Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 820 | TR3 ID: 005010X218

Example 4: List Bill

Scenario Four depicts a list bill. This example illustrates a premium payer, using a third party payroll processor, sending an 820 transaction set where the remittance information and the dollars on travel on separate paths. The payment detail will list each individual employee, the policy numbers, payment amounts and adjustment amounts.

Transmission Explanation

Table 1

ST*820*0002*005010X218~

Beginning of an 820 transaction set. Control number = 0002.

BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~

Financial institution to send the payment of $20,000 separate from the remittance information. The payment will use an ACH CCP format. The premium payer's bank transit routing number is 934257813 and their bank account number is 1234587. The premium receiver's bank transit routing number is 025677833 and their bank account number is 99887766. The effective date of the payment is June 20, 2007.

TRN*3*12345*1231555555~

Since the remittance and dollars travel on separate paths, the financial reassociation trace number of 12345 will be used to reassociated the remittance information with payment. The federal tax id, 231555555, identifies the premium payer.

REF*14*673001~

The premium payer's master account number is 673001.

REF*2F*0004369123~

The consolidated invoice number is 0004369123.

N1*PE*DEF HEALTHCARE CO*FI*998216353~

The premium receiver's name and Federal Tax ID Number.

N1*PR*ABC PLASTICS*FI*000057811~

The premium payer's name and Federal Tax ID Number.

Table 2

ENT*1*2J*34*190206123~

Start of individual detail loop.

NM1*EY*1*SMITH*JOHN****EI*123456~

Individual's name and employee identification number.

RMR*CT*190206123**7000~

Individual's policy and amount being paid.

ENT*2*2J*34*163910163~

Start of individual detail loop.

NM1*EY*1*JONES*MARY****EI*793016~

Individual's name and employee identification number.

RMR*CT*163910163**10000*11000~

Individual's policy, amount being paid, and invoiced amount.

ADX*-1000*52~

Shows an adjustment being made to this Individual's invoice.

ENT*3*2J*34*179203456~

Start of individual detail loop.

NM1*EY*1*JOHNSON*JOE****EI*934213~

Individual's name and employee identification number.

RMR*CT*179203456**3000*3100~

Individual's policy, amount being paid, and invoiced amount.

ADX*-100*52~

Shows an adjustment being made to this individual's invoice.

Table 3

SE*19*0002~

Transaction Set Trailer and control number.