Common use of Attachment E Clause in Contracts

Attachment E. ‌ 3.4.1 E: VDSA Non-MSP Response File Layout – 500 bytes‌ 1. Filler 4 1-4 BCRC use. 2. SSN 9 5-13 Beneficiary’s SSN. Included for Action Types D, S, and N. Field will contain either the SSN that matched, or a corrected SSN based on a Medicare ID match. 3. Medicare ID 12 14-25 Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]). Included for Action Types D, S, and N. If the information submitted on the input record was matched to a Medicare beneficiary, this field will contain the most current Medicare ID for the beneficiary. 4. Covered Individual’s Surname 6 26-31 Beneficiary’s Last Name. Included for Action Types D, S, and N. Field will contain either the name supplied or corrected name from BCRC database. 5. Beneficiary First Initial 1 32 Beneficiary’s First Initial. Included for Action Types D, S, and N. Field will contain either the value supplied or corrected value from BCRC database. 6. Beneficiary Middle Initial 1 33 Beneficiary’s Middle Initial. Included for Action Types D, S, and N. Field will contain the value supplied. 7. Beneficiary Date of Birth 8 34-41 Beneficiary’s DOB (CCYYMMDD). Included for Action Types D, S, and N. Field will contain either the value supplied or a corrected value from BCRC database. 8. Beneficiary Sex Code 1 42 Beneficiary’s Sex: 0 = Unknown 1 = Male 2 = Female Included for Action Types D, S, and N Field will contain either the value supplied or a corrected value from BCRC database. 9. Group Health Plan Number 20 43-62 GHP Number assigned by Payer for Action Type D, or, Unique Benefit Option Identifier, as defined by the RDS Center, and assigned by Payer for Action Types S. Included for Action Types D and S. Field will contain the value supplied on input. 10. Individual Policy number 17 63-79 Policy Number. Included for Action Types D and S. Field will contain the value supplied on input. 11. Effective Date 8 80-87 Start Date of Beneficiary’s Insurance Coverage. (CCYYMMDD). Included for Action Types D and S. Field will contain the effective date applied to the CWF and/or Drug record. 12. Termination Date 8 88-95 End Date of Beneficiary’s Insurance Coverage. (CCYYMMDD) All zeros if open-ended or non-applicable. Included for Action Types D and S. Field will contain the term date applied to the CWF and/or Drug record. 13. Filler 10 96-105 Unused field. Space filled. 14. Rx Insured ID number ▇▇ ▇▇▇-▇▇▇ Insured’s Identification Number. Included for Action Types D and S. Field will contain the value supplied on input. 15. Rx Group Number ▇▇ ▇▇▇-▇▇▇ Rx Group Health Plan Number assigned by payer for Action Type D, or Unique Benefit Option Identifier assigned by payer for Action Type S. Included for Action Types D and S. Field will contain a value supplied on input. 16. Rx PCN ▇▇ ▇▇▇-▇▇▇ Processor Control Number. Included for Action Types D and S. Field will contain the value supplied on input. 17. Rx BIN Number ▇ ▇▇▇-▇▇▇ Benefit International Number. Included for Action Types D and S. Field will contain the value supplied on input. 18. Rx Toll Free Number ▇▇ ▇▇▇-▇▇▇ Toll Free Number, with extension. Included for Action Types D and S. Field will contain the value supplied on input. 19. Person Code ▇ ▇▇▇-▇▇▇ Person Code the Plan uses to identify specific individuals on a policy. Included for Action Types D and S. Defaults to ‘001’ for D records if not provided. 20. Relationship Code ▇ ▇▇▇-▇▇▇ Beneficiary’s Relation to active employee: ‘01’ = Beneficiary is Policy Holder ‘02’ = Spouse or Common Law Spouse ‘03’ = Child ‘04’ = Other ‘20’ = Domestic Partner Included for Action Types D and S. Field will contain a value supplied on input. 21. Partner Assigned DCN ▇▇ ▇▇▇-▇▇▇ The Document Control Number assigned by the VDSA partner. Included for Action Types D, S, and N. Field will contain the value supplied on input. 22. BCRC DCN ▇▇ ▇▇▇-▇▇▇ BCRC Document Control Number. Included for Action Types D, S, and N. Field will contain DCN created for this record by the BCRC. 23. Original Action Type 1 210 Type of Maintenance: ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types D, S, and N. Field will contain the value supplied on input. 24. Action Type 1 211 Type of Maintenance; applied by BCRC. (BCRC may change an S Action Type to a D if RDS rejects the record due to Part D enrollment): ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types D, S and N. BCRC supplied value. 25. Transaction Type 1 212 Type of Maintenance: ‘0’ = Add Record ‘1’ = Delete record ‘2’ = Update record Included for Action Types D and S. Field will indicate type of maintenance applied. 26. Coverage Type 1 213 Type of Coverage: ‘U’ = Drug Only (network Rx) ‘V’ = Drug with Major Medical (non-network Rx) ‘W’ = Comprehensive Coverage - Hosp/Med/Drug (network Rx) ‘X’ = Hospital and Drug (network Rx) ‘Y’ = Medical and Drug (network Rx) ‘Z’ = Health Reimbursement Account. (non-network Rx) ‘4’ = Comprehensive Coverage - Hosp/Med/Drug (non- network Rx) ‘5’ = Hospital and Drug (non-network Rx) ‘6’ = Medical and Drug (non-network Rx) Included for Action Types D and S. Field will contain value supplied on input. 27. Filler 1 214 Unused Field. 28. Reason for Medicare Entitlement 1 215 Reason for Medicare Entitlement: ‘A’ = Aged ‘B’ = ESRD ‘G’ = Disabled Included for Action Types D and N. BCRC supplied value. 29. S Disposition Code ▇ ▇▇▇-▇▇▇ Result from RDS processing. Included for records submitted with S Action Types. RDS supplied value converted to VDSA specific S Disposition Code. Refer to Field 54 (RDS Reason Code) for actual RDS Reason Code as supplied by the RDS Center. 30. S Disposition Date ▇ ▇▇▇-▇▇▇ Date of BENEMSTR/MBD or RDS Result for S disposition code. (CCYYMMDD). Included for records with an original S. RDS supplied value. 31. Current Medicare Part A Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part A Medicare Coverage. (CCYYMMDD) Included for all action types. BCRC supplied value. 32. Current Medicare Part A Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part A Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 33. Current Medicare Part B Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. 34. Current Medicare Part B Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 35. Part D Eligibility Start Date ▇ ▇▇▇-▇▇▇ Earliest date that beneficiary is eligible to enroll in Part D – Refer to Field 42 for the Part D Plan Enrollment Date. (CCYYMMDD). Included for all action types. BCRC supplied value. 36. Part D Eligibility Stop Date* ▇ ▇▇▇-▇▇▇ Date the Beneficiary is no longer eligible to receive Part D Benefits – Refer to Filed 43 for the Part D Plan Termination Date. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 37. Medicare Beneficiary Date of Death* ▇ ▇▇▇-▇▇▇ Medicare beneficiary Date of Death (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if not applicable. 38. Current Medicare Part C Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Part C Plan in which the beneficiary is enrolled. Included for all action types. BCRC supplied value. 39. Current Medicare Part C Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Beneficiary’s current Medicare Part C Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 40. Current Medicare Part C Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of the coverage provided by the Beneficiary’s current Medicare Part C Plan. Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 41. Current Medicare Part D Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Medicare Part D Plan in which the Beneficiary is enrolled. Included for all action types. 42. Current Medicare Part D Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Current Medicare Part D Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 43. Current Medicare Part D Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of coverage provided by the current Medicare Part D Plan. (CCYYMMDD) Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 44. Error Code 1 4 324-327 Error Code 1 – Contains SP or RX error codes from COC or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 45. Error Code 2 4 328-331 Error Code 2 – Contains SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 46. Error Code 3 4 332-335 Error Code 3 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 47. Error Code 4 4 336-339 Error Code 4 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 48. D/N Disposition Code ▇ ▇▇▇-▇▇▇ Result from processing of an action type D or N record. This will also be used to provide a disposition for D records converted from S records – in such case, the S disposition (Field 30) will also be populated. Code supplied by the COB. 49. D/N Disposition Date ▇ ▇▇▇-▇▇▇ Processing date associated with the D/N disposition code. (CCYYMMDD) Supplied by the COB.

Attachment E. ‌ 3.4.1 E: VDSA Non-MSP Response File Layout – 500 bytes‌ 1. Filler 4 1-4 BCRC use. 2. SSN 9 5-13 Beneficiary’s SSN. Included for Action Types action types D, S, and N. Field will contain either the SSN that matched, or a corrected SSN based on a Medicare ID match. 3. Medicare ID 12 14-25 Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]). Included for Action Types action types D, S, and N. If the information submitted on the input record was matched to a Medicare beneficiary, this field will contain the most current Medicare ID for the beneficiary. 4. Covered Individual’s Surname 6 26-31 Beneficiary’s Last Name. Included for Action Types action types D, S, and N. Field will contain either the name supplied or corrected name from BCRC database. 5. Beneficiary First Initial 1 32 Beneficiary’s First Initial. Included for Action Types action types D, S, and N. Field will contain either the value supplied or corrected value from BCRC database. 6. Beneficiary Middle Initial 1 33 Beneficiary’s Middle Initial. Included for Action Types action types D, S, and N. Field will contain the value supplied. 7. Beneficiary Date of Birth 8 34-41 Beneficiary’s DOB (CCYYMMDD). Included for Action Types action types D, S, and N. Field will contain either the value supplied or a corrected value from BCRC database. 8. Beneficiary Sex Code 1 42 Beneficiary’s Sex: 0 = Unknown 1 = Male 2 = Female Included for Action Types action types D, S, and N Field will contain either the value supplied or a corrected value from BCRC database. 9. Group Health Plan Number 20 43-62 GHP Number assigned by Payer for Action Type action type ‘D, ,’ or, Unique Benefit Option Identifier, as defined by the RDS Center, and assigned by Payer for Action Types S. action type ‘S.’ Included for Action Types action types D and S. Field will contain the value supplied on input. 10. Individual Policy number 17 63-79 Policy Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 11. Effective Date 8 80-87 Start Date of Beneficiary’s Insurance Coverage. (CCYYMMDD). Included for Action Types action types D and S. Field will contain the effective date applied to the CWF and/or Drug record. 12. Termination Date 8 88-95 End Date of Beneficiary’s Insurance Coverage. (CCYYMMDD) All zeros if open-ended or non-applicable. Included for Action Types action types D and S. Field will contain the term date applied to the CWF and/or Drug record. 13. Filler National Health Plan ID 10 96-105 Unused fieldNational Health Plan Identifier. Space filledFor action types D and S. (For Future Use). 14. Rx Insured ID number ▇▇ ▇▇▇-▇▇▇ Insured’s Identification Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 15. Rx Group Number ▇▇ ▇▇▇-▇▇▇ Rx Group Health Plan Number assigned by payer for Action Type action type ‘D, ,’ or Unique Benefit Option Identifier assigned by payer for Action Type S. action type ‘S.’ Included for Action Types action types D and S. Field will contain a value supplied on input. 16. Rx PCN ▇▇ ▇▇▇-▇▇▇ Processor Control Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 17. Rx BIN Number ▇ ▇▇▇-▇▇▇ Benefit International Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 18. Rx Toll Free Number ▇▇ ▇▇▇-▇▇▇ Toll Free Number, with extension. Included for Action Types action types D and S. Field will contain the value supplied on input. 19. Person Code ▇ ▇▇▇-▇▇▇ Person Code the Plan uses to identify specific individuals on a policy. Included for Action Types action types D and S. Defaults to ‘001’ for D records if not provided. 20. Relationship Code ▇ ▇▇▇-▇▇▇ Beneficiary’s Relation to active employee: ‘01’ = Beneficiary is Policy Holder ‘02’ = Spouse or Common Law Spouse ‘03’ = Child ‘04’ = Other ‘'20’ ' = Domestic Partner Included for Action Types action types D and S. Field will contain a value supplied on input. 21. Partner Assigned DCN ▇▇ ▇▇▇-▇▇▇ The Document Control Number assigned by the VDSA partner. Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 22. BCRC DCN ▇▇ ▇▇▇-▇▇▇ BCRC Document Control Number. Included for Action Types action types D, S, and N. Field will contain DCN created for this record by the BCRC. 23. Original Action Type 1 210 Type of Maintenance: ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 24. Action Type 1 211 Type of Maintenance; applied by BCRC. (BCRC may change an S Action Type to a D if RDS rejects the record due to Part D enrollment): ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S and N. BCRC supplied value. 25. Transaction Type 1 212 Type of Maintenance: ‘0’ = Add Record ‘1’ = Delete record ‘2’ = Update record Included for Action Types action types D and S. Field will indicate type of maintenance applied. 26. Coverage Type 1 213 Type of Coverage: ‘U’ = Drug Only (network Rx) ‘V’ = Drug with Major Medical (non-network Rx) ‘W’ = Comprehensive Coverage - Hosp/Med/Drug (network Rx) ‘X’ = Hospital and Drug (network Rx) ‘Y’ = Medical and Drug (network Rx) ‘Z’ = Health Reimbursement Account. (non-network Rx) ‘4’ = Comprehensive Coverage - Hosp/Med/Drug (non- network Rx) ‘5’ = Hospital and Drug (non-network Rx) ‘6’ = Medical and Drug (non-network Rx) Included for Action Types action types D and S. Field will contain value supplied on input. 27. Filler 1 214 Unused Field. 28. Reason for Medicare Entitlement 1 215 Reason for Medicare Entitlement: ‘A’ = Aged ‘B’ = ESRD ‘G’ = Disabled Included for Action Types action types D and N. BCRC supplied value. 29. S Disposition Code ▇ ▇▇▇-▇▇▇ Result from RDS processing. Included for records submitted with S Action Types‘S’ action types. RDS supplied value converted to VDSA specific S Disposition Code. Refer to Field 54 (RDS Reason Code) for actual RDS Reason Code as supplied by the RDS Center. 30. S Disposition Date ▇ ▇▇▇-▇▇▇ Date of BENEMSTR/MBD or RDS Result for S disposition code. (CCYYMMDD). Included for records with an original S. S action types. RDS supplied value. 31. Current Medicare Part A Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part A Medicare Coverage. (CCYYMMDD) Included for all action types. BCRC supplied value. 32. Current Medicare Part A Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part A Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 33. Current Medicare Part B Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. 34. Current Medicare Part B Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 35. Part D Eligibility Start Date ▇ ▇▇▇-▇▇▇ Earliest date that beneficiary is eligible to enroll in Part D – Refer to Field 42 for the Part D Plan Enrollment Date. (CCYYMMDD). Included for all action types. BCRC supplied value. 36. Part D Eligibility Stop Date* ▇ ▇▇▇-▇▇▇ Date the Beneficiary is no longer eligible to receive Part D Benefits – Refer to Filed 43 for the Part D Plan Termination Date. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 37. Medicare Beneficiary Date of Death* ▇ ▇▇▇-▇▇▇ Medicare beneficiary Beneficiary Date of Death (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if not applicable. 38. Current Medicare Part C Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Part C Plan in which the beneficiary is enrolled. Included for all action types. BCRC supplied value. 39. Current Medicare Part C Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Beneficiary’s current Medicare Part C Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 40. Current Medicare Part C Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of the coverage provided by the Beneficiary’s current Medicare Part C Plan. Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 41. Current Medicare Part D Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Medicare Part D Plan in which the Beneficiary is enrolled. Included for all action types. 42. Current Medicare Part D Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Current Medicare Part D Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 43. Current Medicare Part D Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of coverage provided by the current Medicare Part D Plan. (CCYYMMDD) Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 44. Error Code 1 4 324-327 Error Code 1 – Contains SP or RX error codes from COC or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 45. Error Code 2 4 328-331 Error Code 2 – Contains SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 46. Error Code 3 4 332-335 Error Code 3 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 47. Error Code 4 4 336-339 Error Code 4 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 48. D/N Disposition Code ▇ ▇▇▇-▇▇▇ Result from processing of an action type D or N record. This will also be used to provide a disposition for D records converted from S records – in such case, the S disposition (Field 30) will also be populated. Code supplied by the COB. 49. D/N Disposition Date ▇ ▇▇▇-▇▇▇ Processing date associated with the D/N disposition code. (CCYYMMDD) Supplied by the COB.

Attachment E. ‌ 3.4.1 E: VDSA Non-MSP Response File Layout – 500 bytes‌ 1. Filler 4 1-4 BCRC use. 2. SSN 9 5-13 Beneficiary’s SSN. Included for Action Types action types D, S, and N. Field will contain either the SSN that matched, or a corrected SSN based on a Medicare ID match. 3. Medicare ID 12 14-25 Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]). Included for Action Types action types D, S, and N. If the information submitted on the input record was matched to a Medicare beneficiary, this field will contain the most current Medicare ID for the beneficiary. 4. Covered Individual’s Surname 6 26-31 Beneficiary’s Last Name. Included for Action Types action types D, S, and N. Field will contain either the name supplied or corrected name from BCRC database. 5. Beneficiary First Initial 1 32 Beneficiary’s First Initial. Included for Action Types action types D, S, and N. Field will contain either the value supplied or corrected value from BCRC database. 6. Beneficiary Middle Initial 1 33 Beneficiary’s Middle Initial. Included for Action Types action types D, S, and N. Field will contain the value supplied. 7. Beneficiary Date of Birth 8 34-41 Beneficiary’s DOB (CCYYMMDD). Included for Action Types action types D, S, and N. Field will contain either the value supplied or a corrected value from BCRC database. 8. Beneficiary Sex Code 1 42 Beneficiary’s Sex: 0 = Unknown 1 = Male 2 = Female Included for Action Types action types D, S, and N Field will contain either the value supplied or a corrected value from BCRC database. 9. Group Health Plan Number 20 43-62 GHP Number assigned by Payer for Action Type action type ‘D, ,’ or, Unique Benefit Option Identifier, as defined by the RDS Center, and assigned by Payer for Action Types S. action type ‘S.’ Included for Action Types action types D and S. Field will contain the value supplied on input. 10. Individual Policy number 17 63-79 Policy Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 11. Effective Date 8 80-87 Start Date of Beneficiary’s Insurance Coverage. (CCYYMMDD). Included for Action Types action types D and S. Field will contain the effective date applied to the CWF and/or Drug record. 12. Termination Date 8 88-95 End Date of Beneficiary’s Insurance Coverage. (CCYYMMDD) All zeros if open-ended or non-applicable. Included for Action Types action types D and S. Field will contain the term date applied to the CWF and/or Drug record. 13. Filler 10 96-105 Unused field. Space filled. 14. Rx Insured ID number ▇▇ ▇▇▇-▇▇▇ Insured’s Identification Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 15. Rx Group Number ▇▇ ▇▇▇-▇▇▇ Rx Group Health Plan Number assigned by payer for Action Type action type ‘D, ,’ or Unique Benefit Option Identifier assigned by payer for Action Type S. action type ‘S.’ Included for Action Types action types D and S. Field will contain a value supplied on input. 16. Rx PCN ▇▇ ▇▇▇-▇▇▇ Processor Control Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 17. Rx BIN Number ▇ ▇▇▇-▇▇▇ Benefit International Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 18. Rx Toll Free Number ▇▇ ▇▇▇-▇▇▇ Toll Free Number, with extension. Included for Action Types action types D and S. Field will contain the value supplied on input. 19. Person Code ▇ ▇▇▇-▇▇▇ Person Code the Plan uses to identify specific individuals on a policy. Included for Action Types action types D and S. Defaults to ‘001’ for D records if not provided. 20. Relationship Code ▇ ▇▇▇-▇▇▇ Beneficiary’s Relation to active employee: ‘01’ = Beneficiary is Policy Holder ‘02’ = Spouse or Common Law Spouse ‘03’ = Child ‘04’ = Other ‘'20’ ' = Domestic Partner Included for Action Types action types D and S. Field will contain a value supplied on input. 21. Partner Assigned DCN ▇▇ ▇▇▇-▇▇▇ The Document Control Number assigned by the VDSA partner. Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 22. BCRC DCN ▇▇ ▇▇▇-▇▇▇ BCRC Document Control Number. Included for Action Types action types D, S, and N. Field will contain DCN created for this record by the BCRC. 23. Original Action Type 1 210 Type of Maintenance: ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 24. Action Type 1 211 Type of Maintenance; applied by BCRC. (BCRC may change an S Action Type to a D if RDS rejects the record due to Part D enrollment): ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S and N. BCRC supplied value. 25. Transaction Type 1 212 Type of Maintenance: ‘0’ = Add Record ‘1’ = Delete record ‘2’ = Update record Included for Action Types action types D and S. Field will indicate type of maintenance applied. 26. Coverage Type 1 213 Type of Coverage: ‘U’ = Drug Only (network Rx) ‘V’ = Drug with Major Medical (non-network Rx) ‘W’ = Comprehensive Coverage - Hosp/Med/Drug (network Rx) ‘X’ = Hospital and Drug (network Rx) ‘Y’ = Medical and Drug (network Rx) ‘Z’ = Health Reimbursement Account. (non-network Rx) ‘4’ = Comprehensive Coverage - Hosp/Med/Drug (non- network Rx) ‘5’ = Hospital and Drug (non-network Rx) ‘6’ = Medical and Drug (non-network Rx) Included for Action Types action types D and S. Field will contain value supplied on input. 27. Filler 1 214 Unused Field. 28. Reason for Medicare Entitlement 1 215 Reason for Medicare Entitlement: ‘A’ = Aged ‘B’ = ESRD ‘G’ = Disabled Included for Action Types action types D and N. BCRC supplied value. 29. S Disposition Code ▇ ▇▇▇-▇▇▇ Result from RDS processing. Included for records submitted with S Action Types‘S’ action types. RDS supplied value converted to VDSA specific S Disposition Code. Refer to Field 54 (RDS Reason Code) for actual RDS Reason Code as supplied by the RDS Center. 30. S Disposition Date ▇ ▇▇▇-▇▇▇ Date of BENEMSTR/MBD or RDS Result for S disposition code. (CCYYMMDD). Included for records with an original S. S action types. RDS supplied value. 31. Current Medicare Part A Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part A Medicare Coverage. (CCYYMMDD) Included for all action types. BCRC supplied value. 32. Current Medicare Part A Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part A Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 33. Current Medicare Part B Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. 34. Current Medicare Part B Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 35. Part D Eligibility Start Date ▇ ▇▇▇-▇▇▇ Earliest date that beneficiary is eligible to enroll in Part D – Refer to Field 42 for the Part D Plan Enrollment Date. (CCYYMMDD). Included for all action types. BCRC supplied value. 36. Part D Eligibility Stop Date* ▇ ▇▇▇-▇▇▇ Date the Beneficiary is no longer eligible to receive Part D Benefits – Refer to Filed 43 for the Part D Plan Termination Date. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 37. Medicare Beneficiary Date of Death* ▇ ▇▇▇-▇▇▇ Medicare beneficiary Date of Death (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if not applicable. 38. Current Medicare Part C Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Part C Plan in which the beneficiary is enrolled. Included for all action types. BCRC supplied value. 39. Current Medicare Part C Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Beneficiary’s current Medicare Part C Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 40. Current Medicare Part C Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of the coverage provided by the Beneficiary’s current Medicare Part C Plan. Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 41. Current Medicare Part D Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Medicare Part D Plan in which the Beneficiary is enrolled. Included for all action types. 42. Current Medicare Part D Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Current Medicare Part D Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 43. Current Medicare Part D Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of coverage provided by the current Medicare Part D Plan. (CCYYMMDD) Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 44. Error Code 1 4 324-327 Error Code 1 – Contains SP or RX error codes from COC or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 45. Error Code 2 4 328-331 Error Code 2 – Contains SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 46. Error Code 3 4 332-335 Error Code 3 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 47. Error Code 4 4 336-339 Error Code 4 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 48. D/N Disposition Code ▇ ▇▇▇-▇▇▇ Result from processing of an action type D or N record. This will also be used to provide a disposition for D records converted from S records – in such case, the S disposition (Field 30) will also be populated. Code supplied by the COB. 49. D/N Disposition Date ▇ ▇▇▇-▇▇▇ Processing date associated with the D/N disposition code. (CCYYMMDD) Supplied by the COB.

Attachment E. ‌ 3.4.1 E: VDSA Non-MSP Response File Layout – 500 bytes‌ 1. Filler 4 1-4 BCRC use. 2. SSN 9 5-13 Beneficiary’s SSN. Included for Action Types action types D, S, and N. Field will contain either the SSN that matched, or a corrected SSN based on a Medicare ID match. 3. Medicare ID 12 14-25 Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]). Included for Action Types action types D, S, and N. If the information submitted on the input record was matched to a Medicare beneficiary, this field will contain the most current Medicare ID for the beneficiary. 4. Covered Individual’s Surname 6 26-31 Beneficiary’s Last Name. Included for Action Types action types D, S, and N. Field will contain either the name supplied or corrected name from BCRC database. 5. Beneficiary First Initial 1 32 Beneficiary’s First Initial. Included for Action Types action types D, S, and N. Field will contain either the value supplied or corrected value from BCRC database. 6. Beneficiary Middle Initial 1 33 Beneficiary’s Middle Initial. Included for Action Types action types D, S, and N. Field will contain the value supplied. 7. Beneficiary Date of Birth 8 34-41 Beneficiary’s DOB (CCYYMMDD). Included for Action Types action types D, S, and N. Field will contain either the value supplied or a corrected value from BCRC database. 8. Beneficiary Sex Code 1 42 Beneficiary’s Sex: 0 = Unknown 1 = Male 2 = Female Included for Action Types action types D, S, and N Field will contain either the value supplied or a corrected value from BCRC database. 9. Group Health Plan Number 20 43-62 GHP Number assigned by Payer for Action Type action type ‘D, ,’ or, Unique Benefit Option Identifier, as defined by the RDS Center, and assigned by Payer for Action Types S. action type ‘S.’ Included for Action Types action types D and S. Field will contain the value supplied on input. 10. Individual Policy number 17 63-79 Policy Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 11. Effective Date 8 80-87 Start Date of Beneficiary’s Insurance Coverage. (CCYYMMDD). Included for Action Types action types D and S. Field will contain the effective date applied to the CWF and/or Drug record. 12. Termination Date 8 88-95 End Date of Beneficiary’s Insurance Coverage. (CCYYMMDD) All zeros if open-ended or non-applicable. Included for Action Types action types D and S. Field will contain the term date applied to the CWF and/or Drug record. 13. Filler 10 96-105 Unused field. Space filled. 14. Rx Insured ID number ▇▇ ▇▇▇-▇▇▇ Insured’s Identification Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 15. Rx Group Number ▇▇ ▇▇▇-▇▇▇ Rx Group Health Plan Number assigned by payer for Action Type action type ‘D, ,’ or Unique Benefit Option Identifier assigned by payer for Action Type S. action type ‘S.’ Included for Action Types action types D and S. Field will contain a value supplied on input. 16. Rx PCN ▇▇ ▇▇▇-▇▇▇ Processor Control Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 17. Rx BIN Number ▇ ▇▇▇-▇▇▇ Benefit International Number. Included for Action Types action types D and S. Field will contain the value supplied on input. 18. Rx Toll Free Number ▇▇ ▇▇▇-▇▇▇ Toll Free Number, with extension. Included for Action Types action types D and S. Field will contain the value supplied on input. 19. Person Code ▇ ▇▇▇-▇▇▇ Person Code the Plan uses to identify specific individuals on a policy. Included for Action Types action types D and S. Defaults to ‘001’ for D records if not provided. 20. Relationship Code ▇ ▇▇▇-▇▇▇ Beneficiary’s Relation to active employee: ‘01’ = Beneficiary is Policy Holder ‘02’ = Spouse or Common Law Spouse ‘03’ = Child ‘04’ = Other ‘'20’ ' = Domestic Partner Included for Action Types action types D and S. Field will contain a value supplied on input. 21. Partner Assigned DCN ▇▇ ▇▇▇-▇▇▇ The Document Control Number assigned by the VDSA partner. Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 22. BCRC DCN ▇▇ ▇▇▇-▇▇▇ BCRC Document Control Number. Included for Action Types action types D, S, and N. Field will contain DCN created for this record by the BCRC. 23. Original Action Type 1 210 Type of Maintenance: ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S, and N. Field will contain the value supplied on input. 24. Action Type 1 211 Type of Maintenance; applied by BCRC. (BCRC may change an S Action Type to a D if RDS rejects the record due to Part D enrollment): ‘D’ = Drug Reporting record ‘S’ = Subsidy Reporting record ‘N’ = Non-Reporting record Included for Action Types action types D, S and N. BCRC supplied value. 25. Transaction Type 1 212 Type of Maintenance: ‘0’ = Add Record ‘1’ = Delete record ‘2’ = Update record Included for Action Types action types D and S. Field will indicate type of maintenance applied. 26. Coverage Type 1 213 Type of Coverage: ‘U’ = Drug Only (network Rx) ‘V’ = Drug with Major Medical (non-network Rx) ‘W’ = Comprehensive Coverage - Hosp/Med/Drug (network Rx) ‘X’ = Hospital and Drug (network Rx) ‘Y’ = Medical and Drug (network Rx) ‘Z’ = Health Reimbursement Account. (non-network Rx) ‘4’ = Comprehensive Coverage - Hosp/Med/Drug (non- network Rx) ‘5’ = Hospital and Drug (non-network Rx) ‘6’ = Medical and Drug (non-network Rx) Included for Action Types action types D and S. Field will contain value supplied on input. 27. Filler 1 214 Unused Field. 28. Reason for Medicare Entitlement 1 215 Reason for Medicare Entitlement: ‘A’ = Aged ‘B’ = ESRD ‘G’ = Disabled Included for Action Types action types D and N. BCRC supplied value. 29. S Disposition Code ▇ ▇▇▇-▇▇▇ Result from RDS processing. Included for records submitted with S Action Types‘S’ action types. RDS supplied value converted to VDSA specific S Disposition Code. Refer to Field 54 (RDS Reason Code) for actual RDS Reason Code as supplied by the RDS Center. 30. S Disposition Date ▇ ▇▇▇-▇▇▇ Date of BENEMSTR/MBD or RDS Result for S disposition code. (CCYYMMDD). Included for records with an original S. S action types. RDS supplied value. 31. Current Medicare Part A Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part A Medicare Coverage. (CCYYMMDD) Included for all action types. BCRC supplied value. 32. Current Medicare Part A Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part A Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 33. Current Medicare Part B Effective Date ▇ ▇▇▇-▇▇▇ Effective Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. 34. Current Medicare Part B Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of Part B Medicare Coverage. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 35. Part D Eligibility Start Date ▇ ▇▇▇-▇▇▇ Earliest date that beneficiary is eligible to enroll in Part D – Refer to Field 42 for the Part D Plan Enrollment Date. (CCYYMMDD). Included for all action types. BCRC supplied value. 36. Part D Eligibility Stop Date* ▇ ▇▇▇-▇▇▇ Date the Beneficiary is no longer eligible to receive Part D Benefits – Refer to Filed 43 for the Part D Plan Termination Date. (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 37. Medicare Beneficiary Date of Death* ▇ ▇▇▇-▇▇▇ Medicare beneficiary Beneficiary Date of Death (CCYYMMDD). Included for all action types. BCRC supplied value. * All zeros if not applicable. 38. Current Medicare Part C Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Part C Plan in which the beneficiary is enrolled. Included for all action types. BCRC supplied value. 39. Current Medicare Part C Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Beneficiary’s current Medicare Part C Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 40. Current Medicare Part C Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of the coverage provided by the Beneficiary’s current Medicare Part C Plan. Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 41. Current Medicare Part D Plan Contractor Number ▇ ▇▇▇-▇▇▇ Contractor Number of the current Medicare Part D Plan in which the Beneficiary is enrolled. Included for all action types. 42. Current Medicare Part D Plan Enrollment Date ▇ ▇▇▇-▇▇▇ Effective Date of coverage provided by the Current Medicare Part D Plan. (CCYYMMDD). Included for all action types. BCRC supplied value. 43. Current Medicare Part D Plan Termination Date* ▇ ▇▇▇-▇▇▇ Termination Date of coverage provided by the current Medicare Part D Plan. (CCYYMMDD) Included for all action types. BCRC supplied value. * All zeros if open-ended or not applicable. 44. Error Code 1 4 324-327 Error Code 1 – Contains SP or RX error codes from COC or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 45. Error Code 2 4 328-331 Error Code 2 – Contains SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 46. Error Code 3 4 332-335 Error Code 3 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 47. Error Code 4 4 336-339 Error Code 4 – May contain SP or RX error codes from COB or RDS processing if applicable. COB supplied value for D/N records. RDS supplied value for S records. 48. D/N Disposition Code ▇ ▇▇▇-▇▇▇ Result from processing of an action type D or N record. This will also be used to provide a disposition for D records converted from S records – in such case, the S disposition (Field 30) will also be populated. Code supplied by the COB. 49. D/N Disposition Date ▇ ▇▇▇-▇▇▇ Processing date associated with the D/N disposition code. (CCYYMMDD) Supplied by the COB.