Medicare Advantage and Prescription Drug Plans December 28 ...

Plan Communications User Guide Appendices, Version 6.3
Item
Segment
Data
Element
Description Length Type Contents
Premium Receiver’s Name 2 AN “N1”
1000A N101 Entity Identifier Code 2/3 ID “PE” (Payee)
1000A N102 Name 1/60 AN Contract Name
1000A N103 Identification Code Qualifier 1/2 ID “EQ” Insurance Company
Assigned ID Number
1000A N104 Identification Code 2/80 AN Contract Number
Premium Payer’s Name 2 AN “N1”
1000B N101 Entity Identifier Code 2/3 ID “PR” (Payer)
1000B N102 Name 1/60 AN “CMS”
1000B N103 Identification Code Qualifier 1/2 ID “EQ” Insurance Company
Assigned ID Number
1000B N104 Identification Code 2/80 AN “CMS”
F.1.2 Detail Record
Item
Segment
Data
Element
Description Length Type Contents
Organization Summary 3 AN “RMR”
Remittance Detail
2300A RMR01 Reference Identification 2/3 ID “CT”
Qualifier
2300A RMR02 Contract Number 1/30 AN Payment Letter – Contract #
2300A RMR04 Detail Premium Payment
Amount
1/18 R Payment Letter – Net Payment
See discussion on Balancing.
2300A RMR05 Billed Premium Amount 1/18 R Payment Letter – Capitated Payment.
See discussion on Balancing.
Summary Line Item 3 AN “IT1”
2310A IT101 Line Item Control 1/20 AN “1” (Assigned for uniqueness)
Number
Member Count 3 AN “SLN”
2315A SLN01 Line Item Control
Number
1/20 AN “1” (Assigned for uniqueness)
2315A SLN03 Information Only
1/1 ID “O” (For Information only)
Indicator
2315A SLN04 Head Count 1/15 R Payment Letter – Total Members
2315A
SLN05-
1
Unit or Basis for
Measurement Code
2/2 ID “IE” - used to identify that the value
of SLN04 represents the number of
contract holders with individual
coverage
Organization Summary 3 AN “ADX”
Remittance Level
Adjustment
2320A ADX01 Adjustment Amount 1/18 R Payment Letter – Total Adjustments is
the difference between Capitated
Payment and Net Payment. See
discussion on Balancing.
December 28, 2012 F-5 820 Format Payment
Advice Data File