Example 15: Replace CSR Manual Adjustment with Retroactive CSR Adjustment — Final Payment Type Code: CSRMADJ/CSRADJ

Transmission Explanation

Table 1

ST*820*0002*005010X306~

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

BPR*I*975*C*ACH*CCP*******01*000000001*DA*123456772123*20140328~

Total payment amount is $975. The payee’s bank transit routing number is 000000001 and their bank account is 123456772123. The EFT effective date is March 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**500~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC payment amount for this policy is $500.

DTM*582****RD8*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

RMR*ZZ*CSR**100~

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

DTM*582****RD8*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

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*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

RMR*ZZ*CSRADJ**100~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The CSR Adjustment (CSRADJ) amount is $100 for this policy. This amount represents a CSR amount from a prior month coverage month.

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

The coverage period for this adjustment transaction is (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*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

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*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

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*20140301-20140331~

The coverage period for this transaction (03/01/2014 – 03/31/2014).

RMR*ZZ*CSRADJ**100~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The CSR Adjustment (CSRADJ) amount is $100 for this policy. This amount represents a CSR amount from a prior month coverage month.

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

The coverage period for this adjustment transaction is (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. This reverses the program level CSR estimate for the February coverage month because the enrollment group (policy) level details have now been updated and provided.

REF*0N*REVMADJRPT*123456~

REF02 refers to the Exchange Report Type code list published and maintained by CMS. The Report Type Code (REVMADJRPT) and the Exchange Report Document Control Number (123456). This Exchange Report Type code refers to a manual adjustment reversal. The Exchange Report Document Control Number references a unique trace number from a prior month HIX 820 where the manual adjustment first occurred (See Scenario 6b).

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

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

Table 3

SE*39*0002~

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