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

Example 7: APTC Adjustments — Final Payment Type Code: APTCADJ

This scenario is for the February 2014 coverage month. Subscriber 1: Jane Smith, Exchange Assigned Subscriber Identifier 777222. Subscriber 2: John Doe, Exchange Assigned Subscriber Identifier 777223.

Jane Smith APTC $500
  CSR $100
  UF -$25
  APTCADJ -$600
  APTCADJ $500
John Doe APTC $400
  CSR $50
  UF -$15
Net Payment   $910

Transmission Explanation

Table 1

ST*820*0002*005010X306~

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

BPR*I*910*C*ACH*CCP*******01*000000001*DA*123456772123*20140228~

Total payment amount is $910. The payee’s bank transit routing number is 000000001 and their bank account is 123456772123. The EFT effective date is February 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~

Exchange Assigned Policy Identifier (4567).

REF*AZ*PLAN1~

Issuer Assigned Policy Identifier (PLAN1).

REF*0F*SUB123~

Issuer Assigned Subscriber Identifier (SUB123).

RMR*ZZ*APTC**500~

RMR02 refers to the Exchange Payment Type code list published and maintained by CMS. The APTC payment amount for this policy is $500.

DTM*582****RD8*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

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*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

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*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

RMR*ZZ*APTCADJ**-600~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The APTC Adjustment (APTCADJ) amount is -$600 for this policy because the APTC amount paid for January was determined to be incorrect. This completely reverses the APTC amount paid for this subscriber for the month of January.

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

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

RMR*ZZ*APTCADJ**500~

RMR02 refers to a code list published and maintained by CMS representing the Exchange Payment Type. The APTC Adjustment (APTCADJ) amount is $500 for this policy because the APTC amount paid for January was determined to be incorrect; this amount is the corrected January APTC.

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

The coverage period for this adjustment transaction is (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*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

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*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

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*20140201-20140228~

The coverage period for this transaction (02/01/2014 – 02/28/2014).

Table 3

SE*35*0002~

Transaction Set Trailer with segment count (35) and Control Number (0002).