2100B Identification Unique “N” – Insurer’s Code Qualifier ID number 2100B Identification Recipient ID 9 Code 2300B INDIVIDUAL PREMIUM REMITTANCE DETAIL RMR=Organization Summary Remittance Detail Sample: RMR*AZ*1234567890123**400.00~ 2300B Reference - Account “11” Identification Number Qualifier 2300B Reference Claim ICN Identification 2300B Monetary Amount Detail Premium Payment Amount REF=Reference Information (1st occurrence) Sample: REF*ZZ*001~ 2300B Reference - Mutually S “ZZ” Identification Identified Qualifier 2300B Reference Capitation Code D Identification 2300B Not Used 2300B Not Used
2100B Identification Code Qualifier “N” – Insurer’s Unique ID number 2100B Identification Code Recipient ID 2300B INDIVIDUAL PREMIUM REMITTANCE DETAIL RMR=Organization Summary Remittance Detail Sample: RMR*AZ*1234567890123**400.00~ 2300B Reference Identification Qualifier “11” - Account Number 2300B Reference Identification Claim ICN 2300B Monetary Amount Detail Premium Payment Amount REF=Reference Information (1st occurrence) Sample: REF*ZZ*001~ 2300B Reference Identification Qualifier “ZZ” - Mutually Identified S 2300B Reference Identification Capitation Code D 2300B Not Used 2300B Not Used 9
PIHP_CSoC_SystemsCompanionGuide-Sept2018_V12.docx