Business Rules for Processing Clause Samples

Business Rules for Processing. ‌ 1. The monthly Input File submitted by the PAP is a full-file-replacement file. The PAP’s entire file (participation record) of enrollees must be submitted each month on this file, and it must include any corrections to errors found in the previous month’s file. Each month’s Input File will fully replace the previous month’s Input File. 2. Data-sharing partners are required to continue to include coverage records for 3 years after the termination date of the coverage. 3. A Response File will be returned to each PAP, containing a response record for each input record received. This Response File will also contain a response record for each deleted record (i.e., records that were in the previous Input File that are not in the current Input File). The disposition of the input record will be provided on its corresponding response record, including whether the record was accepted. 4. The BCRC will attempt to create one record for each enrollee record received. 5. The BCRC will not send incomplete records to the MBD. 6. On all PAP input files, the fields required are Medicare ID (HICN or MBI) or SSN, Surname, First Initial, Date of Birth, Sex Code, Network Indicator, Effective Date, Termination Date, Coverage Type Indicator, Insurance Type Indicator, and PAP ID (in both the Header and Trailer). 7. If a new Input File is received by the BCRC, it is compared with the previously submitted Input File. If it is detected that processing the new Input File will delete at least 30% of the records that were accepted in the previous submission, a “threshold error” will be generated and the file will not be processed without additional confirmation from the data-sharing partner. The PAP will be asked to verify the high number of delete records in the current submission.
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Business Rules for Processing. ‌ 1. The monthly Input File submitted by the partner is a full-file-replacement file. The partner’s entire file (participation record) of enrollees must be submitted each month on this file, and it must include any corrections to errors found in the previous month’s file. Each month’s Input File will fully replace the previous month’s Input File. 2. Data-sharing partners are required to continue to include coverage records for 3 years after the termination date of the coverage. 3. A Response File will be returned to each partner, containing a response record for each input record received. This Response File will also contain a response record for each deleted record (i.e., records that were in the previous Input File that are not in the current Input File). The disposition of the input record will be provided on its corresponding response record, including whether the record was accepted. 4. The BCRC will attempt to create one record for each enrollee record received. 5. The BCRC will not send incomplete records to the MBD. Consequently, incomplete drug records will also not get sent to the Transaction Facilitation Contractor (ADAPs and SPAPs only). 6. On all partner input files, the fields required are Medicare ID (HICN or MBI) or SSN, Surname, First Initial, Date of Birth, Sex Code, Network Indicator, Effective Date, Termination Date, Coverage Type Indicator, Insurance Type Indicator, and SPAP ID (in both the Header and Trailer). 7. If a new Input File is received by the BCRC, it is compared with the previously submitted Input File. If it is detected that processing the new Input File will delete at least 30% of the records that were accepted in the previous submission, a “threshold error” will be generated and the file will not be processed without additional confirmation from the data-sharing partner. The partner will be asked to verify the high number of delete records in the current submission. 8. LIS information will be returned for all qualified SPAP records. Qualified SPAPs are indicated by an Insurance Types of Q. 9. Non-qualified SPAP records will not receive LIS information. Non-qualified SPAPS are indicated by an Insurance Type of N. 10. Responses will be returned with enrollment and LIS information regardless of whether this information has changed since the last submission. 11. If the record cannot be matched in the MBD, the BCRC will return a disposition code of “51”: Not Found, without any enrollment or LIS data, even if that record is ma...
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