ASC X12 Version: 008030 | Transaction Set: 820 | TR3 ID: 008030X334
Example 04: Payment Organizational
Situation - The premium receiver has provided the premium payer with invoice number 0123456789 and plan number 987654321. The premium amount due represents an organizational summary 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*
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 - Organization Level Detail
Loop 2000 - Organization Level Detail
ENT*1*2L*1*932567191~
Indicates the start of a group level premium or contribution payment.
Loop 2400 - Organization Premium Detail
RMR*IK*0123456789*PI*3000~
Indicates the premium payment amount.
REF*18*987654321~
Indicates the plan number.
DTM*582****RD8*20240101-20240131~
Indicates the premium for organizational report period.
Loop 2410 - Line Item
IT1*1~
Indicates the start of line item information.
Loop 2413 - Member Count
SLN*1**O*2*IE~
Indicates the member count.
Table 3
SE*17*0001~
Used to indicate the end of transaction set. 17 segments were sent and the control number in the ST segment is 0001.