Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 820 | TR3 ID: 005010X306

Example 1: Different Types of Payment Made by the HIX

This scenario demonstrates several different types of payments that will be made by the HIX. The total payment is for $220. The example demonstrates: advance payment of the premium tax credit (APTC), retroactive APTC reduction, and cost-sharing reduction payments.

For this example, there is only one QHP for this transaction therefore we reported QHP identifiers at the header for simplicity and the example is for the Individual Market.

Transmission Explanation

Table 1

ST*820*0001*005010X306~

Beginning of an 820 transaction set, Control number = 0001

BPR*I*220*C*ACH*CCP*******01*199999999*DA*98765*20140604~

Total Payment Amount is $220. The payee's bank transit routing number is 199999999 and their bank account is 98765. The Check Issue or EFT effective date is June 4, 2014.

TRN*3*78905~

Reassociation Key provides a sender unique Check or EFT trace number "78905".

REF*38*123456~

The Exchanged assigned QHP Identifier is 123456.

REF*TV*12565496~

The Issuer assigned QHP identifier is 12565496.

N1*PE*BATA INSURANCE CO.*FI*012222222~

The payee’s name (BATA INSURANCE CO.) and Federal Tax ID number (012222222).

N1*RM*GOVERNMENT AGENCY*58*123ABC~

The payer's name is Government Agency with an identifier of 123ABC.

Table 2

ENT*1~

Start of detail loop for first detailed payment record.

NM1*IL*1*DOE*JOHN****C1*777222~

The subscriber's name (JOHN DOE) and Exchange Assigned Subscriber Number is 777222.

REF*POL*1232456~

The Exchange Assigned Policy Identifier is 12565456.

REF*AZ*12565496~

The Issuer Assigned Policy Identifier is 12565496.

REF*0F*555666~

The issuer assigned identifier (555666) for subscriber JOHN DOE.

RMR*ZZ*APTC**35~

Identification Qualifier ZZ = Exchange Payment Type RMR02 refers to a code list published and maintained by CMS representing the payment types. The July 8, 2014 draft version of the Payment Type Codes are used for the purposes of this exercise, APTC = Advance payment of the Premium Tax Credit (APTC) Payment. The APTC amount being paid for this individual is $35.

DTM*582****RD8*20120501-20140531~

This DTM demonstrates the specified date range for which the APTC payment amount applies.

ENT*2~

Start of detail loop for second detailed payment record.

NM1*IL*1*FIRSTONE*EMILY****C1*777333~

The subscriber's name (EMILY FIRSTONE) and exchange assigned identification number (777333).

REF*POL*1232457~

The Exchange Assigned Policy Identifier is 12565457.

REF*AZ*12565497~

The Issuer Assigned Policy Identifier is 12565497.

REF*0F*555777~

The issuer assigned identifier (555666) for subscriber EMILY FIRSTONE.

RMR*ZZ*APTC**35~

Identification Qualifier ZZ = Exchange Payment Type RMR02 refers to a code list published and maintained by CMS representing the payment types. The July 8, 2014 draft version of the Payment Type Codes are used for the purposes of this exercise, APTC = Advance payment of the Premium Tax Credit (APTC) Payment. The APTC amount being paid for this individual is $35.

DTM*582****RD8*20120501-20140531~

This DTM demonstrates the specified date range for which the APTC payment amount applies.

ENT*3~

Start of detail loop for the third detailed payment record.

NM1*IL*1*MIDDLEONE*JULIE****C1*777444~

The subscriber's name (Julie Middleone) and exchange assigned identification number (777444).

REF*POL*1232458~

The Exchange Assigned Policy Identifier is 12565458.

REF*AZ*12565498~

The Issuer Assigned Policy Identifier is 12565498.

REF*0F*544477~

The issuer assigned identifier (544477) for subscriber JULIE MIDDLEONE.

RMR*ZZ*APTC**-350~

RMR02 refers to a code list published and maintained by CMS representing the payment types. The July 8, 2014 draft version of the Payment Type Codes are used for the purposes of this exercise, APTC = Advance payment of the Premium Tax Credit (APTC) Payment. The APTC amount being paid for this individual is $-350. Because this is a negative amount, it reduces the overall BPR02 payment and represents a recovery or retroactive reduction in the individual’s APTC amount.

DTM*582****RD8*20140101-20140331~

This DTM demonstrates the recovered APTC amounts apply to the time period ranging from 1/1/2014 thru 3/31/2014. This date supersedes the effective dates reported at the header level.

ENT*4~

Start of detail loop for the fourth detailed payment record.

NM1*IL*1*NEWONE*KELLY****C1*777111~

The individual's name (KELLY NEWONE) and exchange assigned identification number (777111).

NOTE: The REF containing the Issuer Assigned Identifier is not present because the payer does not have the identifier available. The exchange assigned identifier is the only identifier received in this instance.

REF*POL*1232459~

The Exchange Assigned Policy Identifier is 12565459.

REF*AZ*12565499~

The Issuer Assigned Policy Identifier is 12565499.

RMR*ZZ*APTC**450~

RMR02 refers to a code list published and maintained by CMS representing the payment types. The July 8, 2014 draft version of the Payment Type Codes are used for the purposes of this exercise, APTC = Advance payment of the Premium Tax Credit (APTC) Payment. The APTC amount being paid for this individual is $450.

DTM*582****RD8*20140501-20140531~

This DTM demonstrates the specified date range for which the APTC payment amount applies.

RMR*ZZ*CSR**50~

RMR02 refers to a code list published and maintained by CMS representing the payment types. The July 8, 2014 draft version of the Payment Type Codes are used for the purposes of this exercise, CSR = Cost-Sharing Reduction (CSR) Payment. The amount being paid for this individual is $50.

DTM*582****RD8*20140501-20140531~

This DTM demonstrates the specified date range for which the CSR payment amount applies.

Table 3

SE*37*0001~

Transaction Set Trailer with segment count (37) and Control Number (0001).