ASC X12 Version: 005010 | Transaction Set: 820 | TR3 ID: 005010X306
Example 16: CMS sends HIX 820 to State Based Marketplace — Payment Type Code: APTC/CSR
The example below describe the information that will be sent to “XYZ SBM” for the following scenario: This scenario is for the January 2014 coverage month. Subscriber 1: Jane Smith, Exchange Assigned Subscriber Identifier 777222. Subscriber 2: John Doe, Exchange Assigned Subscriber Identifier 777223. Program: This is a Balancing Loop to bring the BPR02 field to $0.
| Jane Smith | APTC | $600 |
| CSR | $100 | |
| John Doe | APTC | $400 |
| CSR | $50 | |
| Program | BAL | -$1,150 |
| Net Payment | $0 |
Transmission Explanation
Table 1
ST*820*0001*005010X306~
Beginning of an HIX 820 transaction set, Control Number (0001).
BPR*I*0*C*NON************20140128~
This is an informational 820 only. No payment was made. The total amount is $0. The date the 820 was created is January 28, 2014.
TRN*3*MD2014013101~
The unique remittance identification number (MD2014013101).
N1*PE*XYZ SBM*FI*12123123~
The payee name (XYZ SBM) with Tax ID number* (12-123123). Note that an 820 sent to an SBM will reflect payments made to issuers.
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* 12345MD0020011~
The Exchange Assigned Qualified Health Plan Identifier (12345MD0020011).
REF*POL*4567~
The Exchange Assigned Policy Identifier (4567).
REF*AZ*PLAN1~
The Issuer Assigned Policy Identifier (PLAN1).
REF*0F*SMITHJ123~
The Issuer Assigned Subscriber Identifier (SMITHJ123).
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*20140101-20140131~
The coverage period for this transaction (01/01/2014 – 01/31/2014).
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*20140101-20140131~
The coverage period for this transaction is (01/01/2014 – 01/31/2014).
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*12346MD0020055~
The Exchange Assigned Qualified Health Plan Identifier (12346MD0020055).
REF*POL*5678~
The Exchange Assigned Policy Identifier (5678).
REF*AZ*PLAN2~
The Issuer Assigned Policy Identifier (PLAN2).
REF*0F*DOEJ234~
The Issuer Assigned Subscriber Identifier (DOEJ234).
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*20140101-20140131~
The coverage period for this transaction (01/01/2014 – 01/31/2014).
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*20140101-20140131~
The coverage period for this transaction (01/01/2014 – 01/31/2014).
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.
RMR*ZZ*BAL**-1150~
RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The Balancing Adjustment (BAL) transaction amount for this payee is -$1,150. This brings the BPR02 total to $0.
DTM*582****RD8*20140101-20140131~
The coverage period for this transaction is (01/01/2014 – 01/31/2014).
Table 3
SE*30*0001~
Transaction Set Trailer with segment count (30) and Control Number (0001).