Program Components:
This section provides an overview of Electronic Data Interchange (EDI) and retiree processing.
Electronic Data Interchange (EDI)
Electronic Data Interchange (EDI) is the electronic transmission of data between computer systems.
All participants in the RDS Program must use EDI to exchange retiree files with CMS' RDS Center throughout the Application Lifecycle. Plan sponsors choose which Retiree EDI method is used for file exchange during Application Submission: Benefit Options by selecting a Retiree Submission Method for each benefit option defined for the application.
Information is exchanged using a Comma Separated Value (CSV) file or Connect:Direct file where each line represents one beneficiary, Benefit Option, and Subsidy Period.
Examples of EDI include:
Pharmacy Prescriptions: Data is exchanged between the Pharmacy and the Pharmacy Benefit Manager (PBM) at the point of sale when a prescription is presented. The patient's eligibility and cost information are verified and sent back to the Pharmacy.
Auto Loans: When applying for an automobile loan, several dealerships electronically request an applicant's credit history from a credit bureau. The information is electronically communicated to the dealership's computer for analysis and scoring without human intervention.
Merchants and Suppliers: EDI is utilized between merchants and suppliers to electronically communicate purchase orders, shipping invoices, shipping notices, etc.
Retiree Processing
The Plan Sponsor provides demographic and benefit enrollment information about the beneficiaries for whom it is seeking subsidy. CMS' RDS Center evaluates program eligibility and provides the Plan Sponsor with approved Subsidy Periods for each Qualifying Covered Retiree (QCR).
The main components of retiree processing include:
- Selecting the Retiree Submission Method on the RDS Secure Website during the Application Submission Process
- Sending a Valid Initial Retiree List to CMS' RDS Center as part of a timely and complete RDS application prior to the expiration of the Application Deadline
- Sending Monthly Retiree Lists that only include detail records of individuals for whom there is a change of information from the Valid Initial Retiree List
- Processing Retiree Response Files so internal records reflect the correct QCR information and associated Subsidy Periods
- Processing Weekly Notification Files so internal records reflect the correct QCR information and associated Subsidy Periods
- Requesting, downloading, and reviewing Covered Retiree Lists (CRL) for comparison against the Plan Sponsor's internal records with those of CMS' RDS Center
- Reviewing Qualified Covered Retiree Counts for the most recent retiree data derived from the Retiree Response File and Weekly Notification Files
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