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 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 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 other 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 child – use Primary Member’s Indicative Info 3) <blank> 67 904 953 Authorized Representative First Name 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – 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) <blank> 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 child – 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 child – use Primary Member’s Indicative Info 3) 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) <blank> *Zip code will be right 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
Record Type 4 is created for following events: When a dependent becomes a primary member The Carrier, Member SSN, and Person Code will contain the Dependents data and the From Member SSN and Person Code will contain primary member’s data under which this person was a dependent. Primary member becomes dependent The Carrier, Member SSN, and Person Code will contain the new member’s data under whom this person has become dependent and the From Member SSN and Person Code will contain the primary member’s data under which this person was a member. When a dependent moves from one member to another member The Carrier, Member SSN, and Person Code will contain the primary Member’s data and the From Member SSN and Person Code will contain the old member’s data under which this person was a dependent. When the SSN of member is changed The Carrier, Member SSN, and Person Code will contain the new SSN information and the From SSN and Person Code will indicate the old SSN from which they moved. All the other fields for the record type 4 should be blank. Trailer Field Number Start Position Stop Position Field Name Length Data Type Required Format Default Description 1 1 1 Record Type 1 A/N 9 Indicates trailer record 2 2 10 Carrier 9 A/N 3 11 19 Total records 9 N Do NOT include header and trailer = Adds+ Changes+ Total count of records on the file 4 20 28 Total Adds 9 N Number of Add Records. Total count of record type 2 5 29 37 Total Changes 9 N Total Number of Change Records. Total count of record type 3 6 38 46 Total Move History 9 N Total Number of Move Records. Total count of record type 4. 7 47 1500 Filler Contact Information Name Phone E-Mail