BASIC (05-11)

A. Background

The MADCAP paragraphs have been designed to provide non technical explanations of the most common actions affecting the claim of a beneficiary.

B. Kinds of paragraphs used in MADCAP notices

The following kinds of paragraphs are used in MADCAP letters:

1. Automatically generated paragraphs

Automatically generated paragraphs are based on the category of letter generated or requested.

2. Requested paragraphs

When a Claims Representative (CR), Claims Authorizer (CA) or Benefit Authorizer (BA) requests a paragraph, the technician responsible for the notice must record the paragraph identification code (UTI) and Fill-ins, if applicable.

3. Dictated text

Technicians input the dictated text via the NOT screens in MACADE.

For a complete explanation on how to use dictated text in MADCAP notices see NL 00719.025.

4. MADCAP paragraphs in manually prepared notice

When MADCAP cannot produce a notice because the situation is too complicated or rare, the technician must manually prepare the notice.

Technicians can use MADCAP paragraphs in AURORA as long as they provide a clear and complete explanation of the action taken. The technician must provide Fill-ins, when required.

5. Procedure for use of Medicare Part C and or Part D MADCAP paragraphs

Notices involving Medicare Part C or Part D require special processing routines. When a technician needs to complete check paragraphs manually and Part C or Part D entitlement is involved, the technician will now have to wait until the next day when the MBR is updated to provide correct payment information for any UTI that requires a payment amount. In the event of Part C or Part D, the technician will not know the amount of Part C or Part D that is being deducted from the payment until DED/ADD data is built and updated to the MBR.

In DED/ADD data on the MBR, the date shown in the data element "UPDATED" will match the DRD (Debit Run Date) in benefit data. The technician obtains needed information from the DED/ADD data and completes the notice by matching the DRD with the date shown in the data element "UPDATED".

In the data element "ITEM” in DED/ADD data, all net checks payable to the beneficiary are 999 items. All deduction events have their own unique item number. For instance, Part C arrearages is item 460. Item 455 represents Part C deductions for ongoing monthly premiums. All addition events also have their own item numbers. The chart below contains the corresponding FACT query display for Items 445, 450, 455, and 460.

In the data element "TYPE", the MBR will show whether the payment was a PMA, CMA or MBP. CMA's and MBP's from MADCAP are paid based on the beneficiary's payment cycle. For PMA's, we add 7 days to the DRD for our notices and use that as the date it will be paid.

In the data element "SOURCE", the MBR will show the system that was used to generate the payment (T2, MADCAP, BRI, etc).

EXAMPLE 1 - LIMIT Display

DED/ADD

EXAMPLE 2 FACT Query Display

In the following example:

• an action was taken against the beneficiary in the PE Run of 12/20/2005 (DRD = 12/20/2005) resulting in PART C entitlement;

• $300.00 was deducted from the PMA payment for a Part C arrearage resulting in a net PMA of $1554.00;

• $150.00 was withheld from the CMA payment for PART C resulting in a net CMA of $263.00; and

• $150.00 is also withheld from the ongoing MBP for Part C resulting in an ongoing MBP of $263.00.