Department of Health Services - dhcs.ca.gov€¦ · State of California-Health and Human Services...

State of California-Health and Human Services Agency

Department of Health Services

CaliforniaDepartment ofHealth Services

SANDRA SHEWRYDirector

ARNOLDSCHWARZENEGGERGovernor

DATE June21,2006

MMCD All Plan Letter 06003

TO: 1WO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARECONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTHPLAN, PACE PLANS, AIDS HEAL THCARE FOUNDATION

SUBJECT: MEDICARE PART D UPDATE

On December 29, 2005, the California Department of Health Services (CDHS) sent outMedi-Cal Managed Care Division (MMCD) All Plan letter 05015 to inform you of recentchanges to the Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) File layout dueto the implementation of the Medicare Prescription Drug Improvement andModernization Act of 2003 (MMA). The primary ch.ange to the monthly FAME files andthe daily FAME updates was the addition of the Medicare Part D Status Code, whichidentifies a beneficiary's Part D eligibility status. On January 12, 2006, GovernorSchwarzenegger signed emergency legislation, AB132, to ensure that allMedicare/Medi-Cal dual eligible beneficiaries receive their drug benefits.

The purpose of this letter is to provide information regarding

The Medicare Part D Status Code values;

.

The location of the Medicare Part D Status Code on the Non-COHS FAME Files;

.

The State's Emergency Part D Prescription Drug fill process and beneficiaryclaims;

.

The State's notification process for Medicare Part 0 eligible beneficiaries; and

Improvements to the Non-COHS FAME File..

.

Medi-Cal Managed Care Division1501 Capitol Avenue, P.O. Box 997413, MS 4400

Sacramento, CA 95899-7413Phone: (916) 449-5000 Fax: (916) 449-5005

Internet Address: www.dhs.ca.QOV

ARNOLD SCHWARZENEGGER Governor

DATE June 21, 2006

TWO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARE CONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTH PLAN, PACE PLANS, AIDS HEALTHCARE FOUNDATION

http://www.dhs.ca.gov

MMCD All Plan Letter 06003Medicare Part 0 Update -Non-COHS Plans of 4

June21,2006

How to Identify the Medicare Part D Status

The Medicare Part D Status Code is a 1-byte field that occurs at the end of each monthlysegment on the FAME files. The value in this field identifies whether the beneficiary hasPart D eligibility for the month in review. Please note that the Other Health Coverage(OHC) Code may contain a Part D value; however, the OHC Code should not be used toidentify a beneficiary's Part D status.

The valid Part D Status Code values are:

Blank or "0" Indicates that the beneficiary is not eligible for Medicare Part D;

.

"1", "2", or "3": Indicates that the beneficiary is eligible for Medicare Part D andhas been enrolled in a Part D Prescription Drug Plan (PDP);

.

"7": Indicates that the beneficiary is presumed to be eligible. The status of"Presumed Eligible" is applied when a beneficiary has all indications of beingeligible for Medicare Part D but has not been enrolled in a POP; and

"9": Indicates that the beneficiary has decided to opt out of Medicare Part D andinstead has alternate, approved coverage outside of Medi-Cal.

.

Please refer to Attachment A, MMA Part D Quick Reference Guide for additionalinformation regarding the Part 0 Status Code and OHC values.

As mandated, Medicare Part D is effective beginning the month that the Medicare Part DCode displays a valid Part D value in the FAME File. Regardless of a beneficiary'sMedicare Part A and B status, the Health Care Plan should not assume that thebeneficiary is participating in Medicare Part D.

The health care plan will be responsible for the beneficiary's drug coverage and will receivefull capitation payments until the Medicare Part D Status Code displays a valid value ("1", "2"or "3"). If a valid value of "9" is displayed, the beneficiary has affirmatively declined MedicarePart D and is entitled to receive only Part D excluded drugs from the managed care healthplan. Also, a beneficiary with a valid value of "9" will not be able to utilize the Medi-CalEmergency Drug Coverage. Health care plans will not receive capitation for Part D drugs forbeneficiaries with a valid value of "9". Please refer to Attachment A, MMA Part D Quick

Reference Guide.

MMCD All Plan Letter 06003Medicare Part D Update -Non-COHS Plans of 4

June21,2006

Where to Locate the Medicare Part D Status Code

Non-COHS monthly FAME file: The Non-COHS FAME file consists of the currentmonth and 12 months of prior eligibility. The current month's Part D value is locatedin position 239, Please refer to Attachment B. Medicare Part D PDP Non-COHSFAME File Lavout effective 3/24/2006. page 1.

.

The Medicare Part 0 Status Code also appears in the corresponding position for eachmonth of prior eligibility on the FAME files.

How to Determine Emergency Part D Claims

The Emergency Part D Prescription Drug fill process should only be used in one of thefollowing situations:

If a beneficiary is enrolled in a Part D POP but experiences problems (such asexcessive co-pays or POP records containing errors); or

If a beneficiary has a valid Medicare Part D Status Code value but has not beenassigned to a PDP, and the WellPoint drug fill system is not approving the claims.

Claims for Medi-Cal Managed Care dual eligibles without an eligible Part D Status Codewill not be approved for payment through the Emergency Prescription Drug fill process.Such claims should be adjudicated by the Managed Care Health Plans.

Notice of Action Process for Part D Eligible Beneficiaries

By federal mandate, CDHS must send all Part 0 eligible beneficiaries a Notice of Action(NOA) letter that explains the change in their Medi-Cal benefits as they transfer toMedicare Part D. The Reduction of Benefits NOA must provide at least 10 days of notice.Part 0 coverage can begin on the first day of the month following the completion of the 10days. The beneficiary's Medicare Part 0 status will then be updated to reflect the change

in coverage.

Improvements to the Non-COHS FAME File

After March 24, 2006, three new fields were available on the Non-COHS FAME File:

The 5-byte Federal Contract Number;

The 4-byte State Carrier Code; and

.

The 8-byte Policy Start Date (in CCYYMMDD format)

MMCD All Plan Letter 06003Medicare Part D Update -Non-COHS Plans of 4

June21,2006

The 8-byte Policy Start Date (in CCYYMMDD format)

.

Only the current month's POP data will be included Ion each FAME file. Retaining priorfiles will provide a historical reference for POP information. Please refer to AttachmentB. Medicare Part D PDP Non-COHS FAME File Lavout effective 3/24/2006. paae 8.

For more information on the addition of these fields to the Non-COHS FAME File, pleaserefer to the FAME File layout and the Carrier Cross Reference Table. These documentswill soon be available on the HIPAA web site:

http://hipaa.dhs.ca.qov/834.htm#FAME Medicare Part 0 link to "MMA Part 0 CarrierCross Reference Table new 03/22/06" and http://www.medi-cal.ca.gov link to "MedicarePart 0" then link to "MMA Part 0 Carrier Cross Reference File New".

If you have questions about the MMA Part 0 implementation or the information in thisletter, please contact your contract manager. Thank you for your continued cooperation,

Sincerely,

() ~<- rrV\. _R '\~fIn~ssa M. Baird, MP~rchterMedi-Cal Managed Care Division

Attachments

Vanessa M. Baird, MPPA, Cheif Medi-Cal Managed Care Division

ATTACHMENT A

MMA PART D QUICK RI:FERENCE GUIDE

MEDICARE STATUS CODE~

~

iit 1st

2nd

3m

~e

NOTE: Medicare Part A and/or Part B eligibility is arequiremerlt for Medicare Part D eligibility. It is notpossible for a beneficiary to have Medicare Part D

coverage only.

Part A (!:!Qspital)

Part B (~edical)

Part D (Prescription Druo)

MEDICARE STATUS CODE VALIJES (PARTS A, 8, & D)

Part A(Hospital)

Part B(Medical)

Value Part D(Prescription Drug)

blank NOT ELIGIBLENo Medicare Entitlement

NOT ELlGrBLENo Medicare Entitlement-

0

NOT EUGIBIZENo Medicare Entitlement

NOT ElZrGIBLENot entitled to Medicare Part

A in reported month

NOT ELIGIBLENot entitled to Medicare Part

B in reported month

NOT ELIGIBLENot entitled to Medicare Part D in reported

month; Part D eligibility unknown.

1 ELIGIBLEMedicare Part A paid for by

Beneficiary

ELIGIBLEMedicare Part B paid for by

Beneficiary --

ELlG1BLEApproved Low Income Subsidy (LIS) Status

2ELIGIBLEMedicare Part A paid for bythe State of California


the State of California

ELIGIBLEBeneficiary is eligible for Medi-Cal but not

eligible for Medi-Cal payment of Medicare~rt

D formulary d~~

ELIGIBLEBeneficiary entitled to free

Medicare Part A

N/A3 ELIGIBLE

Medicare Savings Program EligibleBeneficiary Dee~ LIS EliQible

N/A N/A4 ELIGIBLEMedicare Part B paid for byState other than California-

N/A5ELIGIBLEMedicare Part A paid for byPension Fund


Pension Fund

ELIGIBLEBeneficiary is presumed

eligible. Cost Avoidance

reported -State pays Part B

premium

ELIGIBLEBeneficiary is presumed eligible. Cost

Avoidance reported for Medicare Part D

fom1ulary drugs

7

ELIGIBLEBeneficiary is presumedeligible. Cost Avoidancereported -State pays Part Apremium

NOT ELIGIBLEAged alien ineligible for

Medicare Part A

NOT ELIGIBLEAged alien ineligible for

Medicare Part B

ELIGIBLEBeneficiary is eligible for Part A or B but has

refused Part D. No prescription benefit

under Medi-Cal for Medicare Part D

formulary d~~!:eceived.

9

Note: Medicare Status Values "6" and "8" (for Parts A & B) have been removed becausethey are no longer valid values.

MMA Part D Quick Reference Guide, v1.2Revised by DHS-ITSD, 2/11/06

Page 1 of 2

MMA PART D QUICK REFERENCE GUIDEMEDICARE STATUS CODE:

Digit Value

1st Part A (Hospital)

2nd Part B (Medical)3rd Part D (Prescription Drug)

MEDICARE STATUS CODE VALUES (PARTS A, B, & D)

Value Part A (Hospital) Part B (Medical) Part D (Prescription Drug)

blank NOT ELIGIBLE No Medicare Entitlement

NOT ELIGIBLE No Medicare Entitlement

NOT ELIGIBLE No Medicare Entitlement

0 NOT ELIGIBLE Not entitled to Medicare Part A in reported month

NOT ELIGIBLE Not entitled to Medicare Part B in reported month

NOT ELIGIBLE Not entitled to Medicare Part D in reported month; Part D eligibility unknown.

1 ELIGIBLE Medicare Part A paid for by Beneficiary

ELIGIBLE Medicare Part B paid for by Beneficiary

ELIGIBLE Approved Low Income Subsidy (LIS) Status

2 ELIGIBLE Medicare Part A paid for by the State of California

ELIGIBLE Medicare Part B paid for by the State of California

ELIGIBLE Beneficiary is eligible for Medi-Cal but not eligible for Medi-Cal payment of Medicare Part D formulary drugs.

3 ELIGIBLE Beneficiary entitled to free Medicare Part A

N/A ELIGIBLE Medicare Savings Program Eligible Beneficiary Deemed LIS Eligible

4 N/A ELIGIBLE Medicare Part B paid for by State other than California

N/A

5 ELIGIBLE Medicare Part A paid for by Pension Fund

ELIGIBLE Medicare Part B paid for by Pension Fund

N/A

7 ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported - State pays Part A premium

ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported - State pays Part B premium

ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported for Medicare Part D formulary drugs

9 NOT ELIGIBLE Aged alien ineligible for Medicare Part A

NOT ELIGIBLE Aged alien ineligible for Medicare Part B

ELIGIBLE Beneficiary is eligible for Part A or B but has refused Part D. No prescription benefit under Medi-Cal for Medicare Part D formulary drugs is received.

.I

Code

0Part A-Dental

Hospital Inpatient 0 1,2,4,5 0, 1, 2, 3, 9L

M

0

P

R

V

Long Term Care

Medical and Allied Services

1,2,3,5Hospital Outpatient 0,1,2,4,5,9 0, 1, 2, 3, 9

Medi-Cal Prescription Drugs

Medicare Part D Prescription Drugs 9 1,2,4,5 0, 1, 2, 3, 9Vision Care

NOTE: If coverage is unknown, OHC is regardedas comprehensive. Provider must bill OHC carrierfor all services.

MMA Part D Quick Reference Guide. v1.2Revised by DHS-ITSD, 2/11/06 Page2of2

SCOPE OF COVERAGE VALUES (HEALTH INFORMATION SYS.)

Code Service

D Dental

I Hospital Inpatient

L Long Term Care

M Medical and Allied Services

O Hospital Outpatient

P Medi-Cal Prescription Drugs

R Medicare Part D Prescription Drugs

V Vision Care

VALID MEDICARE STATUS CODE COMBINATIONS

Part A Part B Part D

0 1, 2, 4, 5 0, 1, 2, 3, 9

1, 2, 3, 5 0, 1, 2, 4, 5, 9 0, 1, 2, 3, 9

9 1, 2, 4, 5 0, 1, 2, 3, 9

OTHER HEALTH COVERAGE (OHC) VALUES

Code ServicePay and Chase OHC/ Post Payment RecoveryA Any carrier (includes multiple

coverage)Cost Avoidance OHCC Champus Prime HMOD Medicare Part DF Medicare RISK HMOK KaiserL Dental only policies

P PHP/HMOs & EPO (Exclusive Provider Option) not otherwise specified

V Any carrier (other than the above; Includes multiple coverage)

9 Healthy FamiliesOther OHC Related CodesN None

p

FIELD LEVEL/NAME -~ --PICTURE--WS-FAMEOUT-REC

5 WS-FO-HEADER GROUP10 FILLER XX10 WS-FO-MEDSID X(9)10 WS-FO-MID-CHECK-DIGIT X10 WS-FO-CNTY-CODE XX10 WS-FO-AID-CODE XX10 WS-FO-SERIAL X(7)10 WS-FO-FBU X10 WS-FO-PERSON XX10 WS-FO-CLIENT-INDEX-NUMBER X(9)10 WS-FO-CIN-CHECK-DIGIT X10 WS-FO-CA-DL-ID-NUMBER X(8)10 WS-FO-LAST-NAME X(20)10 WS-FO-FIRST-NAME X(15)10 WS-FO-INITIAL X10 WS-FO-DOB-C X10 WS-FO-DOB-YYY XXX10 WS-FO-DOB-MM XX10 WS-FO-DOB-DD XX10 WS-FO-SEX X10 WS-FO-CARD-ISSUE-CC XX10 WS-FO-CARD-ISSUE-DATE X(6)10 WS-FO-CHAINED-MEDS-ID X(9)10 WS-FO-PRIOR-MEDS-ID X(9)10 WS-FO-ALIEN-CD X10 WS-FO-ETHNIC-CD X10 WS-FO-HIC-NBR X(12)10 WS-FO-DEATH-CC XX10 WS-FO-DEATH-DATE X(6)10 WS-FO-DEATH-POSTED-CC XX10 WS-FO-DEATH-POSTED X(6)10 WS-FO-MEDS-REN-CC XX10 WS-FO-MEDS-REN-YY XX10 WS-FO-MEDS-REN-MM XX10 WS-FO-MOD-CC XX10 WS-FO-MOD-YY XX10 WS-FO-MOD-MM XX10 WS-FO-MOD-DD XX10 WS-FO-PAPER-CARD-CC XX10 WS-FO-PAPER-CARD-DATE X(6)

5 WS-FO-SEG-TBL(l) OCCURS 13 TIMES GROUP10 WS-FO-SEG-ID(l) XX10 WS-FO-CNTY-CODE(l) XX10 WS-FO-AID-CODE(l) XX10 WS-FO-ESC(l) XXX10 WS-FO-SPEC1-AID(1) XX10 WS-FO-SPEC1-ESC(1) XXX10 WS-FO-SPEC2-AID(1) XX10 WS-FO-SPEC2-ESC(1) XXX10 WS-FO-SPEC3-AID(1) XX10 WS-FO-SPEC3-ESC(1) XXX10 WS-FO-SOC(l) X(5)10 WS-FO-CERT-DAY(l) XX10 FILLER (1) XX10 WS-FO-OHC(l) X10 WS-FO-MEDICARE(l) GROUP

15 WS-FO-MEDICARE-A(l) X15 WS-FO-MEDICARE-B(l) X

10 WS-FO-RESTRICT(l) XXX10 FILLER(l) XX10 WS-FO-HCP1-NUM(1) XXX10 WS-FO-HCP1-STATUS(1) XX10 WS-FO-HCP2-NUM(1) XXX10 WS-FO-HCP2-STATUS(1) XX10 WS-FO-HCP3-NUM(1) XXX10 WS-FO-HCP3-STATUS(1) XX10 WS-FO-HCP4-NUM(1) XXX10 WS-FO-HCP4-STATUS(1) XX10 WS-FO-HCP5-NUM(1) XXX10 WS-FO-HCP5-STATUS(1) XX10 WS-FO-STATE-FED-IND(l) X10 WS-FO-HF-IN-OUT-DAYS(l) X(4)10 WS-FO-MEDICARE-D(l) X10 FILLER(l) X(9)

5 WS-FO-SEG-TBL(2) GROUP

FLD i

23456789

1011121314151617181920212223242526272829303132333435363?38394041

56789

1011121314151617181920212223242526272829303132333435363738

5

END'1555

1672

1112141623242635364464798081848688899197

106115116117129131137139145147149151153155157159161167248169171173176178181183186188191196198200201203202203206208211213216218221223226228231233234238239248329

TART1113

1213151724252736374565808182858789909298

107116117118130132138140146148150152154156158160162168168170172174177179182184187189192197199201202202203204207209212214217219222224227229232234235239240249

ENGTH1555

16729122712918

2015

113221269911

122626222222226

81222323232352212113232323232321419

81

ATTACHMENT B

Medicare Part D PDP Non-COHS FAME File LayoutFIELD LEVEL/NAME PICTURE FLD TART END ENGTH WS-FAMEOUT-REC 1 1555 1555 5 WS-FO-HEADER GROUP 2 1 167 167 10 FILLER XX 3 1 2 2 10 WS-FO-MEDSID X(9) 4 3 11 9 10 WS-FO-MID-CHECK-DIGIT X 5 12 12 1 10 WS-FO-CNTY-CODE XX 6 13 14 2 10 WS-FO-AID-CODE XX 7 15 16 2 10 WS-FO-SERIAL X(7) 8 17 23 7 10 WS-FO-FBU X 9 24 24 1 10 WS-FO-PERSON XX 10 25 26 2 10 10 WS-FO-CLIENT-INDEX-NUMBER X(9) 11 27 35 9 10 WS-FO-CIN-CHECK-DIGIT X 12 36 36 1 10 WS-FO-CA-DL-ID-NUMBER X(8) 13 37 44 8 10 WS-FO-LAST-NAME X(20) 14 45 64 20 10 WS-FO-FIRST-NAME X(15) 15 65 79 15 10 WS-FO-INITIAL X 16 80 80 1 10 WS-FO-DOB-C X 17 81 81 1 10 WS-FO-DOB-YYY XXX 18 82 84 3 10 WS-FO-DOB-MM XX 19 85 86 2 10 WS-FO-DOB-DD XX 20 87 88 2 10 WS-FO-SEX X 21 89 89 1 10 WS-FO-CARD-ISSUE-CC XX 22 90 91 2 10 WS-FO-CARD-ISSUE-DATE X(6) 23 92 97 6 10 WS-FO-CHAINED-MEDS-ID X(9) 24 98 106 9 10 WS-FO-PRIOR-MEDS-ID X(9) 25 107 115 9 10 WS-FO-ALIEN-CD X 26 116 116 1 10 WS-FO-ETHNIC-CD X 27 117 117 1 10 WS-FO-HIC-NBR X(12) 28 118 129 12 10 WS-FO-DEATH-CC XX 29 130 131 2 10 WS-FO-DEATH-DATE X(6) 30 132 137 6 10 WS-FO-DEATH-POSTED-CC XX 31 138 139 2 10 WS-FO-DEATH-POSTED X(6) 32 140 145 6 10 WS-FO-MEDS-REN-CC XX 33 146 147 2 10 WS-FO-MEDS-REN-YY XX 34 148 149 2 10 WS-FO-MEDS-REN-MM XX 35 150 151 2 10 WS-FO-MOD-CC XX 36 152 153 2 10 WS-FO-MOD-YY XX 37 154 155 2 10 WS-FO-MOD-MM XX 38 156 157 2 10 WS-FO-MOD-DD XX 39 158 159 2 10 WS-FO-PAPER-CARD-CC XX 40 160 161 2 10 WS-FO-PAPER-CARD-DATE X(6) 41 162 167 6 5 WS-FO-SEG-TBL(l) OCCURS 13 TIMES GROUP 5 168 248 81 10 WS-FO-SEG-ID(1) XX 6 168 169 2 10 WS-FO-CNTY-CODE(1) XX 7 170 171 2 10 WS-FO-AID-CODE(1) XX 8 172 173 2

XXX 9 174 176 3 10 WS-FO-SPEC1-AID(1) XX 10 177 178 2 10 WS-FO-SPEC1-ESC(1) XXX 11 179 181 3 10 WS-FO-SPEC2-AID(1) XX 12 182 183 2 10 WS-FO-SPEC2-ESC(1) XXX 13 184 186 3 10 WS-FO-SPEC3-AID(1) XX 14 187 188 2 10 WS-FO-SPEC3-ESC(1) XXX 15 189 191 3 10 WS-FO-SOC(1) X(5) 16 192 196 5 10 WS-FO-CERT-DAY(1) XX 17 197 198 2 10 FILLER (1) XX 18 199 200 2 10 WS-FO-OHC(1) X 19 201 201 1 10 WS-FO-MEDICARE(1) GROUP 20 202 203 2 15 WS-FO-MEDICARE-A(1) X 21 202 202 1 15 WS-FO-MEDICARE-B(1) X 22 203 203 1 10 WS-FO-RESTRICT(1) XXX 23 204 206 3 10 FILLER(1) XX 24 207 208 2 10 WS-FO-HCP1-NUM(1) XXX 25 209 211 3 10 WS-FO-HCP1-STATUS(1) XX 26 212 213 2 10 WS-FO-HCP2-NUM(1) XXX 27 214 216 3 10 WS-FO-HCP2-STATUS(1) XX 28 217 218 2 10 WS-FO-HCP3-NUM(1) XXX 29 219 221 3 10 WS-FO-HCP3-STATUS(1) XX 30 222 223 2 10 WS-FO-HCP4-NUM(1) XXX 31 224 226 3 10 WS-FO-HCP4-STATUS(1) XX 32 227 228 2 10 WS-FO-HCP5-NUM(1) XXX 33 229 231 3 10 WS-FO-HCP5-STATUS(1) XX 34 232 233 2 10 WS-FO-STATE-FED-IND(1) X 35 234 234 1 10 WS-FO-HF-IN-OUT-DAYS(1) X(4) 36 235 238 4 10 WS-FO-MEDICARE-D(1) X 37 239 239 1 10 FILLER(1) X(9) 38 240 248 9 5 WS-FO-SEG-TBL(2) GROUP 5 249 329 81

-PICTURE.

XXXXxxXXXXXXXXXXXXXXXXXXXIS)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXXXXXXXXXXXXX(S)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXXXXXXX

FLD START6 2497 2518 2539 255

10 25811 26012 26313 26514 26815 27016 27317 27818 28019 28220 28321 28322 28423 28524 28825 29026 29327 29528 29829 30030 30331 30532 30833 31034 31335 31536 31637 32038 321

5 3306 3307 3328 3349 336

10 33911 34112 34413 34614 34915 35116 35417 35918 36119 36320 36421 36422 36523 36624 36925 37126 37427 37628 37929 38130 38431 38632 38933 39134 39435 39636 39737 40138 402

5 4116 4117 4138 4159 417

10 42011 42212 42513 427

END LENGTH250 2252 2254 2257 3259 2262 3264 2267 3269 2272 3277 5279 2281 2282 1284 2283 1284 1287 3289 2292 3294 2297 3299 2302 3304 2307 3309 2312 3314 2315 1319 4320 1329 9410 81331 2333 2335 2338 3340 2343 3345 2348 3350 2353 3358 5360 2362 2363 1365 2364 1365 1368 3370 2373 3375 2378 3380 2383 3385 2388 3390 2393 3395 2396 1400 4401 1410 9491 81412 2414 2416 2419 3421 2424 3426 2429 3

FIELD LEVEL/NAME 10 WS-FO-SEG-ID(2)

10 WS-FO-CNTY-CODE(2)

10 WS-FO-AID-CODE(2)

10 WS-FO-ESC(2)

10 WS-FO-SPEC1-AID(2)

10 WS-FO-SPEC1-ESC(2)





10 WS-FO-SOC(2)

10 WS-FO-CERT-DAY(2)

10 FILLER (2)

10 WS-FO-OHC(2)

10 WS-FO-MEDICARE(2)

15 WS-FO-MEDICARE-A(2)

15 WS-FO-MEDICARE-B(Z)

10 WS-FO-RESTRICT(2)

10 FILLER (2)

10 WS-FO-HCP1-NUM(2)

10 WS-FO-HCP1-STATUS(2)









10 WS-FO-STATE-FED-IND(2)

10 WS-FO-HF-IN-OUT-DAYS(2)

10 WS-FO-MEDICARE-D(2)

10 FILLER(2)

5 WS-FO-SEG-TBL(3)

10 WS-FO-SEG-ID(3)



10 WS-FO-ESC(3)







10 WS-FO-SOC(3)


10 FILLER(3)

10 WS-FO-OHC(3)



15 WS-FO-MEDICARE-B(3)


10 FILLER (3)














10 FILLER (3)

5 WS-FO-SEG-TBL(4)

10 WS-FO-SEG-ID(4)



10 WS-FO-ESC(4)





FIELD LEVEL/NAME PICTURE10 WS-FOSEG-ID(2)

XX

X(5)

PICTURE--XXXXXX(S)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXXXXXXXXXXXXX(S)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXXXXXXXXXXXXX(S)XXXXXGROUPX

FLD START14 43015 43216 43517 44018 44219 44420 44521 44522 44623 44724 45025 45226 45527 45728 46029 46230 46531 46732 47033 47234 47535 47736 47837 48238 483

5 4926 4927 4948 4969 498

10 50111 50312 50613 50814 51115 51316 51617 52118 52319 52520 52621 52622 52723 52824 53125 53326 53627 53828 54129 54330 54631 54832 55133 55334 55635 55836 55937 56338 564

5 5736 5737 5758 5779 579

10 58211 58412 58713 58914 59215 59416 59717 60218 60419 60620 60721 607

END LENGTH431 2434 3439 5441 2443 2444 1446 2445 1446 1449 3451 2454 3456 2459 3461 2464 3466 2469 3471 2474 3476 2477 1481 4482 1491 9572 81493 2495 2497 2500 3502 2505 3507 2510 3512 2515 3520 5522 2524 2525 1527 2526 1527 1530 3532 2535 3537 2540 3542 2545 3547 2550 3552 2555 3557 2558 1562 4563 1572 9653 81574 2576 2578 2581 3583 2586 3588 2591 3593 2596 3601 5603 2605 2606 1608 2607 1

FIELD LEVEL/NAME 10 WS-FO-SPEC3-AID(4)


10 WS-FO-SOC(4)


10 FILLER (4)

10 WS-FO-OHC(4)

10 WS-FO-MEDlCARE(4)

15 WS-FO-MEDlCARE-A(4)

15 WS-FO-MEDlCARE-B(4)


10 FILLER(4)













10 WS-FO-MEDlCARE-D(4)

10 FILLER(4)

5 WS-FO-SEG-TBL(5)

10 WS-FO-SEG-ID(5)



10 WS-FO-ESC(5)







10 WS-FO-SOC(5)


10 FILLER(5)

10 WS-FO-OHC(5)



15 WS-FO-MEDlCARE-B(5)


10 FILLER(5)













10 WS-FO-MEDlCARE-D(5)

10 FILLER(5)

5 WS-FO-SEG-TBL(6)

10 WS-FO-SEG-ID(6)

10 WS-FO-CNTY-CODE(6)10 WS-FO-AID-CODE(6)

10 WS-FO-ESC(6)







10 WS-FO-SOC(6)


10 FILLER(6)

10 WS-FO-OHC(6)



FIELD LEVEL/NAME PICTURE10 WS-FO-SPEC3-AID(4)10 WS-FO-SPEC3-ESC(4) 10 WS-FO-SOC(4) 10 WS-FO-CERT-DAY(4) 10 FILLER (4)10 WS-FO-OHC(4) 10 WS-FO-MEDlCARE(4) 15 WS-FO-MEDlCARE-A(4)15 WS-FO-MEDlCARE-B(4) 10 WS-FO-RESTRICT(4)10 FILLER(4) 10 WS-FO-HCP1-NUM(4) 10 WS-FO-HCP1-STATUS(4) 10 WS-FO-HCP2-NUM(4) 10 WS-FO-HCP2-STATUS(4) 10 WS-FO-HCP3-NUM(4) 10 WS-FO-HCP3-STATUS(4) 10 WS-FO-HCP4-NUM(4) 10 WS-FO-HCP4-STATUS(4) 10 WS-FO-HCP5-NUM(4) 10 WS-FO-HCP5-STATUS(4) 10 WS-FO-STATE-FED-IND(4)10 WS-FO-HF-IN-OUT-DAYS(4) 10 WS-FO-MEDlCARE-D(4) 10 FILLER(4)5 WS-FO-SEG-TBL(5) 10 WS-FO-SEG-ID(5) 10 WS-FO-CNTY-CODE(5) 10 WS-FO-AID-CODE(5)10 WS-FO-ESC(5) 10 WS-FO-SPEC1-AID(5)10 WS-FO-SPEC1-ESC(5) 10 WS-FO-SPEC2-AID(5)10 WS-FO-SPEC2-ESC(5) 10 WS-FO-SPEC3-AID(5)10 WS-FO-SPEC3-ESC(5) 10 WS-FO-SOC(5)10 WS-FO-CERT-DAY(5) 10 FILLER(5)10 WS-FO-OHC(5) 10 WS-FO-MEDICARE(5)15 WS-FO-MEDlCARE-A(5)15 WS-FO-MEDlCARE-B(5) 10 WS-FO-RESTRICT(5)10 FILLER(5) 10 WS-FO-HCP1-NUM(5)10 WS-FO-HCP1-STATUS(5) 10 WS-FO-HCP2-NUM(5) 10 WS-FO-HCP2-STATUS(5) 10 WS-FO-HCP3-NUM(5)10 WS-FO-HCP3-STATUS(5)10 WS-FO-HCP4-NUM(5) 10 WS-FO-HCP4-STATUS(5) 10 WS-FO-HCP5-NUM(5)10 WS-FO-HCP5-STATUS(5)10 WS-FO-STATE-FED-IND(5) 10 WS-FO-HF-IN-OUT-DAYS(5)10 WS-FO-MEDlCARE-D(5) 10 FILLER(5)5 WS-FO-SEG-TBL(6)10 WS-FO-SEG-ID(6) 10 WS-FO-CNTY-CODE(6)10 WS-FO-AID-CODE(6) 10 WS-FO-ESC(6)10 WS-FO-SPEC1-AID(6) 10 WS-FO-SPEC1-ESC(6)10 WS-FO-SPEC2-AID(6) 10 WS-FO-SPEC2-ESC(6)10 WS-FO-SPEC2-ESC(6)10 WS-FO-SPEC3-ESC(6)10 WS-FO-SOC(6)10 WS-FO-CERT-DAY(6)10 FILLER(6) 10 WS-FO-OHC(6) 10 WS-FO-OHC(6) 15 WS-FO-MEDlCARE-A(6)

FLD START22 60823 60924 61225 61426 61727 61928 62229 62430 62731 62932 63233 63434 63735 63936 64037 64438 645

5 6546 6547 6568 6589 660

10 66311 66512 66813 67014 67315 67516 67817 68318 68519 68720 68821 68822 68923 69024 69325 69526 69827 70028 70329 70530 70831 71032 71333 71534 71835 72036 72137 72538 726

5 7356 7357 7378 7399 741

10 74411 74612 74913 75114 75415 75616 75917 76418 76619 76820 76921 76922 77023 77124 77425 77626 77927 78128 78429 786

END LENGTH608 1611 3613 2616 3618 2621 3623 2626 3628 2631 3633 2636 3638 2639 1643 4644 1653 9734 81655 2657 2659 2662 3664 2667 3669 2672 3674 2677 3682 5684 2686 2687 1689 2688 1689 1692 3694 2697 3699 2702 3704 2707 3709 2712 3714 2717 3719 2720 1724 4725 1734 9815 81736 2738 2740 2743 3745 2748 3750 2753 3755 2758 3763 5765 2767 2768 1770 2769 1770 1773 3775 2778 3780 2783 3785 2788 3

FIELD LEVEL/NAME PICTURE-15 WS-FO-MEDICARE-B(6) X

10 WS-FO-RESTRICT(6) XXX10 FILLER (6) XX10 WS-FO-HCP1-NUM(6) XXX10 WS-FO-HCP1-STATUS(6) XX10 WS-FO-HCP2-NUM(6) XXX10 WS-FO-HCP2-STATUS(6) XX10 WS-FO-HCP3-NUM(6) XXX10 WS-FO-HCP3-STATUS(6) XX10 WS-FO-HCP4-NUM(6) XXX10 WS-FO-HCP4-STATUS(6) XX10 WS-FO-HCP5-NUM(6) XXX10 WS-FO-HCP5-STATUS(6) XX10 WS-FO-STATE-FED-IND(6) X10 WS-FO-HF-IN-OUT-DAYS(6) X(4)10 WS-FO-MEDICARE-D(6) X10 FILLER(6) X(9)

5 WS-FO-SEG-TBL(7) GROUP10 WS-FO-SEG-ID(7) XX10 WS-FO-CNTY-CODE(7) XX10 WS-FO-AID-CODE(7) XX10 WS-FO-ESC(7) XXX10 WS-FO-SPEC1-AID(7) XX10 WS-FO-SPEC1-ESC(7) XXX10 WS-FO-SPEC2-AID(7) XX10 WS-FO-SPEC2-ESC(7) XXX10 WS-FO-SPEC3-AID(7) XX10 WS-FO-SPEC3-ESC(7) XXX10 WS-FO-SOC(7) X(5)10 WS-FO-CERT-DAY(7) XX10 FILLER(7) XX10 WS-FO-OHC(7) X10 WS-FO-MEDICARE(7) GROUP

15 WS-FO-MEDICARE-A(7) X15 WS-FO-MEDICARE-B(7) X

10 WS-FO-RESTRICT(7) XXX10 FILLER (7) XX10 WS-FO-HCP1-NUM(7) XXX10 WS-FO-HCP1-STATUS(7) XX10 WS-FO-HCP2-NUM(7) XXX10 WS-FQ-HCP2-STATUS(7) XX10 WS-FO-HCP3-NUM(7) XXX10 WS-FO-HCP3-STATUS(7) XX10 WS-FO-HCP4-NUM(7) XXX10 WS-FO-HCP4-STATUS(7) XX10 WS-FQ-HCP5-NUM(7) XXX10 WS-FO-HCP5-STATUS(7) XX10 WS-FO-STATE-FED-IND(7) X10 WS-FO-HF-IN-OUT-DAYS(7) X(4)10 WS-FO-MEDICARE-D(7) X10 FILLER(7) X(9)

5 WS-FO-SEG-TBL(8) GROUP10 WS-FO-SEG-ID(8) XX10 WS-FQ-CNTY-CODE(8) XX10 WS-FO-AID-CODE(8) XX10 WS-FO-ESC(8) XXX10 WS-FQ-SPEC1-AID(8) XX10 WS-FO-SPEC1-ESC(8) XXX10 WS-FQ-SPEC2-AID(8) XX10 WS-FQ-SPEC2-ESC(8) XXX10 WS-FQ-SPEC3-AID(8) XX10 WS-FO-SPEC3-ESC(8) XXX10 WS-FQ-SOC(8) X(5)10 WS-FO-CERT-DAY(8) XX10 FILLER (8) XX10 WS-FO-OHC(8) X10 WS-FO-MEDICARE(8) GROUP


10 WS-FO-RESTRICT(8) XXX10 FILLER(8) XX10 WS-FO-HCP1-NUM(8) XXX10 WS-FQ-HCP1-STATUS(8) XX10 WS-FO-HCP2-NUM(8) XXX10 WS-FO-HCP2-STATUS(8) XX10 WS-FO-HCP3-NUM(8) XXX


FIELD LEVEL/NAME PICTURE-10 WS-FO-HCP3-STATUS(B) XX10 WS-FO-HCP4-NUM(B) XXX10 WS-FO-HCP4-STATUS(B) XX10 WS-FO-HCP5-NUM(B) XXX10 WS-FO-HCP5-STATUS(B) XX10 WS-FO-STATE-FED-IND(B) X10 WS-FO-HF-IN-OUT-DAYS(B) X(4)10 WS-FO-MEDICARE-D(B) X10 FILLER(B) X(9)

5 WS-FO-SEG-TBL(9) GROUP10 WS-FO-SEG-ID(9) XX10 WS-FO-CNTY-CODE(9) XX10 WS-FO-AID-CODE(9) XX10 WS-FO-ESC(9) XXX10 WS-FO-SPEC1-AID(9) XX10 WS-FO-SPEC1-ESC(9) XXX10 WS-FO-SPEC2-AID(9) XX10 WS-FO-SPEC2-ESC(9) XXX10 WS-FO-SPEC3-AID(9) XX10 WS-FO-SPEC3-ESC(9) XXX10 WS-FO-SOC(9) X(5)10 WS-FO-CERT-DAY(9) XX10 FILLER(9) XX10 WS-FO-OHC(9) X10 WS-FO-MEDICARE(9) GROUP


10 WS-FO-RESTRICT(9) XXX10 FILLER (9) XX10 WS-FO-HCP1-NUM(9) XXX10 WS-FO-HCP1-STATUS(9) XX10 WS-FO-HCP2-NUM(9) XXX10 WS-FO-HCP2-STATUS(9) XX10 WS-FO-HCP3-NUM(9) XXX10 WS-FQ-HCP3-STATUS(9) XX10 WS-FO-HCP4-NUM(9) XXX10 WS-FO-HCP4-STATUS(9) XX10 WS-FO-HCP5-NUM(9) XXX10 WS-FO-HCP5-STATUS(9) XX10 WS-FO-STATE-FED-IND(9) X10 WS-FO-HF-IN-OUT-DAYS(9) X(4)10 WS-FO-MEDICARE-D(9) X10 FILLER (9) X(9)

5 WS-FO-SEG-TBL(10) GROUP10 WS-FO-SEG-ID(10) XX10 WS-FO-CNTY-CODE(10) XX10 WS-FO-AID-CODE(10) XX10 WS-FO-ESC(10) XXX10 WS-FO-SPEC1-AID(10) XX10 WS-FO-SPEC1-ESC(10) XXX10 WS-FO-SPEC2-AID(10) XX10 WS-FO-SPEC2-ESC(10) XXX10 WS-FO-SPEC3-AID(10) XX10 WS-FO-SPEC3-ESC(10) XXX10 WS-FQ-SOC(10) X(5)10 WS-FO-CERT-DAY(10) XX10 FILLER (10) XX10 WS-FO-OHC(10) X10 WS-FO-MEDICARE(10) GROUP


10 WS-FO-RESTRICT(10) XXX10 FILLER(10) XX10 WS-FO-HCP1-NUM(10) XXX10 WS-FO-HCP1-STATUS(10) XX10 WS-FO-HCP2-NUM(10) XXX10 WS-FO-HCP2-STATUS(10) XX10 WS-FO-HCP3-NUM(10) XXX10 WS-FO-HCP3-STATUS(10) XX10 WS-FO-HCP4-NUM(10) XXX10 WS-FO-HCP4-STATUS(10) XX10 WS-FO-HCP5-NUM(10) XXX10 WS-FO-HCP5-STATUS(10) XX10 WS-FO-STATE-FED-IND(10) X10 WS-FO-HF-IN-OUT-DAYS(10) X(4)10 WS-FO-MEDICARE-D(10) X

FLD303132333435363738

56789

1011121314151617181920212223242526272829303132333435363738

56789

10111213141516171819202122232425262728293031323334353637

END LENGTH790 2793 3795 2798 3800 2801 1805 4806 1815 9896 81817 2819 2821 2824 3826 2829 3831 2834 3836 2839 3844 5846 2848 2849 1851 2850 1851 1854 3856 2859 3861 2864 3866 2869 3871 2874 3876 2879 3881 2882 1886 4887 1896 9977 81898 2900 2902 2905 3907 2910 3912 2915 3917 2920 3925 5927 2929 2930 1932 2931 1932 1935 3937 2940 3942 2945 3947 2950 3952 2955 3957 2960 3962 2963 1967 4968 1

;TART

789791794796799801802806807816816818820822825827830832835837840845847849850850851852855857860862865867870872875877880882883887888897897899901903906908911913916918921926928930931931932933936938941943946948951953956958961963964968

START10 WS-FO-HCP3-STATUS(8)10 WS-FO-HCP4-NUM(8)10 WS-FO-HCP4-STATUS(8)10 WS-FO-HCP5-NUM(8)10 WS-FO-HCP5-STATUS(8)10 WS-FO-STATE-FED-IND(8)10 WS-FO-HF-IN-OUT-DAYS(8)10 WS-FO-MEDICARE-D(8)10 FILLER(8)

FIELD LEVEL/NAME 10 FILLER(10)

5 WS-FO-SEG-TBL(ll)

10 WS-FO-SEG-ID(ll)

10 WS-FO-CNTY-CODE(ll)

10 WS-FO-AID-CODE(ll)

10 WS-FO-ESC(ll)







10 WS-FO-SOC(ll)

10 WS-FO-CERT-DAY(ll)

10 FILLER (11)

10 WS-FO-OHC(ll)

10 WS-FO-MEDICARE(ll)

15 WS-FO-MEDICARE-A(ll)

15 WS-FO-MEDICARE-B(ll)

10 WS-FO-RESTRICT(ll)

10 FILLER(ll)


10 WS-FO"HCP1-STATUS(11)









10 WS-FO-STATE-FED-IND(ll)

10 WS-FO-HF-IN-OUT-DAYS(ll)

10 WS-FO-MEDICARE-D(ll)

10 FILLER(ll)

5 WS-FO-SEG-TBL(12)

10 WS-FO-SEG-ID(12)



10 WS-FO-ESC(12)







10 WS-FO-SOC(12)


10 FILLER (12)

10 WS-FO-OHC(12)



15 WS-FO-MEDICARE-B(12)


10 FILLER(12)














10 FILLER(12)

5 WS-FO-SEG-TBL(13)

10 WS-FO-SEG-ID(13)



10 WS-FO-ESC(13)



-PICTURE-X(9)GROUPXXXXXXXXXXXXXXXXXXXXXXXXX(S)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXXXXXXXXXXXXX(S)XXXXXGROUPXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX(4)XX(9)GROUPXXXXXXXXXXXXXX

FLD START38 969

5 9786 9787 9808 9829 984

10 98711 98912 99213 99414 99715 99916 100217 100718 100919 101120 101221 101222 101323 101424 101725 101926 102227 102428 102729 102930 103231 103432 103733 103934 104235 104436 104537 104938 1050

5 10596 10597 10618 10639 1065

10 106811 107012 107313 107514 107815 108016 108317 108818 109019 109220 109321 109322 109423 109524 109825 110026 110327 110528 110829 111030 111331 111532 111833 112034 112335 112536 112637 113038 1131

5 11406 11407 11428 11449 1146

10 114911 1151

END LENGTH977 9

1058 81979 2981 2983 2986 3988 2991 3993 2996 3998 2

1001 31006 51008 21010 21011 11013 21012 11013 11016 31018 21021 31023 21026 31028 21031 31033 21036 31038 21041 31043 21044 11048 41049 11058 91139 811060 21062 21064 21067 31069 21072 31074 21077 31079 21082 31087 51089 21091 21092 11094 21093 11094 11097 31099 21102 31104 21107 31109 21112 31114 21117 31119 21122 31124 21125 11129 41130 11139 91220 811141 21143 21145 21148 31150 21153 3

FIELD LEVEL/NAME PICTURE10 FILLER(10)5 WS-FO-SEG-TBL(11)10 WS-FO-SEG-ID(11)10 WS-FO-CNTY-CODE(11)10 WS-FO-AID-CODE(11)10 WS-FO-ESC(11)10 WS-FO-SPEC1-AID(11) 10 WS-FO-SPEC1-ESC(11)10 WS-FO-SPEC2-AID(11)10 WS-FO-SPEC2-ESC(11)10 WS-FO-SPEC3-AID(11) 10 WS-FO-SPEC3-ESC(11)10 WS-FO-SOC(11) X(5)10 WS-FO-CERT-DAY(11)10 FILLER (11) 10 WS-FO-OHC(11)10 WS-FO-MEDICARE(11)15 WS-FO-MEDICARE-A(11)15 WS-FO-MEDICARE-B(11)10 WS-FO-RESTRICT(11)10 FILLER(11)10 WS-FO-HCP1-NUM(11)10 WS-FO"HCP1-STATUS(11) 10 WS-FO-HCP2-NUM(11)10 WS-FO-HCP2-STATUS(11) 10 WS-FO-HCP3-NUM(11)10 WS-FO-HCP3-STATUS(11) 10 WS-FO-HCP4-NUM(11)10 WS-FO-HCP4-STATUS(11) 10 WS-FO-HCP5-NUM(11) 10 WS-FO-HCP5-STATUS(11) 10 WS-FO-STATE-FED-IND(11)10 WS-FO-HF-IN-OUT-DAYS(11)10 WS-FO-MEDICARE-D(11)10 FILLER(11)5 WS-FO-SEG-TBL(12) 10 WS-FO-SEG-ID(12) 10 WS-FO-CNTY-CODE(12) 10 WS-FO-AID-CODE(12)10 WS-FO-ESC(12) 10 WS-FO-SPEC1-AID(12) 10 WS-FO-SPEC1-ESC(12)10 WS-FO-SPEC2-AID(12) 10 WS-FO-SPEC2-ESC(12) 10 WS-FO-SPEC3-AID(12) 10 WS-FO-SPEC3-ESC(12) 10 WS-FO-SOC(12) X(5)10 WS-FO-CERT-DAY(12)10 FILLER (12) 10 WS-FO-OHC(12)10 WS-FO-MEDICARE(12)15 WS-FO-MEDICARE-A(12) 15 WS-FO-MEDICARE-B(12) 10 WS-FO-RESTRICT(12)10 FILLER(12) 10 WS-FO-HCP1-NUM(12) 10 WS-FO-HCP1-STATUS(12) 10 WS-FO-HCP2-NUM(12) 10 WS-FO-HCP2-STATUS(12)10 WS-FO-HCP3-NUM(12) 10 WS-FO-HCP3-STATUS(12)10 WS-FO-HCP4-NUM(12) 10 WS-FO-HCP4-STATUS(12)10 WS-FO-HCP5-NUM(12) 10 WS-FO-HCP5-STATUS(12)10 WS-FO-STATE-FED-IND(12) 10 WS-FO-HF-IN-OUT-DAYS(12)10 WS-FO-MEDICARE-D(12)10 FILLER(12) 5 WS-FO-SEG-TBL(13)10 WS-FO-SEG-ID(13) 10 WS-FO-CNTY-CODE(13)10 WS-FO-AID-CODE(13)10 WS-FO-ESC(13) 10 WS-FO-SPEC1-AID(13) 10 WS-FO-SPEC1-ESC(13)

~

FIELD LEVEL/NAME PICTURE--10 WS-FO-SPEC2-AID(13) XX10 WS-FO-SPEC2-ESC(13) XXX10 WS-FO-SPEC3-AID(13) XX10 WS-FO-SPEC3-ESC(13) XXX10 WS-FO-SOC(13) X(5)10 WS-FO-CERT-DAY(13) XX10 FILLER(13) XX10 WS-FO-OHC(13) X10 WS-FO-MEDICARE(13) GROUP


10 WS-FO-RESTRICT(13) XXX10 FILLER (13) XX10 WS-FO-HCP1-NUM(13) XXX10 WS-FO-HCP1-STATUS(13) XX10 WS-FO-HCP2-NUM(13) XXX10 WS-FO-HCP2-STATUS(13) XX10 WS-FO-HCP3-NUM(13) XXX10 WS-FO-HCP3-STATUS(13) XX10 WS-FO-HCP4-NUM(13) XXX10 WS-FO-HCP4-STATUS(13) XX10 WS-FO-HCP5-NUM(13) XXX10 WS-FO-HCP5-STATUS(13) XX10 WS-FO-STATE-FED-IND(13) X10 WS-FO-HF-IN-OUT-DAYS(13) X(4)10 WS-FO-MEDICARE-D(13) X10 FILLER(13) X(9)

5 WS-FO-RES-ADDR-FLAG X5 WS-FO-RES-ADDR-IND X5 WS-FO-RES-ADDR-LINE1 X(38)5 WS-FO-RES-ADDR-LINE2 X(50)5 WS-FO-RES-ADDR-CITY-STATE X(20)5 WS-FO-RES-STATE XX5 WS-FO-RES-ZIP-CODE X(5)5 WS-FO-RES-ZIP-PLUS4 X(4)5 WS-FO-RES-ZIP-DELIV-CODE XX5 WS-FO-RES-ZIP-CHECK-DIGIT X5 WS-FO-CASE-NAME X(18)5 WS-FO-BENE-PHONE X(10)5 WS-FO-LANG-CODE X5 WS-FO-RES-CNTY XX5 WS-FO-MAIL-ADDR-FLAG X5 WS-FO-MAIL-ADDR-LINE1 X(38)5 WS-FO-MAIL-ADDR-LINE2 X(50)5 WS-FO-MAIL-ADDR-CITY-STATE X(20)5 WS-FO-MAIL-STATE XX5 WS-FO-MAIL-ZIP-CODE X(5)5 WS-FO-MAIL-ZIP-PLUS4 X(4)5 WS-FO-MAIL-ZIP-DELIV-CODE XX5 WS-FO-MAIL-ZIP-CHECK-DIGIT X5 WS-FO-CAP-AID-CURR XX5 WS-FO-CAP-AID-TBL(l) OCCURS 12 TIMES

GROUP10 WS-FO-CAP-AID-HIST(l) XX

5 WS-FO-CAP-AID-TBL(2) GROUP10 WS-FO-CAP-AID-HIST(2) XX









5 WS-FO-CAP-AID-TBL(ll) GROUP10 WS-FO-CAP-AID-HIST(ll) XX


FLD START12 115413 115614 115915 116116 116417 116918 117119 117320 117421 117422 117523 117624 117925 118126 118427 118628 118929 119130 119431 119632 119933 120134 120435 120636 120737 121138 121239 122140 122241 122342 126143 131144 133145 133346 133847 134248 134449 134550 136351 137352 137453 137654 137755 141556 146557 148558 148759 149260 149661 149862 1499

63 150164 150163 150364 150363 150564 150563 150764 150763 150964 150963 151164 151163 151364 151363 151564 151563 151764 151763 151964 151963 152164 152163 152364 1523

END LENGTH1155 21158 31160 21163 31168 51170 21172 21173 11175 21174 11175 11178 31180 21183 31185 21188 31190 21193 31195 21198 31200 21203 31205 21206 11210 41211 11220 91221 11222 11260 381310 501330 201332 21337 51341 41343 21344 11362 181372 101373 11375 21376 11414 381464 501484 201486 21491 51495 41497 21498 11500 2

1502 21502 21504 21504 21506 21506 21508 21508 21510 21510 21512 21512 21514 21514 21516 21516 21518 21518 21520 21520 21522 21522 21524 21524 2

PICTURE

5 WS-FO-CAP-AID-TBL(1) OCCURS 12 TIMESGROUP

10 WS-FO-CAP-AID-HIST(1)

5 WS-FO-CAP-AID-TBL(11)10 WS-FO-CAP-AID-HIST(11)

FIELD LEVEL/NAME PICTURE--5 WS-FO-CMS-IND X5 WS-FO-REDETERM-DATE GROUP

10 WS-FO-REDETERM-YR X(4)10 WS-FO-REDETERM-MM XX

FLD START65 152566 152667 152668 1530

END LENGTH1525 11531 61529 41531 2

LAYOUT

FIELD LEVEL/NAME PICTURE FLD START END LENGTH5 WS-FO-CMS-IND X 65 1525 1525 15 WS-FO-REDETERM-DATE GROUP 66 1526 1531 610 WS-FO-REDETERM-YR X(4) 67 1526 1529 410 WS-FO-REDETERM-MM XX 68 1530 1531 25WS-FO-CO-DIST-CODE XXX 69 1532 1534 35 WS-FO-FED-CONTRACT-NUM X(5) 69 1535 1539 55 WS-FO-CARRIER-CODE X(4) 70 1540 1543 45 WS-FO-POLICY-START-DT X(8) 71 1544 1551 85 FILLER X(4) 72 1552 1555 4END OF LAYOUT REPORT

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