Example 08: Outstanding Debt Owed by the Payee or their Affiliates — Initial (Optional) Payment Type Code: REDUCED

Transmission Explanation

Table 1

ST*820*0001*005010X306~

Beginning of an HIX 820 transaction set, Control Number (0001).

BPR*I*0*C*NON************20140210~

Total payment amount is $0. No payment was made. The date the 820 was created is February 10, 2014.

TRN*3*1234512345098~

The unique remittance identification number is 1234512345098.

N1*PE*NATIONAL*FI*121231233~

The payee’s name (NATIONAL) with Tax ID number (121231233).

N1*RM*CMS*58*CMS~

Payer’s name and identifier are both CMS.

PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~

The Payer’s informational contact email (CMS_FEPS@cms.hhs.gov) and telephone number (1-800-267-1515).

Table 2

ENT*1~

Start of detail loop for first detailed payment record.

NM1*IL*1*SMITH*JANE****C1*777222~

The subscriber’s name (JANE SMITH) and Exchange Assigned Subscriber Identifier (777222).

REF*38*12345MD000011221~

The Exchange Assigned Qualified Health Plan Identifier (12345MD000011221).

REF*POL*4567~

The Exchange Assigned Policy Identifier (4567).

REF*AZ*PLAN1~

The Issuer Assigned Policy Identifier (PLAN1).

REF*0F*SUB123~

The Issuer Assigned Subscriber Identifier (SUB123).

RMR*ZZ*APTC**600~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC payment amount for this policy is $600.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

RMR*ZZ*CSR**100~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The CSR payment amount for this policy is $100.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

RMR*ZZ*UF**-25~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$25.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

ENT*2~

Start of the detail loop for second detailed payment record.

NM1*IL*1*DOE*JOHN****C1*777223~

The subscriber’s name (JOHN DOE) and Exchange Assigned Subscriber Identifier (777223).

REF*38*12346MD000011232~

The Exchange Assigned Qualified Health Plan Identifier (12346MD000011232).

REF*POL*5678~

The Exchange Assigned Policy Identifier (5678).

REF*AZ*PLAN2~

The Issuer Assigned Policy Identifier (PLAN2).

REF*0F*SUB234~

The Issuer Assigned Subscriber Identifier (SUB234).

RMR*ZZ*APTC**400~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC payment amount for this policy is $400.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

RMR*ZZ*CSR**50~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The CSR payment amount for this policy is $50.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

RMR*ZZ*UF**-1~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$15.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

ENT*3~

Entity 3 is an example of a transaction at the program level: BAL is a balancing loop which brings the BPR02 total amount to $0 for NON Payment Method Code types. No policy information (2100 Loop) is provided for program level transactions.

RMR*ZZ*BAL**-1100~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The BAL payment type code indicates the balancing amount (-$1,110) that is used to force the BPR02 net payment amount to zero.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

Table 3

SE*34*0001~

Transaction Set Trailer with segment count (34) and Control Number (0001).