Section title: X12 EDI Examples
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ASC X12 Version: 008030 | Transaction Set: 820 | TR3 ID: 008030X334

Example 03: Payment Subscriber and Dependent Combined

Situation - Jayne Doe is the subscriber and is enrolled in a medical and vision plan effective 1/1/2024. She also has a dependent enrolled in the medical and vision plan. The premium payer received a member level bill where the premium amount due represents a combined subscriber and dependent payment amount. This payment is for January 2024.

Transmission Explanation

Table 1

ST*820*0001*008030X334~

Used to indicate the start of a transaction set and to specify a transaction set control number.

BPR*C*3030*C*ACH*CTX*01*9999999992*DA*12345678*1030449999**01*199999999*DA*98765*20231217~

Indicates the total premium payment amount and remittance detail are sent together for this remittance advice.

TRN*1*362436*1030449999~

Indicates transaction trace number for this payment.

REF*14*12345~

Indicates the Master Account number.

DTM*009*20231217~

Indicates the premium payer process date.

DTM*035*20231218~

Indicates the premium payment delivery date.

DTM*582****RD8*20240101-20240131~

Indicates the premium payment for a coverage period.

DTM*097*20231218~

Indicates the premium payment creation date.

Loop 1000A - Premium Receiver's Name

N1*PE**FI*012222222~

Indicates the premium payment receivers identifier.

Loop 1000B - Premium Payer's Name

N1*PR**FI*030449999~

Indicates the premium payers identifier.

Table 2 - Member Level Detail

Loop 8000 - Member Level Detail

INS*Y*18~

Indicates the member as a subscriber.

NM1*IL*1*DOE*JAYNE~

Indicates the member name.

REF*0F*234567890~

Indicates the subscriber identifier.

REF*1L*W12345567~

Indicates the member policy number.

REF*17*1000~

Indicates the member supplemental identifier, 17 - client reporting category.

DTP*356*D8*20240101~

Indicates the member eligibility begin date.

Loop 8200 - Health Coverage

HD*021**HLT*PPOX0001*FAM~

Indicates enrollment for health plan with family coverage.

DTP*348*D8*20240101~

Indicates the benefit begin dates.

Loop 8210 - Member Premium Detail

RMR*AZ*123456**3000~

Indicates the premium payment amount.

REF*18*223456~

Indicates the plan number.

DTM*582*****RD8*20240101-20240131~

Indicates the premium for Individual Coverage period.

Loop 8200 - Health Coverage

HD*021**VIS*VIS00001*FAM~

Indicates enrollment for vision with family coverage.

DTP*348*D8*20240101~

Indicates the benefit begin dates.

Loop 8210 - Member Premium Detail

RMR*AZ*2223456**15~

Indicates the premium payment amount.

REF*18*22445556~

Indicates the plan number.

DTM*582*****RD8*20240101-20240131~

Indicates the premium for Individual Coverage period.

Table 3

SE*27*0001~

Used to indicate the end of transaction set. 27 segments were sent and the control number in the ST segment is 0001.