Example 11: Current Month Debt Amount Covered by an Affiliate’s Payment — Final Payment Type Code: DEBTADJ

Transmission Explanation

Table 1

ST*820*0002*005010X306~

Beginning of an HIX 820 transaction set, Control Number (0002).

BPR*I*0*C*NON************20140228~

Total payment amount is $0. No payment was made. The date the 820 was created is February 28, 2014.

TRN*3*12345678945678~

The unique remittance identification number is 12345678945678.

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*12345MD000011501~

The Exchange Assigned Qualified Health Plan Identifier (12345MD000011501).

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*5674~

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: a Debt Adjustment (DEBTADJ). No policy information (2100 Loop) is provided for program level transactions.

RMR*ZZ*DEBTADJ**125~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The DEBTADJ payment type code indicates the debt amount ($125) for the payee that was covered by an affiliate’s payment. For this example, the debt adjustment was due to a debt amount covered by National (see Scenario 4b). The positive amount in this segment increases the overall BPR02 net payment amount to zero.

REF*0N*AFFRPT*5551202-123456789123459~

REF02 refers to the Exchange Report Type code list published and maintained by CMS. The Report Type Code (AFFRPT) and the Exchange Report Document Control Number (5551202-123456789123459). The Exchange Report Document Control Number in this example represents the affiliate’s payee ID number and the EFT Trace Number from the affiliate’s HIX 820 (see Scenario 4b).

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

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

Table 3

SE*39*0002~

Transaction Set Trailer with segment count (39) and Control Number (0002).