Retiree File Layouts

*Application ID

10

RDS Application ID under which you are submitting this beneficiary for subsidy.
This Application ID must match the Application ID EXACTLY as it appears on the RDS Secure Website, and must correspond to the coverage periods you are submitting.

*SSN

09

Social Security Number (SSN) of the beneficiary for whom you are seeking subsidy. This field may be left blank if a Medicare beneficiary identifier is provided.

• 9 numeric characters. Do not include hyphens or other special characters.
• Cannot contain all zeros.
• First three digits cannot be '666' or '900' - '999'.

*Medicare beneficiary identifier

12

This field may be left blank if the SSN is provided.

May contain:

Medicare Beneficiary Identifier (MBI) of the beneficiary for whom you are seeking subsidy.

• 11 alphanumeric characters.
• Cannot begin with 0.
• Must not start or end with two alphabetic characters.
• Must contain no more than 2 consecutive numbers.
• Must contain no more than 2 consecutive alphabetic characters.
• Must not contain the alphabetic characters S, L, O, I, B, Z.
• Must not contain lowercase letters.
• Do not include hyphens or other special characters.

Medicare Health Insurance Claim Number (HICN) of the beneficiary for whom you are seeking subsidy.

• Valid HICN consists of an SSN followed by an alpha or alphanumeric Beneficiary Identification Code (BIC)
• Characters 1-3 cannot be '000', '666', or '990' - '999'.
• Characters 4-5 cannot be '00'.
• Characters 6-9 cannot be '0000'.
• Character 10 must be a letter.
• Character 11 is dependent on character 10 (can be a space, letter, or number).
• Must not contain lowercase letters.
• Do not include hyphens or other special characters.

Railroad Retirement Board (RRB) number of the beneficiary for whom you are seeking subsidy.

• Up to 12 alphanumeric characters
• 6 or 9 numeric characters preceded by one or more uppercase alpha characters.

*First Name

30

First Name of the beneficiary for whom you are seeking subsidy.

Middle Initial

01

Optional field. Middle Initial of the beneficiary for whom you are seeking subsidy.

*Last Name

40

Last Name of the beneficiary for whom you are seeking subsidy.

*Date of Birth

08

Date of Birth of the beneficiary for whom you are seeking subsidy. Format: CCYYMMDD

*Gender

01

Gender of the beneficiary for whom you are seeking subsidy.
Value '0' = Gender Unknown
Value '1' = Male
Value '2' = Female

*Coverage Effective Date

08

The date the beneficiary's (retiree, spouse, or dependent) coverage under the Plan Sponsor's Prescription Drug Benefit Option begins. Format: CCYYMMDD

*Coverage Termination Date

08

The date the beneficiary's (retiree, spouse, or dependent) coverage under the Plan Sponsor's Prescription Drug Benefit Option ends. Format: CCYYMMDD

This field accepts 99999999 or may be left blank if the date is unknown.

*Unique Benefit Option Identifier

20

Unique Benefit Option Identifier (UBOI) (for example, Rx Group number) corresponding to the benefit under which you are submitting this beneficiary for subsidy.
You MUST reference the UBOI in this field exactly as it was entered on the RDS application, including any leading or trailing zeroes, spaces, punctuation, etc.
Reference the Benefit Option page in the RDS Secure Website if you are unsure what should be entered in this field.

*Relationship to Retiree

02

Relationship to the retiree of the beneficiary for whom you are seeking subsidy.
Value '01' = Self
Value '02' = Spouse
Value '03' = Other

*Transaction Type

03

Value 'ADD' = The beneficiary has either never been submitted for the corresponding RDS Application ID or was submitted but never accepted for a Subsidy Period.
Value 'UPD' = The beneficiary and the corresponding UBOI have been previously accepted for a Subsidy Period for the corresponding RDS application and updated information is being sent.
Value 'DEL' = The beneficiary has been previously approved for subsidy for the corresponding RDS application and Benefit Option. All coverage under this Benefit Option for this Qualifying Covered Retiree (QCR) should be removed.

Record Type

PIC X(01)

Value 'H' = Header Record

Application ID

PIC X(10)

The number assigned to the application by CMS' RDS Center. Includes leading zeroes as needed to completely fill the field.

Creation Date

PIC X(08)

Date the file was created. Format: CCYYMMDD

Creation Time

PIC X(06)

Time the file was created. Format: HHMMSS

Filler

PIC X(175)

Spaces

Record Type

PIC X(01)

Value 'D' = Detail Record

*SSN

PIC X(09)

Social Security Number (SSN) of the beneficiary for whom you are seeking subsidy. This field may contain spaces if a Medicare beneficiary identifier is provided.

• 9 numeric characters. Do not include hyphens or other special characters.
• Cannot contain all zeros.
• First three digits cannot be '666' or '900' - '999'.

*Medicare beneficiary identifier

PIC X(12)

This field may contain spaces if the SSN is provided.

May contain:

Medicare Beneficiary Identifier (MBI) of the beneficiary for whom you are seeking subsidy.

• 11 alphanumeric characters.
• Cannot begin with 0.
• Must not start or end with two alphabetic characters.
• Must contain no more than 2 consecutive numbers.
• Must contain no more than 2 consecutive alphabetic characters.
• Must not contain the alphabetic characters S, L, O, I, B, Z.
• Must not contain lowercase letters.
• Do not include hyphens or other special characters.

Medicare Health Insurance Claim Number (HICN) of the beneficiary for whom you are seeking subsidy.

• Valid HICN consists of an SSN followed by an alpha or alphanumeric Beneficiary Identification Code (BIC)
• Characters 1-3 cannot be '000', '666', or '990' - '999'.
• Characters 4-5 cannot be '00'.
• Characters 6-9 cannot be '0000'.
• Character 10 must be a letter.
• Character 11 is dependent on character 10 (can be a space, letter, or number).
• Must not contain lowercase letters.
• Do not include hyphens or other special characters.

Railroad Retirement Board (RRB) number of the beneficiary for whom you are seeking subsidy.

• Up to 12 alphanumeric characters
• 6 or 9 numeric characters preceded by one or more uppercase alpha characters.

*First Name

PIC X(30)

First Name of the beneficiary for whom you are seeking subsidy.

Middle Initial

PIC X(01)

Optional field. Middle Initial of the beneficiary for whom you are seeking subsidy.

*Last Name

PIC X(40)

Last Name of the beneficiary for whom you are seeking subsidy.

*Date of Birth

PIC X(08)

Date of Birth of the beneficiary for whom you are seeking subsidy. Format: CCYYMMDD

*Gender

PIC X(01)

Gender of the beneficiary for whom you are seeking subsidy.
Value '0' = Gender Unknown
Value '1' = Male
Value '2' = Female

*Coverage Effective Date

PIC X(08)

The date the beneficiary's (retiree, spouse, or dependent) coverage under the Plan Sponsor's Prescription Drug Benefit Option begins. Format: CCYYMMDD

*Coverage Termination Date

PIC X(08)

The date the beneficiary's (retiree, spouse, or dependent) coverage under the Plan Sponsor's Prescription Drug Benefit Option ends. Format: CCYYMMDD

This field accepts 99999999 if the date is unknown.

*Unique Benefit Option Identifier

PIC X(20)

Unique Benefit Option Identifier (UBOI) (for example, Rx Group number) corresponding to the benefit under which you are submitting this beneficiary for subsidy.
You MUST reference the UBOI in this field exactly as it was entered on the RDS application, including any leading or trailing zeroes, spaces, punctuation, etc.
Reference the Benefit Option page in the RDS Secure Website if you are unsure what should be entered in this field.

*Relationship to Retiree

PIC X(02)

Relationship to the retiree of the beneficiary for whom you are seeking subsidy.
Value '01' = Self
Value '02' = Spouse
Value '03' = Other

*Transaction Type

PIC X(03)

Value 'ADD' = The beneficiary has either never been submitted for the corresponding RDS Application ID, or was submitted but never accepted for a Subsidy Period.
Value 'UPD' = The beneficiary and the corresponding UBOI have been previously accepted for a Subsidy Period for the corresponding RDS application and updated information is being sent.
Value 'DEL' = The beneficiary has been previously accepted for a Subsidy Period for the corresponding RDS application and all coverage under this application should be removed.

Record Type

PIC X(01)

Value 'T' = Trailer Record

Application ID

PIC X(10)

The number assigned to the application by CMS' RDS Center. Includes leading zeroes as needed to completely fill the field.

Creation Date

PIC X(08)

Date the file was created. Format: CCYYMMDD

Creation Time

PIC X(06)

Time the file was created. Format: HHMMSS

Number of Detail Records

PIC X(07)

Right justified and includes leading zeros as needed to completely fill the field.

Filler

PIC X(168)

Spaces