Appendix C_020526.pdf

Beneficiary Information on the Cloud (BIC) Transaction Facilitator

Interface Specification Version 7.0 02/07/2024

Document Number: MMA.BIC.1501.6.0.0422

Interface Specification i 2/5/2026

Table of Contents

1. Introduction

2. Data Services Information

2.1 TRF Batch File

2.1.1 TRF File Header

2.1.2 TRF Update Detail Record

2.1.3 TRF Delete Detail Record

2.1.4 TRF File Trailer

3. Assumptions/Constraints/Risks

3.1 Assumptions

3.2 Constraints

3.3 Risks

Appendix A: BIC-TRF Topological Interconnect Diagram

Appendix B: Record of Changes

Appendix C: Acronyms

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List of Figures

Figure 1: BIC-TRF Data Exchanges

List of Tables

Table 1: TRF_HeaderRecord Structure

Table 2: TRF_UpdateDetailRecord Structure

Table 3: TRF_OtherInsurancePeriod Structure

Table 4: TRF_EnrollmentPeriod Structure

Table 5: TRF_DeleteDetailRecord Structure

Table 6: TRF_TrailerRecord Structure

Table 7: Record of Changes

Table 8: Acronyms

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1. Introduction The Center for Medicare & Medicaid Services (CMS) is modernizing and migrating the Medicare Enrollment and Premium Billing Systems (MEPBS) to the Amazon Web Services (AWS) Cloud platform. Part of this initiative includes the Beneficiary Information on the Cloud (BIC) Data Services and Application Programming Interface (API).

BIC allows authorized partners to:

Retrieve information related to Medicare beneficiaries, Update Medicare beneficiary information, and Receive notifications for beneficiary related events, e.g., entitlement change, death, etc., of interest to them.

The MEPBS Transaction Facilitation (TRF) process coordinates a daily data exchange between MEPBS (source system) and the TRF Contractor (target system).

MEPBS transmits beneficiary data, including Part A, B, C, and Part D enrollment data and Part D payer data, to the TRF Contractor as a daily batch file. Pharmacies access this data to verify the active enrollment of beneficiaries filling prescriptions in a participating Part D drug program.

This document provides interface specifications for interaction between BIC and the TRF system. The topological interface diagram is in Appendix A.

NOTE: All sample beneficiary data provided is de-identified.

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2. Data Services Information

2.1 TRF Batch File

BIC generates one TRF batch file daily and submits it to the TRF Contractor. The TRF file format is JavaScript Object Notation (JSON) and delimited by a new line. It has three types of records:

• Header Record – The header record is the first record of the file; the TRF batch file contains only one Header Record.

• Detail Record – The batch file may contain multiple detail records. The detail record is either update or delete type. Each detail record contains information for one beneficiary.

• Trailer Record – The trailer record is the last record of the file; the TRF batch file contains only one Trailer Record.

BIC transmits the batch file to TRF using CMS Enterprise File Transfer (EFT).

2.1.1 TRF File Header

The TRF JSON batch file has one instance of the TRF_HeaderRecord record at the beginning of the file. It is a required record and delimited by a new line. The table below lists the elements in the TRF_HeaderRecord object.

Table 1: TRF_HeaderRecord Structure

Attribute Type Length Description recordType String 1 Attribute indicating type of record in file.

Required. Value: H transmissionDateTime String 26 Date/Time of file transmission.

Required.

Format: YYYY-MM-DDTHH:mm:ss.SSSSSS

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2.1.2 TRF Update Detail Record

The TRF JSON batch file has one or more instances of the TRF_UpdateDetailRecord between the batch header and trailer records for beneficiaries that need updating. A new line delimits it.

The table below lists the elements in the TRF_UpdateDetailRecord object.

Table 2: TRF_UpdateDetailRecord Structure

Attribute Type Max Length

Description recordType String 1 Attribute indicating type of record in file.

Required. Value: ‘U’ data Object Attributes of the beneficiary reported.

See below for the structure of TRF_UpdateDetail.

beneficiaryStatus Array Beneficiary Information. Maximum one occurrence.

See below for the structure of TRF_BeneficiaryStatus.

claimAccountNum String 9 Beneficiary Claim Account Number.

This number identifies the primary Medicare Beneficiary under the Social Security Administration (SSA) or Railroad Retirement Board (RRB) programs.

beneficiaryKey Number 10 System generated number used internally to represent a Medicare beneficiary.

mbi String 11 Active Beneficiary Medicare Beneficiary Identifier

(MBI).

bicCd String 2 The Beneficiary Identification Code establishes the beneficiary relationship to a primary SSA or RRB wage earner and justifies entitlement to Medicare Benefits.

ssn String 9 Beneficiary Social Security Number (SSN).

9 digits; No dashes.

rrbNum String 12 Beneficiary RRB Number gender String 1 Beneficiary Gender

Optional.

Values: 1 - Male, 2 - Female, 0 – Unknown birthDt String 10 Beneficiary Date of Birth

YYYY-MM-DD

deathDt String 10 Beneficiary Date of Death, if available

YYYY-MM-DD

firstName String 30 Beneficiary First name middleName String 14 Beneficiary Middle name.

lastName String 40 Beneficiary Surname/Last name

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Attribute Type Max Length

Description mailingAddr Array Beneficiary mailing address. Array of type TRF_MailingAddress. See below for the structure of TRF_MailingAddress.

Maximum one occurrence.

addrLine1 String 40 Beneficiary Mailing street address line 1 addrLine2 String 40 Beneficiary Mailing street address line 2 addrLine3 String 40 Beneficiary Mailing street address line 3 addrLine4 String 40 Beneficiary Mailing street address line 4 addrLine5 String 40 Beneficiary Mailing street address line 5 addrLine6 String 40 Beneficiary Mailing street address line 6 city String 40 Beneficiary Mailing City stateCd String 2 Beneficiary Mailing State Code zipCd String 9 Beneficiary Mailing ZIP Code entitlementPartA Array Array of objects containing Medicare Part A Entitlement Periods information for the beneficiary.

Array of TRF_Period objects. Maximum 10 occurrences.

See below for structure of TRF_Period.

startDt String 10 Beneficiary Medicare Part A Entitlement Effective Date.

YYYY-MM-DD.

stopDt String 10 Beneficiary Medicare Part A Entitlement Stop Date.

YYYY-MM-DD if terminated, otherwise null returned.

entitlementPartB Array Array of objects containing Medicare Part B Entitlement Periods information for the beneficiary.

Array of TRF_Period objects. Maximum 10 occurrences.

See below for structure of TRF_Period.

startDt String 10 Beneficiary Medicare Part B Entitlement Effective Date.

YYYY-MM-DD.

stopDt String 10 Beneficiary Medicare Part B Entitlement Stop Date.

YYYY-MM-DD if terminated, otherwise null returned.

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Description eligibilityPartD Array Array of objects containing Medicare Part D Eligibility Periods information for the beneficiary.

Array of TRF_Period objects. Maximum 10 occurrences.

See below for structure of TRF_Period.

startDt String 10 Beneficiary Medicare Part D Eligibility Effective Date.

YYYY-MM-DD.

stopDt String 10 Beneficiary Medicare Part D Eligibility Stop Date.

YYYY-MM-DD if terminated, otherwise null returned.

partD_OptOut Array Array of objects containing the Part D Opt Out Switch information.

Maximum one occurrence.

See below for structure of TRF_PartD_OptOut isOptOut Boolean Part D Opt Out Switch Values: True or False otherInsurancePrimary Array Array of objects containing Primary Other Drug Insurance information for the beneficiary.

Array of TRF_OtherInsurancePeriod objects.

Maximum 48 occurrences.

See Table 3 for structure of TRF_OtherInsurancePeriod.

otherInsuranceSupplemental Array Array of objects containing Supplemental Other Drug Insurance information for the beneficiary.

Array of TRF_OtherInsurancePeriod objects.

Maximum 48 occurrences.

See for structure of TRF_OtherInsurancePeriod.

lowIncomeSubsidy Array Array of objects containing Deemed/Low Income Subsidy information for the beneficiary.

Array of TRF_LowIncomeSubsidyPeriod objects. Maximum 12 occurrences.

See below for structure of TRF_LowIncomeSubsidyPeriod object.

indicator String 1 Deemed/LIS Indicator Values: 'D' FOR Deemed period, 'L' FOR LIS period startDt String 10 Deemed/LIS Start Date

YYYY-MM-DD.

stopDt String 10 Deemed/LIS Start Date

YYYY-MM-DD.

lisCopayLevel String 1 LIS Co-Payment Level

‘1', ‘2’, ‘3’, or '4'

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Description enrollmentMAPD Array Array of objects containing Medicare Advantage and/or Part D enrollment information for the beneficiary.

Array of TRF_EnrollmentPeriod objects.

Maximum 96 occurrences.

See Table 4 for structure of TRF_EnrollmentPeriod object.

employerSubsidy Array Array of objects containing Employer Subsidy information for the beneficiary.

Array of TRF_Period objects. Maximum 10 occurrences.

startDt String 10 Employer Subsidy Start Date

YYYY-MM-DD.

stopDt String 10 Employer Subsidy Start Date

YYYY-MM-DD

mbiHistory Array Array of TRF_MBI objects. Maximum 14 occurrences.

See below for structure of TRF_MBI object.

mbi String 11 Beneficiary MBI effectiveDt String 10 Beneficiary MBI Effective Date

YYYY-MM-DD

effectiveReasonCd String 2 Beneficiary MBI Effective Reason Code from the beneficiary most recent Beneficiary MBI period.

The value indicates the reason of an MBI assignment to the beneficiary. The valid values are the following.

• A = Accretion;

• I = Initial bulk MBI assignment;

• BA = (Special authorized);

• BB = (Breach);

• BP = (Provider issue);

• BR = (Religious/cultural);

• BT = (Medical/Identity theft);

• BZ = (Other);

• CA = (Special authorized);

• CB = (CMS breach);

• CE = (Entitlement and casework issues);

• CF = (Confirmed fraud);

• CT = (Medical/Identity theft); and

• CZ = (Other).

endDt String 10 Beneficiary MBI End Date, for historical MBI

YYYY-MM-DD

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Description endReasonCd String 2 Beneficiary MBI End Reason Code from the beneficiary most recent Beneficiary MBI period.

The value indicates the reason for the deactivation of an MBI for the beneficiary. The valid values are the following:

• X= Cross-reference merge;

• BA = (Special authorized);

• BB = (Breach);

• BP = (Provider issue);

• BR = (Religious/cultural);

• BT = (Medical/Identity theft);

• BZ = (Other);

• CA = (Special authorized);

• CB = (CMS breach);

• CE = (Entitlement and casework issues);

• CF = (Confirmed fraud);

• CT = (Medical/Identity theft); and

• CZ = (Other).

disability Array Array of TRF_DisabilityPeriod objects. Maximum 10 occurrences.

See below for structure of TRF_DisabilityPeriod object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD indicator String 1 Values:

• ‘1’ = Disabled without End Stage Renal Disease (ESRD) (disability insurance benefits

(DIB);

• ‘2’ = ESRD Only;

• ‘3’ = Disabled with ESRD (both DIB and

ESRD).

hospice Array Array of TRF_HospicePeriod objects. Maximum

24 occurrences.

See below for structure of TRF_HospicePeriod object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD npi String 10 Hospice National Provider Identifier (NPI) dialysisClinical Array Array of objects containing Clinical Dialysis Periods.

Array of TRF_Period objects. Maximum 10 occurrences.

startDt String 10 YYYY-MM-DD.

stopDt String 10 YYYY-MM-DD

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Description dialysisEntitlement Array Array of objects containing Dialysis Entitlement Periods.

Array of TRF_Period objects. Maximum 10 occurrences.

startDt String 10 YYYY-MM-DD.

stopDt String 10 YYYY-MM-DD esrdTransplant Array Array of objects containing Kidney Transplant Periods.

Array of TRF_TransplantPeriod objects.

Maximum 10 occurrences.

transplantDt String 10 YYYY-MM-DD.

failDt String 10 YYYY-MM-DD medicaid Array Array of TRF_MedicaidPeriod objects. Maximum 48 occurrences.

See below for structure of TRF_MedicaidPeriod object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD dualStatusCd String 2 Dual Eligible Status Code

Code Description 01 Eligible is entitled to Medicare - Qualified

Medicare Beneficiary (QMB) only.

02 Eligible is entitled to Medicare - QMB and

Medicaid coverage including Rx (Medicaid drug coverage criterion only applies through December 2005).

03 Eligible is entitled to Medicare - Specified Low-Income Medicare Beneficiary (SLMB) only.

04 Eligible is entitled to Medicare - SLMB AND Medicaid coverage including Rx (Medicaid drug coverage criterion only applies through December 2005).

05 Eligible is entitled to Medicare - Qualified Disabled & Working Individual (QDWI).

06 Eligible is entitled to Medicare - Qualifying Individual (QI).

08 Eligible is entitled to Medicare - Other Dual Eligible (Non-QMB, SLMB, QDWI or QI) with Medicaid coverage including Rx (Medicaid drug coverage criterion only applies through December 2005).

09 Eligible is entitled to Medicare - Other Dual Eligible but without Medicaid coverage.

10 Territory buy-ins.

99 Unknown.

Interface Specification 10 2/5/2026

Description institutional Array Array of TRF_InstitutionalPeriod objects.

Maximum 48 occurrences.

See below for structure of TRF_InstitutionalPeriod object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD indicator String 1 This will be blank for institutional periods unlawfully present Array Array of TRF_UnlawfullyPresent objects.

Maximum 10 occurrences.

See below for structure of TRF_UnlawfullyPresent object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD incarcerated Array Array of TRF_ Incarcerated objects. Maximum 10 occurrences.

See below for structure of TRF_Incarcerated object.

startDt String 10 YYYY-MM-DD endDt String 10 YYYY-MM-DD

The table below lists the elements in the TRF_OtherInsurancePeriod object.

Table 3: TRF_OtherInsurancePeriod Structure

Attribute Type Length Description effectiveDt String 10 Insurance Effective Date.

YYYY-MM-DD

terminationDt String 10 Termination Date

YYYY-MM-DD

insurerName String 32 Insurer's Name policyNum String 17 Policy Number relationCd String 2 Relationship Code:

Values: ‘01’, ‘02’, ‘03’, ‘04’, ‘05’, ‘06’, ‘07’, ‘08’, ‘09’, ‘10’, ‘11’, ‘12’, ‘13’, ‘14’, ‘15’, 16’, ‘17’, ‘18’, ‘19’, or ‘20’ rx_memberId String 20 Rx ID Number rx_groupNum String 15 Rx Group Number rx_bin String 6 Rx Prescription Bank Identification Number (BIN) rx_pcn String 10 Rx Prescription Processor Control Number (PCN)

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Attribute Type Length Description planTollFreeNum String 18 Plan Toll Free Number supplementalType String 1 Supplemental Type Code:

L = Supplemental M = Medigap N = State Program (Non-Qualified SPAP) O = OtherP = Patient Assistance Program Q = Qualified SPAPR = Charity S = AIDS Drug Assistance Program T = Federal Health Program 1 = Medicaid 2 = Tricare 3 = Major Medical personCd String 3 Person Code payerOrder Number 5 Payer Order

The table below lists the elements in the TRF_EnrollmentPeriod object.

Table 4: TRF_EnrollmentPeriod Structure

Attribute Type Length Description contractNum String 5 Contract Number (identifies which Plan) contractName String 50 Contract Name endDt String 10 PBP End Date

YYYY-MM-DD

startDt String 10 PBP Start Date

YYYY-MM-DD

programType String 1 Code indicating the type of Medicare Part C and/or Part D enrollment.

1 – MA/Part C only;

2 – PDP/Part D only;

3 – MA & PDP

Interface Specification 12 2/5/2026 enrollmentSource String 1 Enrollment Source Code:

A=Part D Auto Enrolled by CMS B=Beneficiary Election C=Part D Facilited enrollment by CMS D=System Generated Enrollment (Rollover) E=Plan submitted auto-enrollments F=Plan submitted facilitated enrollments G=Point of Sale (POS) submitted enrollments H=CMS- or Plan submitted re-assignment enrollments I=Assigned to Plan-submitted transactions with enrollment source other than any of the following: B, E, F, G, H and blank J=State Submitted MMP Passive Enrollment K=CMS Submitted MMP Passive Enrollment L=Beneficiary MMP Election N=Rollover by Plan Transaction Space=not applicable pbpNum String 3 PBP Number (further identifies which Plan) rxDetails Array Array of objects containing 4Rx data. This will be present only when programType is 2 or 3.

Array of TRF_RxDetail objects. Maximum 10 occurrences.

See below for structure of TRF_RxDetail object.

bin String 6 Rx BIN endDt String 10 YYYY-MM-DD groupNum String 15 Rx Group Number memberId String 20 Rx ID Number pcn String 10 Rx PCN startDt String 10 YYYY-MM-DD

2.1.3 TRF Delete Detail Record

The TRF JSON batch file has one or more instances of the TRF_DeleteDetailRecord between the batch header and trailer records for beneficiaries that need deleting. A new line delimits it.

The table below lists the elements in the TRF_DeleteDetailRecord object.

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Table 5: TRF_DeleteDetailRecord Structure recordType String 1 Attribute indicating type of record in file.

Required.

Value: ‘D’ for Delete claimAccountNum String 9 Beneficiary Claim Account Number.

bicCd String 2 The Beneficiary Identification Code establishes the beneficiary relationship to a primary SSA or RRB wage earner and justifies entitlement to Medicare Benefits.

beneficiaryKey Number 10 System generated number used internally to represent a Medicare beneficiary.

mbi String 11 Active Beneficiary Medicare Beneficiary Identifier (MBI).

2.1.4 TRF File Trailer

The TRF JSON batch file has one instance of the TRF_TrailerRecord record at the end of the file. It is a required record and delimited by a new line. The table below lists the elements in the TRF_TrailerRecord object.

Table 6: TRF_TrailerRecord Structure

Attribute Type Length Description recordType String 1 Attribute indicating type of record in file.

Required.

Value: ‘T’ for Trailer detailRecordCount Number 10 Number of detail records in the file.

updateRecordCount Number 10 Number of TRF Update detail records in the file.

deleteRecordCount Number 10 Number of TRF Delete detail records in the file.

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3. Assumptions/Constraints/Risks

3.1 Assumptions

• Update record includes all the data associated with a Beneficiary when any of the fields that are in the update interface update for a beneficiary.

• There is no file created if beneficiary data update has not occurred since the last generation of the TRF file.

• The JSON file does not include attributes without a value.

• The CMS Consolidated Information Technology Infrastructure Contract (CITIC) contractor is responsible for management of the EFT process used by this interface.

• After the CME database receives updates from Enrollment Database (EDB) and

Medicare Advantage Prescription Drug System (MARx), CME creates and sends the outbound file daily.

3.2 Constraints

• None.

3.3 Risks

• None.

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Appendix A: BIC-TRF Topological Interconnect Diagram The figure below displays the interconnectivity between the BIC and TRF systems.

Figure 1: BIC-TRF Data Exchanges

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Appendix B: Record of Changes Table 7: Record of Changes

Version Number

Date Author/Owner Description of Change

1.0 03/20/2020 Laura Anto/NGC Baseline Version

1.1 04/03/2020 Laura Anto/NGC Updated Tables 3 and 7 based on feedback from

TRF team Added the following attributes to Delete record:

• MBI, activeMBI, beneficiaryKey Added the following attributes to Update record:

• BeneficiaryKey

• Combined enrollmentPartC and enrollmentPartD into a single type enrollmentMAPD

2.0 04/20/2020 Laura Anto/NGC Added new table 7 for the TRF_UpdateDetailRecord class model. Corrected inconsistencies between Table 3 and Table 8.

Added field length for all attributes

3.0 05/12/2020 Laura Anto/NGC Updated the definition of the following objects:

• ‘data’ object within the

TRF_UpdateDetailRecord

• TRF_OtherInsurancePeriod

• TRF_DeleteDetailRecord

Removed the class models.

4.0 05/19/2020 Laura Anto/NGC Replaced Health Insurance Claim Number (HICN) with claimAccountNumber and bicCd for DeleteDetailRecord.

Corrected length of MBI to 11.

5.0 06/19/2020 Laura Anto/NGC Updated Table 6 to add the following attributes to the Trailer Record:

• updateRecordCount

• deleteRecordCount

6.0 04/20/2022 L. Anto/Peraton Updated Table 2, Institutional indicator will always be blank.

7.0 02/07/25 S.Beachnau/Pera ton

Updated Table 3, corrected field order and added supplementalType Table 4 corrected field order and added enrollmentSource

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Appendix C: Acronyms Table 8: Acronyms

Acronym Literal Translation

API Application Programming Interface

AWS Amazon Web Services

BIC Beneficiary Information on the Cloud

BIN Bank Identification Number

CITIC Consolidated Information Technology Infrastructure Contract

CMS Centers for Medicare & Medicaid Services

EDB Enrollment Database

EFT Enterprise File Transfer

HHSM Health and Human Services Management

HICN Health Insurance Claim Number

ID Identifier

JSON JavaScript Object Notation

MARx Medicare Advantage Prescription Drug System

MBI Medicare Beneficiary Identifier

MEPBS Medicare Enrollment and Premium Billing Systems

MMA Medicare Modernization Act

NHC Nursing Home Care

PCN Processor Control Number

QDWI Qualified Disabled & Working Individual

QI Qualified Individual

QMB Qualified Medicare Beneficiary

RRB Railroad Retirement Board

Rx Prescription

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Acronym Literal Translation

SLMB Specified Low-Income Medicare Beneficiary

SSA Social Security Administration

SSN Social Security Number

TRF Transaction Facilitation