Section title: X12 EDI Examples
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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).