Example 13: CSR Manual Adjustment — Final Payment Type Code: CSRMADJ

Transmission Explanation

Table 1

ST*820*0002*005010X306~

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

BPR*I*325*C*ACH*CCP*******01*000000001*DA*123456772123*20140228~

Total payment amount is $325. The payee’s bank transit routing number is 000000001 and their bank account is 123456772123. The EFT effective date is February 28, 2014.

TRN*3*123456789123459~

The EFT Trace number (123456789123459).

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**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*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).

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**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*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 CSR Manual Adjustment (CSRMADJ). No policy information (2100 Loop) is provided for program level transactions.

RMR*ZZ*CSRMADJ**200~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The CSRMADJ transaction amount is $200.

REF*0N*MADJRPT*123456~

REF02 refers to the Exchange Report Type code list published and maintained by CMS. The Report Type Code (MADJRPT) and the Exchange Report Document Control Number (123456). The Exchange Report Document Control Number references a unique trace number that may be included on a future HIX 820 if the manual adjustment is reversible (reference Scenario 7b).

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

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

Table 3

SE*31*0002~

Transaction Set Trailer with segment count (31) and Control Number (0002).