Solicitation Number 24322620R0001 - Attachments 3-15--01.21.2020.pdf
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- Solicitation number
- 243226
- Issued by
-
Office of Personnel Management
About this file
This document contains attachments related to a solicitation for Federal Annuitant Health Benefits Open Season Services. The Office of Personnel Management (OPM) seeks a contractor to distribute Open Season materials to approximately 2.7 million annuitants and process enrollment changes for the annual Open Season period when annuitants can change their health benefits coverage. The contractor must mail Open Season information and Federal Dental and Vision Plan notifications to annuitants based on their geographic location. The contractor will also process annuitant health benefits enrollment changes to ensure their annuity payments accurately reflect any changes as of January 1. The proposed single award firm-fixed price contract has a one-year base period and four one-year options with a period of performance through 2025. Questions are due by January 31, 2020 and proposals are due February 28, 2020, with award anticipated by May 29, 2020. The incumbent is General Dynamics Information Technology, Inc.
The attachments include file format specifications and record layouts for data files the OPM will provide to the contractor related to annuitant demographics, benefits enrollments, address information and other data elements.
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ATTACHMENT 3
MASTER FILE OF ANNUITANT NAME AND ADDRESS
(OPM to Contractor)
Office of Personnel Management
Format Specification for Data File
FILE NAME: BRGMRP.GM99T1
MEDIA: ELECTRONIC DATA FILE
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27900
RECORD LENGTH: 450
SEQUENCE: ZIP CODE
FOR EACH CASE ONE 450 CHARACTER RECORD WILL BE SENT AS FOLLOWS:
Field Description
Length
Start/End Pos
Data Type
Values, Edits
1 Record ID 1 01 AN Value: blank 2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 4 202-205 UNUSED
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout) 28 Annuitant E-mail address 100 347-446 AN Annuitant E-mail Address
29 FILLER 4 447-450 AN FILLER
ATTACHMENT 4
SPOUSE EQUITY MASTER FILE
FILE NAME: BRGMRP.GM99T4
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27900
RECORD LENGTH: 450
Pos
2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 4 202-205 UNUSED
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout)
29 FILLER 4 447-450 AN FILLER
ATTACHMENT 5
SUSPENDED ENROLLMENT MASTER FILE
FILE NAME: BRGMRP.GM41T1
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27900
RECORD LENGTH: 450
Pos
2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 4 202-205 UNUSED
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout) 28 Annuitant E-mail address 100 347-446 AN Annuitant E-mail Address 29 Suspend Type 1 447 AN ‘ ‘=Suspend, ‘T’=TRICARE, ‘C’=CHAMP/VA
30 FILLER 3 448-450 AN FILLER
ATTACHMENT 6
SPOUSE SUSPENDED ENROLLMENT MASTER FILE
FILE NAME: BRGMRP.GM41T4
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27900
RECORD LENGTH: 450
Pos
2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 4 202-205 UNUSED
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout) 28 Annuitant E-mail address 100 347-446 AN Annuitant E-mail Address 29 Suspend Type 1 447 AN ‘ ‘=Suspend, ‘T’=TRICARE, ‘C’=CHAMP/VA
30 FILLER 3 448-450 AN FILLER
ATTACHMENT 7
FEDVIP MASTER FILE
FILE NAME: BRGMRP.GM42T1
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27900
RECORD LENGTH: 450
Pos
2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 4 202-205 UNUSED
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout)
30 FILLER 4 447-450 AN FILLER
ATTACHMENT 8
ELECTED SURVIVOR FILE
FILE NAME: BRGMRP.GM52T2
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27825
RECORD LENGTH: 265
SEQUENCE: CLAIM NUMBER
FOR EACH CASE ONE 265 CHARACTER RECORD WILL BE SENT AS FOLLOWS:
Pos
1 Claim Number 9 01-09 AN Format: A00000000, F00000000 2 Last Name 12 10-21 AN Annuitant Last Name 3 First Name 7 22-28 A Annuitant First Name 4 Middle Initial 1 29 A Annuitant Middle Initial (not required) 5 Relationship Code 2 30-31 A 1 = Female, 2 = Male 6 SSN 9 32-40 AN Annuitant Social Security Number
7 DOB 8 41-48 N MMDDCCYY
8 Gender 1 49 AN ‘M’ = Male, ‘F’ = Female 9 Other Insurance Indicator 1 50 AN ‘Y’ = Yes, ‘N’ = No 10 Medicare Indicator 1 51 AN ‘Y’ = Yes, ‘N’ = No 11 Medicare Part A Indicator 1 52 AN ‘Y’ = Yes, ‘N’ = No 12 Medicare Part B Indicator 1 53 AN ‘Y’ = Yes, ‘N’ = No 13 CHAMP/TRICARE Indic 1 54 AN ‘Y’ = Yes, ‘N’ = No 14 Primary Insurance Name 35 55-89 AN Name of Primary Insurance 15 Primary Insurance Policy# 30 90-119 AN Policy Number of Primary Insurance 16 Dependent Address 1 35 120-154 AN Address Line 1 of Dependent 17 Dependent Address 2 35 155-189 AN Address Line 2 of Dependent 18 Dependent Address 3 35 190-224 AN Address Line 3 of Dependent 19 Dependent City 23 225-247 AN City of Dependent 20 Dependent State 2 248-249 AN State of Dependent 21 Dependent Zip 11 250-260 AN Zip Code of Dependent 22 Foreign Address Indicator 1 261 AN ‘Y’ = Yes, ‘N’ = No, ‘ ‘ = No Address provided
23 FILLLER 4 265 FILLER
ATTACHMENT 9
HB NEW ENROLLEE RECORD
FILE NAME: BRGMRP.GM48S1
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27600
RECORD LENGTH: 460
FOR EACH CASE ONE 346 CHARACTER RECORD WILL BE SENT AS FOLLOWS:
Pos
2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown 3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Old HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 FIPS Code 2 198-199 AN FIPS Country Code 19 Court Action Indicator 1 200 AN Indicates whether annuitant has a court action.
20 Negative Net Indicator 1 201 AN Value: ‘N’ = Potential Negative Net or blank
21 FILLER 14 202-215 UNUSED
22 Macon Address – line 1 35 216-250 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 251-285 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 286-320 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 321-343 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 344-345 AN State (for Macon layout) 27 Macon Zip 11 346-356 AN Zip Code (for Macon layout) 28 Annuitant E-mail 346 357-456 AN Annuitant’s E-mail Address
29 FILLER 4 457-460 FILLER
ATTACHMENT 10
HB BROCHURE REQUEST
FILE NAME: BRGMRP.GM50T2
FILE FORMAT: FIXED BLOCK
BLOCK SIZE: 27786
RECORD LENGTH: 356
FOR EACH CASE ONE 346 CHARACTER RECORD WILL BE SENT AS FOLLOWS:
Pos
1 FILLER 1 01 AN Value: ‘2’ 2 Claim Number 9 02-10 AN Format: A00000000, F00000000 3 Last Name 12 11-22 A Annuitant Last Name 4 First Name 7 23-29 A Annuitant First Name 5 Middle Initial 1 30 A Annuitant Middle Initial (not required) 6 SSN 9 31-39 AN Annuitant Social Security Number 7 DOB 8 40-47 N CCYYMMDD- If unknown, set to 19000101 8 Gender/Marital Status 1 48 AN M = Male/Unknown
F = Female/Unknown 1 = Male/Unknown 2 = Female/Unknown
3 = Male/Unmarried 4 = Female/Unmarried 5 = Male/Married 6 = Female/Married
9 Current HB Code 3 49-51 AN Annuitant’s Prior HB Code 10 CCN 9 52-60 AN HB Carrier Control Number, Format: 000000000 11 Address – Line 1 22 61-82 AN Annuitant Mailing Address (1) 12 Address – Line 2 22 83-104 AN Annuitant Mailing Address (2) 13 Address – Line 3 22 105-126 AN Annuitant Mailing Address (3) 14 Address – Line 4 22 127-148 AN Annuitant Mailing Address (4) 15 Address – Line 5 22 149-170 AN Annuitant Mailing Address (5) 16 Address – Line 6 22 171-192 AN Annuitant Mailing Address (6) 17 Zip Code 5 193-197 AN Annuitant Zip Code 18 Request Code 1 2 198-199 AN HB Code of Requested Brochure 19 Request Code 2 2 200-201 AN HB Code of Requested Brochure 20 Request Code 3 2 202-203 AN HB Code of Requested Brochure 21 Request Code 4 2 204-205 AN HB Code of Requested Brochure 22 Request Code 5 2 206-207 AN HB Code of Requested Brochure
23 FILLER 8 208-215
22 Macon Address – line 1 35 206-240 AN Street Address – line 1 (for Macon layout) 23 Macon Address – line 2 35 241-275 AN Street Address – line 2 (for Macon layout) 24 Macon Address – line 3 35 276-310 AN Street Address – line 3 (for Macon layout)
Foreign Address – Valid city address 25 Macon City 23 311-333 AN City (for Macon layout)
Domestic Address – valid city name Foreign Address – valid country name
26 Macon State 2 334-335 AN State (for Macon layout) 27 Macon Zip 11 336-346 AN Zip Code (for Macon layout)
28 FILLER 10 347-356
ATTACHMENT 11
CHANGE OF RECORD ADDRESS FORMAT
(Contractor to OPM)
FOR EACH CASE, TWO 89 CHARACTER RECORDS WILL BE SENT AS FOLLOWS:
RECORD 1
Pos
1 Type of Change 1 01 AN Value: ‘C’ 2 Action Code 1 02 AN Blank 3 Card Number 1 03 AN Value: ‘1’ 4 Claim Number 9 04-12 AN 5 Type Payee Code 1 13 AN Blank 6 Address Line 1 22 14-35 AN 7 Address Line 2 22 36-57 AN 8 Address Line 3 22 58-79 AN 9 Record ID 1 80 AN Value: “-“
10 Batch Number 9 81-89 AN
RECORD 2
Pos
1 Type of Change 1 01 AN Value: ‘C’ 2 Action Code 1 02 AN Blank 3 Card Number 1 03 AN Value: ‘2’ 4 Claim Number 9 04-12 AN 5 Type Payee Code 1 13 AN Blank 6 Address Line 4 22 14-35 AN 7 Address Line 5 22 36-57 AN 8 Address Line 6 17 58-74 AN 9 Record ID (ZIP CODE) 5 75-79 AN SEE NOTE 1
10 Record ID 1 80 AN Blank for Domestic, “F” for Foreign 11 Receipt-Type 1 81 AN 12 Batch Number 9 81-89 AN
NOTE 1: ZIP CODE FOR DOMESTIC ADDRESS. ZIP CODE MUST BE PART OF SIX LINES OF ADDRESS.
POSITION OF GEOGRAPHIC CODE FOR FOREIGN ADDRESS PRECEDED BY TWO BLANKS.
SPECIAL NOTE: LAST NON-BLANK LINE OF ADDRESS SHOULD NOT EXCEED 16 POSITIONS.
ATTACHMENT 12
OPEN SEASON CHANGE RECORD FORMAT
FOR EACH CASE, ONE 89 CHARACTER RECORD WILL BE SENT AS FOLLOWS:
Pos
1 Type of Change 1 01 AN Value: ‘G’ 2 FILLER 2 02-03 Blank 3 Claim Number 9 04-12 AN 4 Batch Number 9 13-21 AN 5 Current HB Code 3 22-24 AN 6 New HB Code 3 25-27 AN 7 HB Effective Date 8 28-35 AN 8 HB Transaction Date 8 36-43 AN Format: CCYYMMDD 9 Type of Action 1 44 AN ‘C’ – Change
10 SSN/Claim Number 9 45-53 AN
11 FILLER 36 54-89
NOTE: THE HB EFFECTIVE DATE WILL ALWAYS BE JANUARY 1 OF THE CALENDAR YEAR. (e.g. 20200101)
ATTACHMENT 13
OPEN SEASON SUSPEND RECORD FORMAT
Pos
2 FILLER 2 02-03 Blank 3 Claim Number 9 04-12 AN 4 Batch Number 9 13-21 AN 5 Current HB Code 3 22-24 AN 6 New HB Code 3 25-27 AN 7 HB Effective Date 8 28-35 AN 8 HB Transaction Date 8 36-43 AN Format: CCYYMMDD 9 Type of Action 1 44 AN ‘S’ – Suspend
‘H’ – Husband/Wife Suspend ‘M’ – Medicare/Tricare Suspend ‘V’ – Champus/VA Suspend ‘R’ – Reemployed Annuitant
10 SSN/Claim Number 9 45-53 AN
ATTACHMENT 14
OPEN SEASON ADD RECORD FORMAT
Pos
2 FILLER 2 02-03 Blank 3 Claim Number 9 04-12 AN 4 Batch Number 9 13-21 AN 5 Current HB Code 3 22-24 AN 6 New HB Code 3 25-27 AN 7 HB Effective Date 8 28-35 AN 8 HB Transaction Date 8 36-43 AN Format: CCYYMMDD 9 Type of Action 1 44 AN ‘A’ – Add
10 SSN/Claim Number 9 45-53 AN
ATTACHMENT 15
OPEN SEASON CANCELLATION RECORD FORMAT
Pos
2 FILLER 2 02-03 Blank 3 Claim Number 9 04-12 AN 4 Batch Number 9 13-21 AN 5 Current HB Code 3 22-24 AN 6 New HB Code 3 25-27 AN 7 HB Effective Date 8 28-35 AN 8 HB Transaction Date 8 36-43 AN Format: CCYYMMDD 9 Type of Action 1 44 AN ‘D’ – Drop
10 SSN/Claim Number 9 45-53 AN
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