15 170 229 Mailing Address1 60 A/N Y Address_Line1 of this person record, if it doesn’t exist then use the Member Address_Line1. Address Type = ‘R’ 16 230 259 Mailing Address2 30 A/N Y Address_Line2 of this person record, if it doesn’t exist then use the Member Address_Line2. Address Type = ‘R’ 17 260 309 Mailing City 50 A/N Y City of this person record, if it doesn’t exist then use the Member City Address Type = ‘R’ 18 310 311 Mailing State 2 A/N Y State of this person record, if it doesn’t exist then use the Member State Address Type = ‘R’ 19 312 321 Mailing Zip 10 A/N *See Description Y Zip of this person record, if it doesn’t exist then use the Member Zip Address Type = ‘R’ *Zip code will be right justified and padded with leading spaces. 20 322 331 Phone 10 A/N N (Home) of this person record, if it doesn’t exist then use the Member phone Address Type = ‘R’ If not supplied: Null or ‘0000000000’ 21 332 332 Alt Ins Indicator 1 A/N N Not Used 22 333 342 Alt Ins Code 10 A/N N Not Used 23 343 360 Alt Ins ID 18 A/N N Not Used 24 361 371 Filler 11 For Future Additions 25 372 381 Status 10 A/N N Member or dependents status code. For example, Active, Medicare, Cobra etc. 26 382 391 Plan 10 A/N N Selected benefit level, elected by the member. Examples Healthchoice Hi option, Healthchoice Low option etc. Enrollment_type_id 27 392 399 Plan Eff Date 8 N N Not used
49 536 550 Country 15 A/N N Country of Address. Populate the country 50 551 553 Reason 3 N Y or N Change Type: 1st Position – Eligibility, 2nd Position – Address, 3rd Position – Indicative 51 554 561 Date of Death 8 N N YYYYMMDD The death date of this person record 52 562 571 Member_Code 10 A/N Y Unique Member Number Right Justified 53 572 621 Employer Name 50 A/N N Employer Name 54 622 681 Permanent Address_1 60 A/N Y Address_Line1 of this person record, if it doesn’t exist then use the Member Address_Line1. Address Type = ‘C’ If ‘C’ is null, use ’R’ 55 682 711 Permanent Address_2 30 A/N Y Address_Line2 of this person record, if it doesn’t exist then use the Member Address_Line2. Address Type = ‘C’ If ‘C’ is null, use ’R’ 56 712 761 Permanent City 50 A/N Y City of this person record, if it doesn’t exist then use the Member City Address Type = ‘C’ If ‘C’ is null, use ’R’ 57 762 763 Permanent State 2 A/N Y State of this person record, if it doesn’t exist then use the Member State Address Type = ‘C’ If ‘C’ is null, use ’R’ 58 764 773 Permanent Zip 10 A/N *See Description Y Zip of this person record, if it doesn’t exist then use the Member Zip Address Type = ‘C’ If ‘C’ is null, use ’R’ *Zip code will be right justified and padded with leading spaces. 59 774 798 County 25 A/N N County of Permanent Residence of this person record Member Medicare Info Datasheet 60 799 848 Email 50 A/N N Email Address of this person record Address Type = ‘R’
61 849 849 Plan Premium Payment Option 1 A/N Y 1 1=EGID will bill the member 62 850 850 ESRD 1 A/N Y Y=Yes N=Blank Member is ESRD Medicare Info Datasheet 63 851 851 Request Materials in Language Other Than English 1 A/N Y Y=Yes N-No Default=N or <Blank> Language preference or another format than English MAPD will contact the Beneficiary if the box on the enrollment form is marked ‘Yes’ Medicare Info Datasheet 64 852 852 Language Preference and Alternative Formats 1 A/N Y N=No Default=N NOT USED 65 853 853 Beneficiary Signature and/or Authorized Representative Signature 1 A/N Y Y=Yes Form is signed. Default to Y since no enrollments will be sent if form is not signed. 66 854 903 Authorized Representative Last Name 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent – use Primary Member’s Indicative Info 3) <blank> 67 904 953 Authorized Representative Name 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent – use Primary Member’s Indicative Info 3) <blank> 68 954 954 Authorized Representative Middle Initial 1 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) 69 955 1014 Authorized Representative Address1 60 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 70 1015 1044 Authorized Representative Address2 30 A/N N 1) Medicare Info Datasheet 2) Person record is dependent – use
Primary Member’s Indicative Info 3) <blank> 71 1045 1094 Authorized Representative City 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 72 1095 1096 Authorized Representative State 2 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent – use Primary Member’s Indicative Info 3) <blank> 73 1097 1106 Authorized Representative Zip 10 A/N *See Description Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) *Zip code will be justified and padded with leading spaces. 74 1107 1116 Authorized Representative Phone 10 A/N N 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> NOT USED 75 1117 1124 Employer or Union Name 8 A/N Y OSEEGIB 76 1125 1128 Employer or Union Group Number 4 A/N Y 9010 77 1129 1129 Plan Change? 1 A/N Y Y=Yes N=Blank Yes=info is completed on form. Used when changing from one plan to another same carrier. NOT USED 78 1130 1130 Info Provided Under “Please Read and Sign Below”? 1 A/N Y Y=Yes N=No Default is Y because info is on the form and member signed the form 79 1131 1131 Release of Information Elements Provided? 1 A/N Y Y=Yes N=No Default is Y because info is on the form and member signed the form
80 1132 1132 PCP/PCD Status 1 A/N PCP/PCD Patient Status: N = New C = Current If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 81 1133 1182 PCP/PCD First Name 50 A/N PCP/PCD Provider First Name If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 82 1183 1232 PCP/PCD Last Name 50 A/N PCP/PCD Provider Last Name If the Fund is Health then populate Primary Care Provider. If the Fund is Dental then populate Dental Provider. 83 1233 1258 RX OGI 26 A/N Other Group Insurance Plan Name 84 1259 1278 RX ID# For OGI 20 A/N Other Group Insurance Member ID# 85 1279 1293 RX For OGI 15 A/N Other Group Insurance Group # 86 1294 1303 EBC Debit Card 9 A/N N (Ex. A20100401) A=Active I=Inactive Blank EBC Debit Card Indicator and Start/Stop Date 87 1304 1500 Filler 198 For Future Additions Note 1: To identify the record type is 2 or 3 All member and dependent records need to be identified as record type 2 (add record) or record type 3 (change record). A member or dependent that is enrolled in a given plan for the first time is an ADD record and should be indicated as a record type 2. For example, a member/dependent is active in Health Healthchoice from 1/1/2015 to 12/31/2016. On 1/1/2017 they move to HealthCare X then the member record should be identified as record type 2. To identify the record type 4. For record type 4 only the following fields will be populated Carrier Member SSN From Member SSN Effective Date Person Code