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Attachment J.2
Attachment j.2- medicare eligibility index record layout specifications
| Part D Payer Source Elements |
| Part D Payer Data Types |
| Data Requirement Data Definition |
Primary
| Social Security Number |
| CHAR(9) |
| The beneficiary's current identification number that was assigned by the Social Security Administration. |
| Health Insurance Claim Number |
| CHAR(12) |
| The number identifying the primary Medicare Beneficiary under the SSA or RRB programs. This number along with the Beneficiary Identification Code uniquely identifies a Medicare Beneficiary. |
A code that is used in conjunction with the Beneficiary Claim Account Number to uniquely identify a Medicare Beneficiary. The BIC Code establishes the beneficiary's relationship to a primary Social Security Administration (SSA) or Railroad Retirement Board (RRB) wage earner and is used to justify entitlement to Medicare benefits.
| Beneficiary's Surname |
| CHAR(6) |
| The last name (surname) of the Medicare Beneficiary including any following titles. |
Beneficiary's First Initial
| CHAR(1) |
| The first initial of the first name of the beneficiary. |
| Beneficiary's Date of Birth |
| Date CCYYMMDD |
| The date of birth of the Medicare Beneficiary. |
| Beneficiary's Sex Code |
| CHAR(1) |
| Represents the sex of the Medicare Beneficiary. Examples include: Male and Female |
| MSP Reason |
| CHAR(1) |
| Captures the reason why the beneficiary has MSP coverage |
| Coverage Code |
| CHAR(1) |
| Code indicating the type of coverage. |
| Insurer's Name |
| CHAR(32) |
| The name of the group coverage plan in which the beneficiary is enrolled. |
| Insurer's Address-1 |
| CHAR(32) |
| The first line of the insurer's mailing address. |
| Insurer's Address-2 |
| CHAR(32) |
| The second line of the insurer's mailing address. |
| Insurer's City |
| CHAR(15) |
| The name of the city for the insurer's mailing address |
| Insurer's State |
| CHAR(2) |
| The postal state code for the insurer's mailing address. |
| Insurer's Zip Code |
| CHAR(9) |
| The zip code associated with the insurer's address. |
| Policy Number |
| CHAR(17) |
| The identifier for the group coverage plan in which the beneficiary is enrolled. |
| Effective Date |
| Date CCYYMMDD |
| The start date of the other drug insurance coverage for the beneficiary. |
| Termination Date |
| Date CCYYMMDD |
| The termination date of the other drug insurance coverage for the beneficiary. |
| Relationship Code |
| CHAR(2) |
| A code identifying the beneficiary's relationship to the Policy Holder. |
| Policy Holder's First Name |
| CHAR(9) |
| The first name of the Drug Insurance Policy Holder. |
| Policy Holder's Last Name |
| CHAR(16) |
| The last name of the Drug Insurance Policy Holder. |
| Policy Holder's SSN |
| CHAR(12) |
| The social security number of the Drug Insurance Policy Holder |
| Group Policy Number |
| CHAR(20) |
| A number assigned by the Primary Payer that identifies the Group Policy |
| Group Policy Name |
| CHAR(17) |
| The name of the group plan. |
RxID Number
| RX Plan Toll Free Number |
| CHAR(15) |
Supplemental
| Social Security Number |
| CHAR(9) |
| The beneficiary's current identification number that was assigned by the Social Security Administration. |
| Health Insurance Claim Number |
| CHAR(12) |
| The number identifying the primary Medicare Beneficiary under the SSA or RRB programs. This number along with the Beneficiary Identification Code uniquely identifies a Medicare Beneficiary. |
A code that is used in conjunction with the Beneficiary Claim Account Number to uniquely identify a Medicare Beneficiary. The BIC Code establishes the beneficiary's relationship to a primary Social Security Administration (SSA) or Railroad Retirement Board (RRB) wage earner and is used to justify entitlement to Medicare benefits.
| Beneficiary's Surname |
| CHAR(6) |
| The last name (surname) of the Medicare Beneficiary including any following titles. |
Beneficiary's First Initial
| CHAR(1) |
| The first initial of the first name of the beneficiary. |
| Beneficiary's Date of Birth |
| Date CCYYMMDD |
| The date of birth of the Medicare Beneficiary. |
| Beneficiary's Sex Code |
| CHAR(1) |
| Represents the sex of the Medicare Beneficiary. Examples include: Male and Female |
| Supplemental Type Code |
| CHAR(1) |
| Code indicating the type of supplemental insurance. For example TRICARE. |
| Coverage Code |
| CHAR(1) |
| Code indicating the type of coverage |
| Insurer's Name |
| CHAR(32) |
| The name of the group coverage plan in which the beneficiary is enrolled. |
| Insurer's Address-1 |
| CHAR(32) |
| The first line of the insurer's mailing address. |
| Insurer's Address-2 |
| CHAR(32) |
| The second line of the insurer's mailing address. |
| Insurer's City |
| CHAR(15) |
| The name of the city for the insurer's mailing address |
| Insurer's State |
| CHAR(2) |
| The postal state code for the insurer's mailing address. |
| Insurer's Zip Code |
| CHAR(9) |
| The zip code associated with the insurer's address. |
| Policy Number |
| CHAR(17) |
| The identifier for the group coverage plan in which the beneficiary is enrolled. |
| Effective Date |
| Date CCYYMMDD |
| The start date of the other drug insurance coverage for the beneficiary. |
| Termination Date |
| Date CCYYMMDD |
| The termination date of the other drug insurance coverage for the beneficiary. |
| Member ID Number |
| CHAR(10) |
| An identifying number for the insured who is enrolled in other drug coverage insurance. |
RxID Number
| RX Plan Toll Free Number |
| CHAR(15) |
| Qualifying Indicator |
| CHAR(2) |
| Relationship Code |
| CHAR(2) |
| A code identifying the beneficiary's relationship to the Policy Holder. |
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