CMS Pub. 100-24, ch. 3, § 3.5.2

Item Field Size Position Format Description

1 Medicare Number 12 1-12 Alpha-numeric

The beneficiary HICN, a

nine-position numeric value

followed by an alpha-numeric BIC. If the

beneficiary is entitled under

a RRB claim number, this

field will contain an 11-position alpha-numeric

pseudo HICN. Positions 11

and 12 may be blank. This

field will convey the

Medicare number from the

EDB. CMS will not return

the MBI in this state buy-in

reply.

Item Field Size Position Format Description

2 Surname 24 13-36 Alpha-numeric

A maximum of 24 alpha-numeric characters. The

name will match the surname

on the EDB. Any unused

positions will be blank.

3 Given Name 15 37-51 Alphabetic A maximum of 15 alphabetic

characters. The name will

match the given name on the

EDB. Any unused positions

will be blank.

4 Middle Initial 1 52 Alphabetic An alphabetic character. If

the beneficiary's middle

initial is not reflected on the

EDB, the field will be blank.

5 Sex Code 1 53 Alphabetic A one-position alphabetic

code (male = “M”, female =

“F”).

6 Date of Birth 8 54-61 Numeric An eight-position numeric

field, CCYYMMDD. A date

such as November 1, 1939

will be displayed as

19391101. The date of birth

will match the date of birth

on the EDB.

7 Beneficiary’s Social

Security Number

9 62-70 Numeric A nine-position numeric

field. The SSN will be

extracted from the EDB. This

field may be blank if the EDB

does not currently have the

beneficiary’s SSN.

8 Buy-in Eligibility

Code

2 71-72 Alphabetic/

Blank

Position 71 is a one-position

alphabetic code which

describes the reason the

beneficiary is eligible for

buy-in. Position 72 is

reserved for future

expansion.

Item Field Size Position Format Description

9 Agency Code 3 73-75 Alpha-numeric

A three-position alpha-numeric code that is based

on the state code which

appears in the SSI record

furnished by SSA.

10 Record Identification

Code “A”

1 76 Alphabetic “A” constant. The “A”

identifies this record as an

SSI alert record.

11 Transaction Code 2 77-78 Numeric Positions 77 and 78 will

contain an “86” for an SSI

accretion alert record or an

“87” for an SSI deletion

alert record.

12 Filler 3 79-81 Positions reserved for future

use.

13 SSI Start Date Month

(CCYYMM)

6 82-87 Numeric A six -position numeric field

which contains the beginning

date (year and month) of the

most recent period of SSI

entitlement. SSA furnishes

this date for code 86 records.

14 SSI Stop Date Month

(CCYYMM)

6 88-93 Numeric A six-position numeric field

which contains the ending

date (year and month) of the

last period of SSI

entitlement. SSA furnishes

this date for code 87 records.

15 Medicare Entitlement

Date Month

(CCYYMM)

6 94-99 Numeric A six-position numeric field

which indicates the year and

month in which the

beneficiary became entitled

to Medicare Part B. This

date is provided to assist the

state in determining the

effective date for buy-in

coverage. This field is

applicable to accretion alert

records only.

Item Field Size Position Format Description

16 Filler 27 100-126 Positions reserved for future

use.

17 ZIP Code of

Residence

9 127-135 Numeric A nine-position numeric code

that is reflected on the EDB.

If the EDB only reflects the

five-position zip code, the

five positions will be

reflected and the remaining

positions will be blank.

18 County Code of

Residence

3 136-138 Numeric A three-position numeric

code developed from the SSI

record. SSA furnishes this

code.

19 SSI Living

Arrangement Code

1 139 Alphabetic A one-position alphabetic

code of “D” which indicates

that the beneficiary is a

resident of a Title XIX

institution. This field may be

blank.

20 SSI Status Code

(SISC)

1 140 Alphabetic A one-position alphabetic

code which describes the

beneficiary's SSI status.

21 Agency Client

Identification

Number

20 141-160 Alpha-numeric

The beneficiary’s client (or

Medicaid) identification

number or any other

identifier of the state’s

choice.