transactions has been processed. Provides a count of all transactions within the batch and details the number of rejected and accepted transactions. It provides an image of the rejected and accepted transactions. Once batch is processed P.uuuuuuu.BCSSD.Annnnn.Bnnnnn. Thhmmss.pn Connect:Direct [Mainframe]: zzzzzzzz.uuuuuuu.bcssd.annnnn.b nnnnn.thhmmss Connect:Direct [Non-mainframe]: [directory]uuuuuuu.bcssd.annnnn. Bnnnnn.Thhmmss 9 Transmission Message (STATUS) This message is no longer generated as a result of the April 2011 software release. This information is now incorporated into the Batch Completion Status Summary (BCSS) data file. Response to transaction batch file Obsolete CMS Transmittals to the Plans 10 Coordination of Benefits (Validated Other Insurer Information) Detail Record Primary Record Supplemental Record PCUG Record Layout F.6 containing members' primary and secondary coverage that has been validated through COB processing. forwards this report whenever a Plan's enrollees are affected. It may be as often as daily.the enrollees included on the report are those newly enrolled who have known Other Health Insurance (OHI) and those Plan enrollees with changes to their OHI. MBD () As Needed (can be daily) P.Rxxxxx.MARXCOB.Dyymmdd.Th hmmsst.pn zzzzzzzz.rxxxxx.marxcob.dyym mdd.thhmmsst [directory]rxxxxx.marxcob.dyy mmdd.thhmmsst 9

11 11 MA Full Dual Auto Assignment Notification Header Record Detail Record (Transaction) Trailer Record PCUG Record Layout F.24 file of Full Dual Beneficiaries in an existing Plan. MBD P.Rxxxxx.#ADUA4.Dyymmdd.Thh mmsst.pn zzzzzzzz.rxxxxx.#adua4.dyymmd d.thhmmsst [directory]rxxxxx.#adua4.dyymm dd.thhmmsst 12 Auto Assignment (PDP) Address Notification Header Record Detail Record(s) Trailer Record PCUG Record Layout F.25 file of addresses of Beneficiaries who have been either Auto Assigned or Facilitated Assigned to PDPs MBD P.Rxxxxx.#APDP4.Dyymmdd.Thhm msst.pn zzzzzzzz.rxxxxx.#apdp4.dyymmd d.thhmmsst [directory]rxxxxx.#apdp4.dyymm dd.thhmmsst 13 NoRx Header Record Detail Record Trailer Record PCUG Record Layout F.21 containing records identifying those enrollees that do not currently have 4Rx information stored in CMS files. A Detail Record Type containing a value of NRX in positions 1 3 of the file layout will indicate that this record is a request for your organization to send CMS 4Rx information for the beneficiary. MBD P.Rxxxxx.#NORX.Dyymmdd.Thhm msst.pn zzzzzzzz.rxxxxx.#norx.dyymmdd.thhmmsst [directory]rxxxxx.#norx.dyymmd d.thhmmsst 14 Batch Eligibility Query (BEQ) Request Acknowledgment (Accept/Reject) PCUG Sample J.16 MBD will determine if a BEQ Request is Accepted or Rejected. MBD will issue an acknowledgment of receipt and status to the Sending Entity. If Accepted the file will be processed. If Rejected, the shall inform the Sending Entity of the first Error Condition that caused the BEQ Request to be Rejected. A rejected file will not be returned. MBD Response to BEQ N/A 15 Batch Eligibility Query (BEQ) Response Header Record Detail Record (Transaction) Trailer Record PCUG Record Layout F.23 containing records produced as a result of processing the transactions of accepted BEQ Request files. Detail records for all submitted records that were successfully processed will contain Processed Flag = Y. Detail records for all submitted records that were not successfully processed contain Processed Flag = N. MBD Response to BEQ P.Rxxxxx.#BQN4.Dyymmdd.Thhm msst.pn Connect:Direct [Mainframe]: zzzzzzzz.rxxxxx.#bqn4.dyymmdd. Thhmmsst Connect:Direct [Non-mainframe]: [directory]rxxxxx.#bqn4.dyymmd d.thhmmsst 10

12 16 ECRS containing errors and statuses of ECRS submissions. ECRS PCOB.BA.ECRS.ccccc.RESPONSE. ssssss GHI 17 Prescription Drug Event (PDE) PDFS Response containing responses if files are accepted or rejected. PDE RSP.PDFS_RESP_ssssss 18 Prescription Drug Event (PDE) Drug Processing System (DDPS Return provides feedback on every record processed in a batch. Up to 10 specific errors are reported for each PDE in the file. PDE RPT.DDPS_TRANS_VALIDATION _ssssss 19 Prescription Drug Event (PDE) DDPS Transaction Error Summary provides frequency of occurrence for each error code encountered during the processing of a PDE file. The percentage to the total errors is also computed and displayed for each error code. PDE RPT.DDPS_ERROR_SUMMARY_s sssss 20 Front-End Risk Adjustment System (FERAS) Response s indicates that the file was accepted or rejected by the Front-End Risk Adjustment System. FERAS RSP.FERAS_RESP_ssssss 21 Front-End Risk Adjustment System (FERAS) Response s contains all of the submitted transactions whether or not the file contains errors. FERAS RPT.RAPS_RETURN_FLAT_ssssss 22 Front-End Risk Adjustment System (FERAS) Response s Transaction Error lists the transactions that contained errors and identifies the errors found. FERAS RPT.RAPS_ERRORRPT_ssssss 23 Front-End Risk Adjustment System (FERAS) Response s Transaction Summary contains all of the transactions submitted, whether accepted or rejected. FERAS RPT.RAPS_SUMMARY_ssssss 24 Front-End Risk Adjustment System (FERAS) Response s Duplicate Diagnosis Cluster identifies diagnosis clusters with 502 error message, clusters accepted, but not stored. FERAS RPT.RAPS_DUPDX_RPT_ssssss 11

13 P.Rxxxxx.DTRRD.Dyymmdd.Thhm msst.pn 25 Transaction Reply Activity PCUG Record Layout F.15 file version of the Transaction Reply Activity. zzzzzzzz.rxxxxx.dtrrd.dyymmdd.thhmmsst [directory]rxxxxx.dtrrd.dyymmd d.thhmmsst 26 Electronic Services (EDS) Response containing responses if files are accepted or rejected. EDS P.xxxxx.EDS_RESPONSE.pn 27 Electronic Services (EDS) Reject IC ISAIEA containing responses if files are accepted or rejected. EDS P.xxxxx.EDS_REJT_IC_ISAIEA.pn 28 Electronic Services (EDS) Reject Function Transaction containing responses if files are accepted or rejected. EDS P.xxxxx.EDS_REJT_FUNCT_TRA NS.pn 29 Electronic Services (EDS) Accept Function Transaction containing responses if files are accepted or rejected. EDS P.xxxxx.EDS_ACCPT_FUNCT_TR ANS.pn 30 Electronic Services (EDS) Response Claim Number containing responses if files are accepted or rejected. EDS P.xxxxx.EDS_RESP_CLAIM_NUM. pn Weekly Transmittals ( & s) 31 LIS/Part D Premium PCUG Record Layout F.19 The data in the report reflects LIS info, premium subsidy levels, Lowincome co-pay levels, etc. for all Beneficiaries who have a low-income designation enrolled in a Plan. This data file is produced bi-weekly. It is not automatically transmitted to the Plans. Through the UI plans can request or reorder this data file. Biweekly P.Rxxxxx.LISPRMD.Dyymmdd.Thh mmsst.pn zzzzzzzz.rxxxxx.lisprmd.dyymm dd.thhmmsst [directory]rxxxxx.lisprmd.dyym mdd.thhmmsst 12

14 Transmittals ( & s) P.Fxxxxx.MONMEMR.Dyymm01.T hhmmsst.pn 32 Part C Membership Detail (Non Drug ) aka: Membership (MMR) PCUG Sample J.6 listing every Part C Medicare member of the contract and providing details about the payments and adjustments made for each. P.Rxxxxx.MONMEMR.Dyymm01.T hhmmsst.pn zzzzzzzz.fxxxxx.monmemr.dyy zzzzzzzz.rxxxxx.monmemr.dyy [directory]fxxxxx.monmemr.dyy zzzzzzzz.rxxxxx.monmemr.dyy P.Fxxxxx.MONMEMDR.Dyymm01. Thhmmsst.pn 33 Part D Membership Detail (Drug ) aka: Membership (MMR) PCUG Sample J.5 listing every Part D Medicare member of the contract and provides details about the payments and adjustments made for each. P.Rxxxxx.MONMEMDR.Dyymm01. Thhmmsst.pn zzzzzzzz.fxxxxx.monmemdr.dy y zzzzzzzz.rxxxxx.monmemdr.dy y [directory]fxxxxx.monmedr.dyy [directory]rxxxxx.monmedr.dyy P.Fxxxxx.MONMEMD.Dyymm01.T hhmmsst.pn 34 Membership Detail PCUG Record Layout F.9 file version of the Membership Detail s. This file contains the data for both Part C and Part D members. P.Rxxxxx.MONMEMD.Dyymm01.T hhmmsst.pn zzzzzzzz.fxxxxx.monmemd.dyy zzzzzzzz.rxxxxx.monmemd.dyy [directory]fxxxxx.monmemd.dyy [directory]rxxxxx.monmemd.dyy 13

15 35 Membership Summary PCUG Sample J.7 summarizing payments to a Plan for the month, in several categories, and adjustments, by all adjustment categories. This report contains data for both Part C and Part D members. P.Fxxxxx.MONMEMSR.Dyymm01. Thhmmsst.pn P.Rxxxxx.MONMEMSR.Dyymm01. Thhmmsst.pn zzzzzzzz.fxxxxx.monmemsr.dyy zzzzzzzz.rxxxxx.monmemsr.dyy [directory]fxxxxx.monmemsr.dy y [directory]rxxxxx.monmemsr.dy y P.Fxxxxx.MONMEMSD.Dyymm01. Thhmmsst.pn 36 Membership Summary PCUG Record Layout F.10 file version of the Membership Summary for both Part C and Part D members. P.Rxxxxx.MONMEMSD.Dyymm01. Thhmmsst.pn zzzzzzzz.fxxxxx.monmemsd.dyy zzzzzzzz.rxxxxx.monmemsd.dy y [directory]fxxxxx.monmemsd.dy y [directory]rxxxxx.monmemsd.dy y 37 RAS RxHCC Model Output AKA: Part D Risk Adjustment Model Output PCUG Sample J.10 showing the Part D risk adjustment factors for each beneficiary. forwards this report that is produced by RAS to plans as part of the month-end processing. RAS () (.pdf) P.Rxxxxx.PTDMODR.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.ptdmodr.dyym [directory]rxxxxx.ptdmodr.dyy 38 RAS RxHCC Model Output AKA: Part D Risk Adjustment Model Output Header Record Detail / Beneficiary Record Format Trailer Record PCUG Record Layout F.14 file version of the RAS RxHCC Model Output. forwards this report that is produced by RAS to Plans as part of the month-end processing. RAS () P.Rxxxxx.PTDMODD.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.ptdmodd.dyym [directory]rxxxxx.ptdmodd.dyy 14

16 39 Part C Risk Adjustment Model Output PCUG Sample J.9 showing the Hierarchical Condition Codes (HCCs) used by the Risk Adjustment System (RAS) to calculate Part C risk adjustment factors for each beneficiary. forwards this report that is produced by RAS to plans as part of the month-end processing. RAS () P.Rxxxxx.HCCMODR.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.hccmodr.dyym [directory]rxxxxx.hccmodr.dyy 40 Part C Risk Adjustment Model Output Header Record Detail Record Trailer Record PCUG Record Layout F.13 file version of the Risk Adjustment Model Output RAS () P.Rxxxxx.HCCMODD.Dyymm01.T hhmmsst.pn zzzzzzzz.rxxxxx.hccmodd.dyym [directory]rxxxxx.hccmodd.dyy 41 BIPA 606 Payment Reduction PCUG Sample J.1 listing members for whom the plan is paying a portion of the Part B premium. Generated only if there are pre-2006 adjustments that involve BIPA 606 premium reductions., if applicable P.Rxxxxx.BIPA606R.Dyymm01.Thh mmsst.pn zzzzzzzz.rxxxxx.bipa606r.dyym [directory]rxxxxx.bipa606r.dyym 42 BIPA 606 Payment Reduction PCUG Record Layout F.4 file version of the BIPA 606 Reduction., If applicable P.Rxxxxx.BIPA606D.Dyymm01.Thh mmsst.pn zzzzzzzz.rxxxxx.bipa606d.dyym [directory]rxxxxx.bipa606d.dyym 43 Bonus Payment PCUG Sample J.2 listing members for whom the plan is to be paid a bonus. (Plans are paid a bonus for extending services to Beneficiaries in some underserved areas.) Generated only if there are pre-2006 adjustments that involve bonus payments., if applicable P.Rxxxxx.BONUSRPT.Dyymm01.T hhmmsst.pn zzzzzzzz.rxxxxx.bonusrpt.dyy [directory]rxxxxx.bonusrpt.dyy 15

17 file version of the Bonus Payment P.Rxxxxx.BONUSDAT.Dyymm01.T hhmmsst.pn 44 Bonus Payment PCUG Record Layout F.5 will default to The date in the file name defaults to 01 denoting the first day of the current payment month, if applicable zzzzzzzz.rxxxxx.bonusdat.dyy [directory]rxxxxx.bonusdat.dyy 45 Demographic PCUG Sample J.3 Summary, by state and county, of the membership of the plan. Members are counted in categories that parallel the factors used in calculating the demographic payment, as well as ESRD and hospice status. Gentran mailbox; P.Rxxxxx.DEMOGRPH.Dyymm01. Thhmmsst.pn zzzzzzzz.rxxxxx.demogrph.dyy [directory]rxxxxx.demogrph.dy y 46 Summary of Bills PCUG Sample J.8 summarizing all Medicare fee-for-service activity, both Part A and Part B, for Beneficiaries enrolled in the contract P.Rxxxxx.SUMBILLS.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.sumbills.dyym [directory]rxxxxx.sumbills.dyy 47 HMO Bill Itemization PCUG Sample J.4 listing the Part A bills that were processed under Medicare fee-forservice for Beneficiaries enrolled in the contract. P.Rxxxxx.BILLITEM.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.billitem.dyym [directory]rxxxxx.billitem.dyym 48 Part B Claims Record Type 1 Record Type 2 file listing the Part B physician and supplier claims and Part B home health claims that were processed under Medicare fee-for-service for Beneficiaries enrolled in the contract. P.Rxxxxx.CLAIMDAT.Dyymm01.T hhmmsst.pn zzzzzzzz.rxxxxx.claimdat.dyy PCUG Record Layout F.12 [directory]rxxxxx.claimdat.dyy 16

18 49 Payment Records PCUG Sample J.11 listing the Part B physician and supplier claims that were processed under Medicare fee-for-service for Beneficiaries enrolled in the contract. P.Rxxxxx.PAYRECDS.Dyymm01.T hhmmsst.pn zzzzzzzz.rxxxxx.payrecds.dyy [directory]rxxxxx.payrecds.dyy 50 Premium Withholding (MPWR) Header Record Detail Record Trailer - T1 - Total at segment level Trailer - T2 - Total at PBP level Trailer - T3 - Total at contract level PCUG Record Layout F.11 reconciliation file of premiums withheld from SSA, RRB, or OPM checks. Includes Part C and Part D premiums and any Part D Late Penalties. This file is produced by the Premium Withhold System (PWS). makes this report available to plans as part of the month-end processing. PWS () P.Rxxxxx.MPWRD.Dyymm01.Thhm msst.pn zzzzzzzz.rxxxxx.mpwrd.dyymm0 1.Thhmmsst [directory]rxxxxx.mpwrd.dyymm 01.Thhmmsst 51 Failed Payment Reply Detail Record file reporting payment actions which failed to complete. Payment Cycle P.Rxxxxx.FPRRD.Dyymm01.Thhm msst.pn zzzzzzzz.rxxxxx FPRRD.Dyy PCUG Record Layout F.32 [directory]rxxxxx. FPRRD.Dyy 52 Plan Payment (APPS Payment Letter) PCUG Sample J.12 itemizing the final monthly payment to the plan. This report is produced by the APPS when final payments are calculated. makes this report available to plans as part of the month-end processing. APPS P.Fxxxxx.PLANPAY.Dyymm01.Thh mmsst.pn P.Rxxxxx.PLANPAY.Dyymm01.Th hmmsst.pn zzzzzzzz.fxxxxx.planpay.dyym zzzzzzzz.rxxxxx.planpay.dyym [directory]fxxxxx.planpay.dyym [directory]rxxxxx.planpay.dyym 17

19 53 Plan Payment (APPS Payment Letter) PCUG Record Layout F.26 This data file itemizes the final monthly payment to the MCO. This data file and subsequent report is produced by the APPS when final payments are calculated. CMS makes this report available to MCO s as part of monthend processing. APPS P.Rxxxxx.PPRD.Dyymm01.Thhmms st.pn zzzzzzzz.rxxxxx.pprd.dyymm01.t hhmmsst [directory].rxxxxx.pprd.dyymm01.thhmmsst 54 Interim APPS Plan Payment PCUG Sample J.13 When a Plan is approved for an interim payment outside of the normal monthly process, an interim Plan Payment is distributed to that Plan. The report contains the amount and reason for the interim payment. Plans can also request these reports via the user interface under the weekly report section of the menu. APPS As needed P.Rxxxxx.PLNPAYI.Dyymm01.Thh mmsst.pn zzzzzzzz.rxxxxx.plnpayi.dyymm 01.Thhmmsst [directory]rxxxxx.plnpayi.dyym 55 Interim APPS Plan Payment PCUG Sample Layout F.26 The Interim APPS Plan Payment and is provided when a Plan is approved for an interim payment outside of the normal monthly process. The data file / report contains the amount and reason for the interim payment to the Plan. APPS As needed P.Rxxxxx.PPRID.Dyymmdd.Thhmm sst.pn zzzzzzzz.rxxxxx.pprid.dyymmdd. Thhmmsst [directory].rxxxxx.pprid.dyymmd d.thhmmsst Format Payment Advice PCUG Record Layout F.1 HIPAA-Compliant version of the Plan Payment. This data file itemizes the final monthly payment to the plan. This data file is not available through. the first day of the CCM APPS P.Rxxxxx.PLAN820D.Dyymm01.Th hmmsst.pn zzzzzzzz.rxxxxx.plan820d.dyym [directory]rxxxxx.plan820d.dyy 57 Full PCUG Record Layout F.16 includes all active Plan membership on the date the file is run. This file is considered a definitive statement of current plan enrollment. This file uses the same format as the weekly TRR. CMS announces the availability of each month s file. and distinguishes this file from the Loss of Subsidy (Deemed Status) P.Rxxxxx.FEFD.Dyymm01.Thhmms st.pn zzzzzzzz.rxxxxx.fefd.dyymm01.t hhmmsst [directory]rxxxxx.fefd.dyymm01. Thhmmsst 18

20 58 Prescription Drug Event (PDE) DBC Cumulative Beneficiary Summary includes summary for the beneficiary of accumulated overall totals in PDE amount fields with accumulated totals for covered drugs. PDE RPT.DDPS.CUM_BENE_ACT_CO V_ssssss 59 Prescription Drug Event (PDE) DBC Cumulative Beneficiary Summary includes summary for the beneficiary of accumulated overall totals in PDE amount fields with accumulated totals for enhanced drugs. PDE RPT.DDPS_CUM_BENE_ACT_EN H_ssssss 60 Prescription Drug Event (PDE) DBC Cumulative Beneficiary Summary includes summary for the beneficiary of accumulated overall totals in PDE amount fields with accumulated totals for over-the-counter drugs. PDE RPT.DDPS_CUM_BENE_ACT_OT C_ssssss 61 Front-End Risk Adjustment System (FERAS) Response s Plan Activity provides monthly summary of the status of submissions by submitter and plan number. FERAS RPT.RAPS_MONTHLY_ssssss 62 Front-End Risk Adjustment System (FERAS) Response s Cumulative Plan Activity provides cumulative summary of the status of submissions by Submitter ID and plan number. FERAS RPT.RAPS_CUMULATIVE_ssssss 63 Front-End Risk Adjustment System (FERAS) Response s Frequency provides monthly summary of all errors on all file submissions within the month. FERAS RAPS_ERRORFREQ_MNTH_ssssss P.Fxxxxx.LISLEPD.Dyymm01.Thh mmsst.pn 64 LIS/LEP Header Record Detail Record Trailer Record PCUG Record Layout F.17 This report provides information on lowincome subsidized Beneficiaries and on direct-billed Beneficiaries with late enrollment penalties.. P.Rxxxxx.LISLEPD.Dyymm01.Thh mmsst.pn zzzzzzzz.fxxxxx.lislepd.dyymm0 1.Thhmmsst zzzzzzzz.rxxxxx.lislepd.dyymm 01.Thhmmsst [directory]fxxxxx.lislepd.dyymm 01.Thhmmsst [directory]rxxxxx.lislepd.dyym 19

21 65 LIS History (LISHIST) PCUG Record Layout F.20 This file supplements existing files that provide LIS notifications. It provides a complete picture of a beneficiary s LIS eligibility over a period of time not to exceed 36 months. defaults to dd denoting the day of the calendar month P.Rxxxxx.LISHIST.Dyymmdd.Thhm msst.pn zzzzzzzz.rxxxxx.lishist.dyymmd d.thhmmsst [directory]rxxxxx.lishist.dyymm dd.thhmmsst 66 Agent Broker Compensation PCUG Record Layout F.28 This data file provides six-year broker compensation cycle-year counts. is sent to Plans 1) when a beneficiary enrolls, 2) each January when the cycle-year count increments and 3) as necessary when retroactive change affects the compensation cycle. Plans may re-order the 6- year Broker Compensation via the UI., generally with the first weekly TRR of the month P.Rnnnnn.COMPRPT.Dyymmdd.Th hmmsst.pn zzzzzzzz.rnnnnn.comprpt.dyym mdd.thhmmsst [directory]rnnnnn.comprpt.dyym mdd.thhmmsst 67 MSP Information PCUG Record Layout F.29 This data file is sent directly to Plans on the first Monday after the month-end processing completes. This file contains a subset of information to allow Plans to reconcile payment; the full monthly MSP COB file distributed at the beginning of each month contains more detail. MDB P.Rxxxxx.MSPCOBAD.Dyymmdd.T hhmmsst.pn zzzzzzzz.rxxxxx.mspcobad.dyy mmdd.thhmmsst [directory].rxxxxx.mspcobad.dy ymmdd.thhmmsst 68 Other Health Coverage Information PCUG Record Layout F.30 Quarterly CMS provides Plans with a file listing the Beneficiaries who are enrolled in their plan(s) where Medicare is listed secondary. As a monthly report, this vehicle provides Plans with regular updates to the MSP data. MDB Gentran: P.Rxxxxx.MSPCOBMA.Dyymmdd. Thhmmsst.pn zzzzzzzz.rxxxxx.mspcobma.dyy mmdd.thhmmsst [directory].rxxxxx.mspcobma.dy ymmdd.thhmmsst 69 Front-End Risk Adjustment System (FERAS) Response s Frequency Quarterly provides quarterly summary of all errors on all file submissions within the three-month quarter. FERAS Quarterly RAPS_ERRORFREQ_QTR_ssssss 20

22 P.Rxxxxx.MPERD.Dyymmdd.Thhm msst.pn 70 Missing Payment Exception Record Layout file reporting payment actions which failed to complete. Payment Cycle zzzzzzzz.rxxxxx. MPERD.Dyymmdd.Thhmmsst [directory]rxxxxx. MPERD.Dyymmdd.Thhmmsst Yearly 71 RAS Final Yearly Model Output, Part D indicates the yearend Part D risk adjustment factors for each beneficiary. forwards this report, produced by RAS, to Plans as part of the month-end processing. RAS () (.pdf) Yearly P.Rxxxxx.PTDMOFR.Yeeee.Cvvvvv.Thhmmss.pn zzzzzzzz.rxxxxx.ptdmofr.yeeee. Cvvvvv.Thhmmss [directory]rxxxxx.ptdmofr. Yeeee.Cvvvvv.Thhmmss 72 RAS Final Yearly Model Output, Part D file version of the year end Part D RAS Model Output. forwards this report, produced by RAS, to Plans as part of the month-end processing. RAS () Yearly P.Rxxxxx.PTDMOFD.Yeeee.Cvvvvv.Thhmmss.pn zzzzzzzz.rxxxxx.ptdmofd.yeeee. Cvvvvv.Thhmmss [directory]rxxxxx.ptdmofd.yeee e.cvvvvv.thhmmss 73 RAS Final Yearly Model Output, Part C indicates the year end Part C risk adjustment factors for each beneficiary. forwards this report, produced by RAS, to Plans as part of the month-end processing. RAS () (.pdf) Yearly P.Rxxxxx.HCCMOFR.Yeeee.Cvvvv v.thhmmss.pn zzzzzzzz.rxxxxx.hccmofr.yeeee. Cvvvvv.Thhmmss [directory]rxxxxx.hccmofr.yeee e.cvvvvv.thhmmss 74 RAS Final Yearly Model Output, Part C file version of the year end Part C RAS Model Output. forwards this report, produced by RAS, to Plans as part of the month-end processing. RAS () Yearly P.Rxxxxx.HCCMOFD.Yeeee.Cvvvv v.thhmmss.pn zzzzzzzz.rxxxxx.hccmofd.yeeee. Cvvvvv.Thhmmss [directory]rxxxxx.hccmofd.yeee e.cvvvvv.thhmmss 21

23 75 Loss of Subsidy PCUG Record Layout E.18 The first file is sent in September and identifies members receiving a joint CMS and SSA letter informing them they will not have Deemed status for the following year. The second file is sent in December and is an updated version of the September file, indicating those Beneficiaries who still do not have Deemed status for the following year. The data file has a record length of 500 bytes. The TRC used for this special file type is 996. TRC 996 indicates the loss of Deeming which means the Beneficiary will not be redeemed for the upcoming period. Twice Yearly P.Rxxxxx.EOYLOSD.Dyymmdd.Th hmmsst.pn zzzzzzzz.rxxxxx.eoylosd.dyym mdd.thhmmsst [directory]rxxxxx.eoylosd.dyym mdd.thhmmsst 76 PDP Loss Once a year notification file sent by CMS providing a preliminary listing of LIS-eligible Beneficiaries whom CMS reassigns to a new PDP or to a new PBP within the same plan sponsor effective January 1, The LOSS file notifies PDPs of the members they will lose as a result of reassignment to other Plans. These members are classified as losing members. MBD Yearly P.Rxxxxx.APDP5.LOSS.Dyymmdd. Thhmmsst.pn zzzzzzzz.rxxxxx.apdp5.loss.dyy mmdd.thhmmsst [directory]rxxxxx.apdp5.loss.dy ymmdd.thhmmsst 77 PDP Gain Once a year notification file, sent by CMS, provides a preliminary listing of LIS-eligible Beneficiaries whom CMS reassigns to a new PDP or to a new PBP within the same Plan sponsor effective January 1, The GAIN file notifies PDPs of members they will gain as a result of the yearly reassignment. These members are classified as gaining members. MBD Yearly P.Rxxxxx.APDP5.GAIN.Dyymmdd. Thhmmsst.pn zzzzzzzz.rxxxxx.apdp5.gain.dyy mmdd.thhmmsst [directory]rxxxxx.apdp5.gain.dy ymmdd.thhmmsst 22

24 78 September Preliminary PDP Notification for Plans Losing Beneficiaries to Reassignment PCUG Record Layout F.2 This file is sent to PDPs losing Beneficiaries to reassignment due to premium increase (i.e., the premium going above LIS benchmark in the next year, or going from basic to enhanced benefit). It is a preliminary list of those Beneficiaries CMS expects the Plan to lose due to reassignment. It is used to help PDPs target the appropriate Annual Notice of Change to these Beneficiaries. Please note the file does not include individuals who may regain Deemed status in October, nor those whom a State Pharmaceutical Assistance Program (SPAP) may reassign if it has the authority to enroll on behalf of its members. MBD Yearly P.Rxxxxx.APDP5.PRLIM.Dyymmdd.Thhmmsst.pn zzzzzzzz.rxxxxx.apdp5.prlim.dy ymmdd.thhmmsst [directory]rxxxxx.apdp5.prlim.d yymmdd.thhmmsst 79 Long-Term Institutionalized Resident PCUG Record Layout F.27 The Long-Term Institutionalized (LTI) Resident provides Part D sponsors a list of their Beneficiaries who are LTI residents during July and January of each year. This report contains basic information on the Beneficiaries and their institutions (Skilled Nursing Home or Nursing Home). MDS Twice Yearly P.Rxxxxx.LTCRPT.Dyymmdd.Thhm msst.pn zzzzzzzz.rxxxxx.ltcrpt.dyymmd d.thhmmsst [directory]rxxxxx.ltcrpt.dyymm dd.thhmmsst 80 No Premium Due PCUG Record Layout F.31 The no premium due data file reports members that had a Part C premium, but will no longer have the Part C premium in the upcoming year. This data file is produced during end of year processing. Yearly P.Rxxxxx.SPCLPEX.Dyymmdd.Thh mmsst.pn zzzzzzzz.rxxxxx.spclpex.dyymm dd.thhmmsst [directory]rxxxxx.spclpex.dyym mdd.thhmmsst 23