5. Attachment D - Enrollment File Layout and Schedule.pdf

Functional Design Document

NGA Human Resources page 1 of 8 3/24/2025

Header Record Field Name Field

Length Field Type

Decimal Offset

Position (if fixed)

SAP Fields Field Description Valid Values

Client Code 3 N 1-3 Client Specific Code United Healthcare – MA-PD - 231 Humana – MA-PD – 260

CHP – MA-PD - 041

Filler 1 X 4 Space Fill Record Count 9 N 5-13 # of records on the file Filler 1 X 14 Space Fill Run Date 8 N 15-22 Date file was created Formatted YYYYMMDD Filler 1 X 23 Space Fill Coverage Period 6 N 24-29 Coverage Period Formatted YYYYMM

Detail Record Field Name Field

Length Field Type

Decimal Offset

Position (if fixed)

SAP Fields Field Description Valid Values

PLAN TYPE 3 N 1 T5UBA-

PLNNO+1(3)

Plan type code of the HMO that the subscriber belongs to

321 = UNITED HEALTHCARE

MA-PD

421 = CAPITAL HEALTH

PLAN MA-PD

921 = HUMANA MA-PD

SSN 9 N 4 PA0002-PERID

PA0106-PERID

SSN of the subscriber or Dependent

RELATED SSN 9 13 PA0002-PERID SSN of subscriber in

SAP

If Subscriber, populate SSN; if Dependent, populate SSN of subscriber to whom their enrollment is tied.

MEDICARE ID

NUMBER

11 X 22 PA9301-

MEDICARE_ID

PA0021-

ZZ_MEDCARD

Subscriber’s or Dependent’s Medicare ID

Subscriber’s or Dependent’s Medicare ID

FILLER 6 X 33 Filler Filler

RELATIONSHIP

CODE

2 X 39 PA0021-FAMSA If subscriber, field is blank; if dependent, relationship of the

Blank = Subscriber 2 = Spouse 10 = Disabled Dependent

Attachment D - Enrollment File Layout and Schedule

NGA Human Resources page 2 of 8 3/24/2025 dependent to the subscriber

DATE OF BIRTH 8 N 41 PA0002-GBDAT

PA0021-FGBDT

Birthday of the subscriber or dependent

Formatted YYYYMMDD

GENDER 1 X 49 PA0002-GESCH

PA0021-FASEX

Gender of the subscriber or dependent

M for male, F for female

MAILING

ADDRESS

60 X 50 PA0006-STRAS,

where PA0006-

SUBTY = 3

PA0006-LOCAT,

where PA0006-

SUBTY = 3

If Subscriber, populate mailing address of the subscriber; if dependent, populate mailing address of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

First 30 Characters are Address Line 1; Next 30 Characters are Address Line 2

MAILING CITY 30 X 110 PA0006-ORT01,

where PA0006-

SUBTY = 3

If Subscriber, populate mailing city of the subscriber; if dependent, populate mailing city of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

MAILING STATE 2 X 140 PA0006-STATE,

where PA0006-

SUBTY = 3

If Subscriber, populate mailing state of the subscriber; if dependent, populate mailing state of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

MAILING ZIP 9 X 142 PA0006-PSTLZ,

where PA0006-

SUBTY = 3

If Subscriber, populate mailing zip code of the subscriber; if dependent, populate

NGA Human Resources page 3 of 8 3/24/2025 mailing zip code of subscriber to whom their enrollment is tied

HOME

ADDRESS

60 X 151 PA0006-STRAS,

where PA0006-

SUBTY = 1

PA0006-LOCAT,

where PA0006-

SUBTY = 1

If Subscriber, populate home address of the subscriber; if dependent, populate home address of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

First 30 Characters are Address Line 1; Next 30 Characters are Address Line 2

HOME CITY 30 X 211 PA0006-ORT01,

where PA0006-

SUBTY = 1

If Subscriber, populate home city of the subscriber; if dependent, populate home city of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

HOME STATE 2 X 241 PA0006-STATE,

where PA0006-

SUBTY = 1

If Subscriber, populate home state of the subscriber; if dependent, populate home state of subscriber to whom their enrollment is tied

Field should be forced to UPPER

CASE

HOME ZIP 9 X 243 PA0006-PSTLZ,

where PA0006-

SUBTY = 1

If Subscriber, populate home zip code of the subscriber; if dependent, populate home zip code of subscriber to whom their enrollment is tied

HOME COUNTY

CODE

2 N 252 Function module -

Z_UTL_GET_EMPL

If Subscriber, populate home

01 = ALACHUA

02 = BAKER

NGA Human Resources page 4 of 8 3/24/2025

OYEE_COUNTY

PA0006-COUNC

where subty = ‘1’(Home County) county code of the subscriber; if dependent, populate home county code of subscriber to whom their enrollment is tied

03 = BAY

04 = BRADFORD

05 = BREVARD

06 = BROWARD

07 = CALHOUN

08 = CHARLOTTE

09 = CITRUS

10 = CLAY

11 = COLLIER

12 = COLUMBIA

13 = DADE

14 = DESOTO

15 = DIXIE

16 = DUVAL

17 = ESCAMBIA

18 = FLAGLER

19 = FRANKLIN

20 = GADSDEN

21 = GILCHRIST

22 = GLADES

23 = GULF

24 = HAMILTON

25 = HARDEE

26 = HENDRY

27 = HERNANDO

28 = HIGHLANDS

29 = HILLSBOROUGH

30 = HOLMES

31 = INDIAN RIVER

32 = JACKSON

33 = JEFFERSON

34 = LAFAYETTE

35 = LAKE

36 = LEE

37 = LEON

38 = LEVY

39 = LIBERTY

40 = MADISON

41 = MANATEE

42 = MARION

NGA Human Resources page 5 of 8 3/24/2025

43 = MARTIN

44 = MONROE

45 = NASSAU

46 = OKALOOSA

47 = OKEECHOBEE

48 = ORANGE

49 = OSCEOLA

50 = PALM BEACH

51 = PASCO

52 = PINELLAS

53 = POLK

54 = PUTNAM

55 = ST JOHNS

56 = ST LUCIE

57 = SANTA ROSA

58 = SARASOTA

59 = SEMINOLE

60 = SUMTER

61 = SUWANNEE

62 = TAYLOR

63 = UNION

64 = VOLUSIA

65 = WAKULLA

66 = WALTON

67 = WASHINGTON

99 = OUT OF STATE

blank = UNKNOWN

FILLER 1 X 254 Filler Filler

COVERAGE

CODE

2 N 255 Fill all records with

Coverage code of the subscriber

63 = Medicare I

COVERAGE

DATE

8 N 257 PA0167- PARDT (if PARDT is null, use

PA0167-BEGDA)

Coverage effective date of the subscriber or dependent.

Formatted YYYYMMDD

SIGNATURE

DATE

8 X 265 Date subscriber or dependent enrolled in coverage

Formatted YYYYMMDD

Populate the date the first full monthly file is sent for the coverage month based on the date in the Coverage Date field.

NGA Human Resources page 6 of 8 3/24/2025

If 1st time on the file, run date.

If not 1st time on the file, use signature date from previous run.

VOLUNTARY/IN

VOLUNTARY

INDICATOR

1 X 273 Values are based on the Termination Reason below If 02, 03,05; then I If 01 or 04; then V

If not terminated, field is blank;

if terminated, Voluntary/Involuntary Termination Indicator

Blank = Not terminated

I = Involuntary – Coverage cancelled due to non-payment, Enrollee (or dependent) loses Medicare coverage (Part A or Part B) and is now ineligible for MA-PD plan, Death of enrollee or dependent, Non-employee loses MA-PD coverage due to divorce

V = Voluntary – Everything else

TERMINATION

REASON

2 N 274 01 – check

ZCA_FULFILL_REQ

for ITEMC = CANL 02 – check PA0000 for MASSN 06 or 23 and MASSG 60 or 03 – check PA0378 for EVENT LE25 or

LE26

04 – all else where

COVERAGE TERM

DATE is filled in below 05 – check PA0211 for ENDDA in the coverage month

01 = Cancellation due to non-payment 02 = Death 03 = Divorce 04 = Other (notified by carrier that member lost eligibility for Medicare) 05 = COBRA coverage period end

FILLER 2 X 276 Filler Filler

COVERAGE

TERM DATE

8 N 278 PA0167-ENDDA Coverage Term Date FORMAT YYYYMMDD

NGA Human Resources page 7 of 8 3/24/2025

If the subscriber is termed in the current month, the subscriber will continue on the file with the Term Date populated.

If an MA-PD plan is canceled before the effective date, the Termination Date needs to be the same as the original Effective date.

There will be no retro terminations

– all other terminations will have the Termination Date as the last day of the current coverage month.

Blank fill if coverage not terminated

FIRST NAME 40 X 286 PA0002-VORNA Subscriber’s or dependent’s First Name

Field will be all UPPER CASE.

MIDDLE INITIAL 1 X 326 PA0002-INITS Subscriber’s or dependent’s Middle Initial

Field will be UPPER CASE.

LAST NAME 40 X 327 PA0002-NACHN Subscriber’s or dependent’s Last Name

Field will be all UPPER CASE.

PREVIOUS SSN 9 N 367 PA0002-PERID Previous SSN of subscriber or dependent if it had been corrected

If the subscriber or dependent has an SSN correction performed, populate in the former (incorrect SSN) in this field. Otherwise it is blank

PRIMARY

PHONE

NUMBER

10 N 376 PA0006-TELNR,

where PA0006-

SUBTY = 10

Primary phone number for subscriber

For Subscriber or Dependent, populate the primary phone number from the subscriber’s home address record, else leave blank.

ALTERNATE

PHONE

NUMBER

10 N 386 PA0006-NUM01,

where PA0006-

SUBTY = 10

Alternate phone number for subscriber

For Subscriber or Dependent, populate the alternate phone number from the subscriber’s home address record, else leave

NGA Human Resources page 8 of 8 3/24/2025 blank.

NOTIFICATION

EMAIL

ADDRESS

100 X 396 PA0006-

ZNOTIF_EMAIL

where PA0006-

SUBTY = NOTF

Subscriber’s Notification Email Address

For Subscriber or Dependent, populate the notification email address from the subscriber’s record, else leave blank.

ESRD END

DATE

8 N 496 PA9301-

ESRD_END

PA0021-

ESRD_END

ESRD End Date FORMAT YYYYMMDD

If ESRD End Date is >= first day of the coverage month, populate date; if the ESRD End Date is < first day of the coverage month, do not send.

Blank fill if no data RACE 2 X 504 PA0077-RACKY Race Subscriber records:

01 = White 02 = Black or African American 03 = Hispanic or Latino 04 = Asian 05 = American Indian or Alaskan Native 06 = Native Hawaiian or Other Pacific Islander 07 = Some Other Race or Two or More Races Blank fill if no data

Dependent records:

Blank

ETHNICITY 2 Z 506 PA0077-ETHEN Ethnicity Subscriber records:

E1 = Hispanic or Latino E2 = Not Hispanic or Latino Blank fill if no data

Dependent records:

Blank

Month End Monthly Carrier

Files File # 1 File # 2 File # 3 File # 4

Coverage Month Date file sent to the vendors from

PF

Date file sent to the vendors from

PF *

Date file sent to the vendors from

PF *

Date file sent to the vendors from

PF *

Date file sent to the vendors from

PF *

Jan-25 12/27/2024 1/4/2025 1/11/2025 1/18/2025 1/25/2025 Feb-25 1/30/2025 2/8/2025 2/15/2025 2/22/2025 Mar-25 2/27/2025 3/8/2025 3/15/2025 3/22/2025 Apr-25 3/28/2025 4/5/2025 4/12/2025 4/19/2025 May-25 4/28/2025 5/3/2025 5/10/2025 5/17/2025 5/24/2025 Jun-25 5/28/2025 6/7/2025 6/14/2025 6/21/2025 Jul-25 6/27/2025 7/5/2025 7/12/2025 7/19/2025

Aug-25 7/29/2025 8/2/2025 8/9/2025 8/16/2025 8/23/2025 Sep-25 8/27/2025 9/6/2025 9/13/2025 9/20/2025 Oct-25 9/26/2025 10/4/2025 10/11/2025 10/18/2025 10/25/2025 Nov-25 10/30/2025 11/8/2025 11/15/2025 11/22/2025 Dec-25 11/26/2025 12/6/2025 12/13/2025 12/20/2025 Jan-26 12/29/2025 1/3/2026 1/10/2026 1/17/2026 1/24/2026

2025 MA-PD Weekly Vendor Files