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

Example 3: Payments Exceed Charges — Final Payment | Payment Type Code: BAL

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.

Jane Smith APTC $600
  CSR $100
  UF -$25
John Doe APTC $400
  CSR $50
  UF -$15
Net Payment   $1,110

Transmission Explanation

Table 1

ST*820*0002*005010X306~

Beginning of an HIX 820 transaction set, Control Number (0002).

BPR*I*1110*C*ACH*CCP*******01*000000001*DA*123456772123*20140128~

Total payment amount is $1,110. The payee’s bank transit routing number is 000000001 and their bank account is 123456772123. The EFT effective date is January 28, 2014.

TRN*3*123456789123459~

The EFT Trace number (123456789123459).

N1*PE*NATIONAL*FI*121231233~

The payee’s name (NATIONAL) with Tax ID number (121231233).

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*12345MD000011221~

The Exchange Assigned Qualified Health Plan Identifier (12345MD000011221).

REF*POL*4567~

The Exchange Assigned Policy Identifier (4567).

REF*AZ*PLAN1~

The Issuer Assigned Policy Identifier (PLAN1).

REF*0F*SUB123~

The Issuer Assigned Subscriber Identifier (SUB123).

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 (01/01/2014 – 01/31/2014).

RMR*ZZ*UF**-25~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$25.

DTM*582****RD8*20140101-20140131~

The coverage period for this transaction (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*12346MD000011232~

The Exchange Assigned Qualified Health Plan Identifier (12346MD000011232).

REF*POL*5678~

The Exchange Assigned Policy Identifier (5678).

REF*AZ*PLAN2~

The Issuer Assigned Policy Identifier (PLAN2).

REF*0F*SUB234~

The Issuer Assigned Subscriber Identifier (SUB234).

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).

RMR*ZZ*UF**-15~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The UF amount for this policy is -$15.

DTM*582****RD8*20140101-20140131~

The coverage period for this transaction (01/01/2014 – 01/31/2014).

Table 3

SE*31*0002~

Transaction Set Trailer with segment count (31) and Control Number (0002).