Example 10: Debt Amount Covered by an Affiliate’s Payment — Initial (Optional) Payment Type Code: DEBTADJ

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*123456789123385~

The unique remittance identification number is 123456789123385.

N1*PE*NATIONAL EAST*FI*121231244~

The payee’s name (NATIONAL EAST) with Tax ID number (121231244).

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*HOPE*AMY****C1*777339~

The subscriber’s name (AMY HOPE) and Exchange Assigned Subscriber Identifier (777339).

REF*38*12345MD000011500~

The Exchange Assigned Qualified Health Plan Identifier (12345MD000011500).

REF*POL*4599~

The Exchange Assigned Policy Identifier (4599).

REF*AZ*PLAN2~

The Issuer Assigned Policy Identifier (PLAN2).

REF*0F*SUB1234~

The Issuer Assigned Subscriber Identifier (SUB1234).

RMR*ZZ*APTC**100~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC 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*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**-35~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$35.

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

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

RMR*ZZ*APTCADJ**-450~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The APTC Adjustment (APTCADJ) amount is -$450 for this policy because the APTC amount paid for January was determined to be incorrect. This completely reverses the APTC amount paid for this subscriber for the month of January.

DTM*582****RD8*20140101-20140131~

The coverage period for this adjustment transaction is (01/01/2014 – 01/31/2014).

RMR*ZZ*APTCADJ**100~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The APTC Adjustment (APTCADJ) amount is $100 for this policy because the APTC amount paid for January was determined to be incorrect; this amount is the corrected January APTC.

DTM*582****RD8*20140101-20140131~

The coverage period for this adjustment transaction is (01/01/2014 – 01/31/2014).

ENT*2~

Start of the detail loop for second detailed payment record.

NM1*IL*1*RENEE*JENNIFER****C1*777335~

The subscriber’s name (JENNIFER RENEE) and Exchange Assigned Subscriber Identifier (777335).

REF*38*12346MD000011501~

The Exchange Assigned Qualified Health Plan Identifier (12346MD000011501).

REF*POL*5678~

The Exchange Assigned Policy Identifier (5674).

REF*AZ*PLAN4~

The Issuer Assigned Policy Identifier (PLAN4).

REF*0F*SUB2348~

The Issuer Assigned Subscriber Identifier (SUB2348).

RMR*ZZ*APTC**100~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC 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*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**-40~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$40.

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**125~

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 ($125) 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*38*0001~

Transaction Set Trailer with segment count (38) and Control Number (0001).