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

Example 5: Charges Exceed Payments (SHOP) — Final Payment | Payment Type Code: INVOICE

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: Invoice Amount to bring the BPR02 field to $0.

Jane Smith UF -$25
John Doe UF -$15
Program INVOICE $40
Net Payment $0

Transmission Explanation

Table 1

ST*820*0002*005010X306~

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

BPR*I*0*C*NON************20140128~

Total payment amount is $0. No payment was made. The date the 820 was created is January 28, 2014.

TRN*3*123456789123567~

The unique remittance identification number (123456789123567).

N1*PE*USINS*FI*121231234~

The payee’s name (USINS) with Tax ID number (121231234).

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*12345MD000011222~

Exchange Assigned Qualified Health Plan Identifier (12345MD000011222).

REF*1L*987654~

Issuer Assigned Employer Group Identifier (987654). This indicates the enrollment is from a SHOP exchange.

REF*POL*4567~

Exchange Assigned Policy Identifier (4567).

REF*AZ*PLAN1~

Issuer Assigned Policy Identifier (PLAN1).

REF*0F*SUB123~

Issuer Assigned Subscriber Identifier (SUB123).

RMR*ZZ*UF**-25~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The FFM 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*12346MD000011237~

The Exchange Assigned Qualified Health Plan Identifier (12346MD000011237).

REF*1L*678910~

Issuer Assigned Employer Group Identifier (678910). This indicates the enrollment is from a SHOP exchange.

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*UF**-15~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. 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).

ENT*3~

Entity 3 is an example of a transaction at the program level, an Invoice amount. No policy information (2100 Loop) is provided for program level transactions.

RMR*ZZ*INVOICE**40~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The INVOICE payment type code indicates the amount ($40) that will be invoiced / billed to the payee since the total charges for the period have exceeded the total payments. The positive amount in this segment increases the overall BPR02 net payment amount to zero.

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

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

Table 3

SE*28*0002~

Transaction Set Trailer with segment count (28) and Control Number (0002).