820 Health Insurance Exchange Related Payments (X306)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1803*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*180353*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140128~
TRN*3*MD2014013101~
N1*PE*XYZ SBE*FI*12123123~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*SMITH*JANE****C1*123456777222~
REF*38* 12345MD0020002~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SMITHJ123~
RMR*ZZ*APTC**600~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*123456777223~
REF*38*12346MD0020002~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*DOEJ234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140101-20140131~
ENT*3~
RMR*ZZ*BAL**-1150~
DTM*582****RD8*20140101-20140131~
SE*30*0001~
ST*820*0002*005010X306~
BPR*I*1357.04*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**600.35~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20161201-20161231~
ENT*2~
RMR*ZZ*CSRMADJ**235.78~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*APTCMADJ**310.59~
REF*0N*ISSUERIDRPT*23456~
DTM*582****RD8*20170101-20170131~
ENT*4~
RMR*ZZ*CSRMADJ**210.32~
REF*0N*ISSUERIDRPT*23456~
DTM*582****RD8*20170101-20170131~
SE*23*0002~
ST*820*0003*005010X306~
BPR*I*520.91*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**310.59~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20161201-20161231~
ENT*2~
RMR*ZZ*CSRMADJ**210.32~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20161201-20161231~
SE*15*0003~
ST*820*0004*005010X306~
BPR*I*2467.88*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*2~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*UFMADJ**-321.85~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
RMR*ZZ*SHOUF**-310.59~
REF*0N*ISSUERIDRPT*29497~
REF*0N*SHOPUFRPT*8374575~
DTM*582****RD8*20170101-20170131~
ENT*5~
RMR*ZZ*SHOPUF**-210.32~
REF*0N*ISSUERIDRPT*29497~
REF*0N*SHOPUFRPT*736495~
DTM*582****RD8*20170101-20170131~
ENT*6~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170101-20170131~
ENT*7~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170101-20170131~
SE*53*0004~
ST*820*0005*005010X306~
BPR*I*550*C*ACH*CCP*******01*777770000*DA*65996655*20150228~
TRN*3*5678332~
N1*PE*HUMANA OF DC*FI*121231233~
N1*RM*CMSSHOP*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*LOPEZ*JANE****C1*123450006777222~
REF*38*12345MD000011201~
REF*1L*3259250~
REF*POL*175687498825178~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*EMPLOYEEPREM**100~
REF*0N*PAYMENTTRANSACTIONID*DC99999999999~
DTM*582****RD8*20150201-20150228~
RMR*ZZ*EMPLOYERPREM**200~
DTM*582****RD8*20150201-20150228~
ENT*2~
NM1*IL*1*LOPEZ*JOHN****C1*123450006777222~
REF*38*12345MD000011201~
REF*POL*175687498825178~
REF*6O*123450000879455~
REF*1W*DEP12~
RMR*ZZ*DEPENDENTPREM**50~
REF*0N*PAYMENTTRANSACTIONID*DC99999999999~
DTM*582****RD8*20150201-20150228~
RMR*ZZ*EMPLOYERPREM**200~
DTM*582****RD8*20150201-20150228~
SE*30*0005~
ST*820*0006*005010X306~
BPR*I*550*C*ACH*CCP*******01*777770000*DA*65996655*20150102~
TRN*3*5678333~
N1*PE*HUMANA OF DC*FI*121231233~
N1*RM*CMSSHOP*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*LOPEZ*JANE****C1*123450006777222~
REF*38*12345MD0000112201~
REF*POL*175687498825178~
RMR*ZZ*EMPLOYEEPREM**100~
REF*0N*PAYMENTTRANSACTIONID*DC99999999999~
DTM*582****RD8*20150101-20150131~
RMR*ZZ*EMPLOYERPREM**200~
DTM*582****RD8*20150101-20150131~
ENT*2~
NM1*IL*1*LOPEZ*JOHN****C1*123450006777222~
REF*38*12345MD000011201~
REF*POL*175687498825178~
REF*6O*123450000879455~
RMR*ZZ*DEPENDENTPREM**50~
REF*0N*PAYMENTTRANSACTIONID* DC99999999999~
DTM*582****RD8*20150101-20150131~
RMR*ZZ*EMPLOYERPREM**200~
DTM*582****RD8*20150101-20150131~
SE*26*0006~
ST*820*0007*005010X306~
BPR*I*175*C*ACH*CCP*******01*777770000*DA*65996655*20150331~
TRN*3*5678332~
N1*PE*HUMANA OF DC*FI*121231233~
N1*RM*CMSSHOP*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*LOPEZ*JANE****C1*123450006777222~
REF*38*12345MD000011201~
REF*1L*3259250~
REF*POL*175687498825178~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*EMPLOYEEPREM**100~
REF*0N*PAYMENTTRANSACTIONID*DC99999999999~
DTM*582****RD8*20150301-20150331~
RMR*ZZ*EMPLOYERPREM**200~
DTM*582****RD8*20150301-20150331~
ENT*2~
NM1*IL*1*LOPEZ*JOHN****C1*123450006777222~
REF*38*12346MD000011201~
REF*POL*175687498825178~
REF*6O*123450000879455~
REF*1W*DEP123~
RMR*ZZ*DEPENDENTPREMADJCANCEL**-50~
REF*0N*PAYMENTTRANSACTIONID*DC99999999999~
DTM*582****RD8*20150201-20150228~
RMR*ZZ*EMPLOYERPREMADJCANCEL**-200~
DTM*582****RD8*20150201-20150228~
RMR*ZZ*DEPENDENTPREM**25~
REF*0N*PAYMENTTRANSACTIONID*DC99999999910~
DTM*582****RD8*20150201-20150214~
RMR*ZZ*EMPLOYERPREM**100~
DTM*582****RD8*20150201-20150214~
SE*35*0007~
ST*820*0008*005010X306~
BPR*I*1050*C*ACH*CCP*******01*000090007*DA*222222222*20170303~
TRN*3*224001~
N1*PE*BCBSC*FI*231610057~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*EXTLOAN**1000~
REF*0N*ISSUERIDRPT*94376~
REF*0N*INFORPT*NOTE~
DTM*582****RD8*20160101-20160131~
ENT*2~
RMR*ZZ*SHOPUF**50~
REF*0N*ISSUERIDRPT*94376~
REF*0N*SHOPUFRPT*MA NOTES ARE PLACED HERE~
DTM*582****RD8*20150101-20150131~
ENT*3~
RMR*ZZ*APTCMADJ**1000~
REF*0N*ISSUERIDRPT*94376~
REF*0N*INFORPT*NOTE~
DTM*582****RD8*20160101-20160131~
ENT*4~
RMR*ZZ*RA**-1000~
REF*0N*ISSUERIDRPT*12345~
REF*0N*RARPT*I15CO123454376001 - MA NOTES CONCATENATED WITH INVOICE NUMBER~
DTM*582****RD8*20150101-20150131~
SE*27*0008~
GE*8*000000001~
IEA*1*000000001~

1st Transaction: Scenario 12: State Based Exchange Example

2nd Transaction: Scenario 13: SBE-only Issuers in Same Payee Group

3rd Transaction: Scenario 14: 2016 SBE Payee Leaving the Marketplace

4th Transaction: Scenario 15: FFE SHOP Issuers Participating in the Individual Market

5th Transaction: Scenario 16: SHOP Family Plan (Employee + Dependent) Initial Enrollment Payment with Effectuated Issuer Identifiers

6th Transaction: Scenario 17: SHOP Family Plan (Employee + Dependent) Initial Enrollment Premium Payment using Payment Transaction ID and Issuer is yet to Effectuate the 834 Enrollment

7th Transaction: Scenario 18: FFE SHOP Death of a Dependent

8th Transaction: Scenario 19: Transaction Details Included in the HIX820 Effective in the July 2017 Payment Cycle

Multiple scenarios

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1742*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*174215*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*1110*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*1234567890~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170101-20170131~
ENT*2~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170101-20170131~
SE*31*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for FFE issuers who are new to the Individual Market in 2017. This means the Payee Group does not have any SBE issuers in their payee group. This transaction corresponds to CMS PPR – New 2017 FFE Issuers.

Scenario 1: New 2017 FFE Issuers

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1759*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175922*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*3540.96*C*ACH*CCP*******01*000000001*DA*123456772123*20170228~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**2000~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*2~
RMR*ZZ*CSRMADJ**700~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*UFMADJ**-300~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTCADJ**-600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSRADJ**-100~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UFADJ**25~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*APTCADJ**174.19~
DTM*582****RD8*20170101-20170109~
RMR*ZZ*CSRADJ**29.03~
DTM*582****RD8*20170101-20170109~
RMR*ZZ*UFADJ**-7.26~
DTM*582****RD8*20170101-20170109~
ENT*5~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTCADJ**461.29~
DTM*582****RD8*20170110-20170131~
RMR*ZZ*CSRADJ**88.71~
DTM*582****RD8*20170110-20170131~
RMR*ZZ*UFADJ**-21.29~
DTM*582****RD8*20170110-20170131~
RMR*ZZ*APTC**650~
DTM*582****RD8*20170201-20170228~
RMR*ZZ*CSR**125~
DTM*582****RD8*20170201-20170228~
RMR*ZZ*UF**-30~
DTM*582****RD8*20170201-20170228~
ENT*6~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170201-20170229~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170201-20170229~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170201-20170229~
SE*67*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for the February 2017 payment month. In this scenario the APTC for the January coverage month represented in Scenario 1 has been reversed in the amount of - $600 for this policy (000018209074370) due to a mid-month new born. The subscriber, Lucille Knowlesde, has a new exchange policy ID (00001820906438) that includes a new dependent with a DOB of January 10th. For the month of January, the APTC $600 will be prorated across the two policies. The new policy (00001820906438) that includes the additional dependent is effective Jan 10 - Jan 31st with a new APTC amount of $650 prorated.

Scenario 10: Financial Change in Circumstances (CIC) Partial Month

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1801*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*180110*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*3350.64*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*1234567890~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20162101-20162131~
ENT*2~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497OR006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170101-20170131~
ENT*4~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497OR006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170101-20170131~
SE*35*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for SBE state transitioning to FFE for 2017. Included in this example are the 2016 Restatements from the Manual Process as Program-Level Amounts (2300 Loop only) as well as a new REF Report Type Code of ISSUERIDRPT. In the document control number is the 5-digit HIOS Issuer ID. This transaction corresponds to CMS PPR –2016 SBE State Transitioning to FFE for 2017.

Scenario 11: 2016 SBE State Transitioning to FFE for 2017

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1743*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*174352*000000001*X*005010X306~
ST*820*124930286*005010X306~
BPR*I*520.91*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**310.59~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20170101-20170131~
ENT*2~
RMR*ZZ*CSRMADJ**210.32~
REF*0N*ISSUERIDRPT*12345~
DTM*582****RD8*20170101-20170131~
SE*15*124930286~
GE*1*000000001~
IEA*1*000000001~

This scenario is for new 2017 SBE-only Issuers. Included in this example is the new 2017 Payment Information from the SBE Issuer from the Manual Process as Program-Level Amounts (2300 only) as well as a REF Report Type Code of ISSUERIDRPT. In the document control number is the 5-digit HIOS Issuer ID.

Scenario 2: New 2017 SBE-only Issuers

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1747*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*174726*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*2988.79*C*ACH*CCP*******01*066033492*DA*123456789123456000*20160121~
TRN*3*1234567890~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20162131~
ENT*2~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*UFMADJ**-321.85~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20160101-20160131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20160101-20160131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20160101-20160131~
ENT*5~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20160101-20160131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20160101-20160131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20160101-20160131~
SE*43*0002~
GE*1*000000001~
IEA*1*000000001~

The Payee Group has FFE Issuers on PBP but the SBE issuers have not yet converted to PBP and are being paid using the Manual process. Included in this example are the 2016 Restatements from the Manual Process as Program-Level Amounts (2300 Loop only) as well as a REF Report Type Code of ISSUERIDRPT. In the document control number is the 5-digit HIOS Issuer ID.

Scenario 3: PBP Issuers Only

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1748*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*174855*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*1110*C*ACH*CCP*******01*000000001*DA*123456772123*20140128~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*SMITH*JANE****C1*123456777222~
REF*38*12345MD000011202~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*APTC**600~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*123456777223~
REF*38*12346MD000011202~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140101-20140131~
SE*31*0002~
GE*1*000000001~
IEA*1*000000001~

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

Scenario 4: Final HIX 820 – Payments Exceed Charges

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1750*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175011*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*0*C*NON************20170128~
TRN*3*123456789123567~
N1*PE*USINS*FI*121231234~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*INVOICE**140.50~
DTM*582****RD8*20170101-20170131~
ENT*2~
RMR*ZZ*UF**-100.50~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170101-20170131~
ENT*4~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170101-20170131~
SE*30*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for the January 2017 payment month for a FFE Stand Alone Dental Plan with No APTC payment. Payment Type Code: Invoice Amount to bring the BPR02 field to $0. This transaction corresponds to CMS PPR – Charges Exceed Payments Net Zero HIX 820 with an Invoice line – FFE SADP with no APTC.

Scenario 5: Charges Exceed Payments (Net Zero HIX 820 with an Invoice line) – FFE SADP with no APTC

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1751*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175127*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*0*C*NON************20140128~
TRN*3*123456789123567~
N1*PE*USINS*FI*121231234~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*SMITH*JANE****C1*123456777222~
REF*38*12345MD000011202~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*123456777223~
REF*38*12346MD000011202~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140101-20140131~
ENT*3~
RMR*ZZ*INVOICE**40~
DTM*582****RD8*20140101-20140131~
SE*26*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for the January 2014 coverage month. Subscriber 1: Jane Smith, Exchange Assigned Subscriber Identifier 123456777222. Subscriber 2: John Doe, Exchange Assigned Subscriber Identifier 123456777223. Program: Invoice Amount to bring the BPR02 field to $0.

Scenario 6: Final HIX 820 – Charges Exceed Payments - FFE User Fees

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1754*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175410*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*4345.83*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**600.35~
REF*0N*ISSUERIDRPT*56789~
DTM*582****RD8*20161201-20161231~
ENT*2~
RMR*ZZ*CSRMADJ**235.78~
REF*0N*ISSUERIDRPT*56789~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*5~
RMR*ZZ*UFMADJ**-321.85~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*6~
RMR*ZZ*APTCMADJ**310.59~
REF*0N*ISSUERIDRPT*56789~
DTM*582****RD8*20170101-20170131~
ENT*7~
RMR*ZZ*CSRMADJ**210.32~
REF*0N*ISSUERIDRPT*56789~
DTM*582****RD8*20170101-20170131~
ENT*8~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170101-20170131~
ENT*9~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170101-20170131~
SE*59*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for FFE and SBE Issuers in the same payee group who participated in 2016 and 2017. This means the Payee Group will have both SBE issuers and FFE issuers. Included in this example are the 2016 Restatements for SBE Issuer and FFE Issuer and the new 2017 Payment Information from the SBE Issuer from the Manual Process as Program-Level Amounts (2300 only) as well as a REF Report Type Code of ISSUERIDRPT. In the document control number is the 5-digit HIOS Issuer ID. This transaction corresponds to CMS PPR – Scenario 4: FFE and SBE Issuers in Same Payee Group.

Scenario 7: FFE and SBE Issuers in Same Payee Group

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1755*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175550*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*2863.79*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170222~
TRN*3*123456789123459~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*REDUCED**-125~
REF*0N*INVOICERPT*U1401B0051001001~
DTM*582****RD8*20170201-20170228~
ENT*2~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
RMR*ZZ*UFMADJ**-321.85~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*5~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170102-20170228~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170201-20170228~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170201-20170228~
ENT*6~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170201-20170229~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170201-20170229~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170201-20170229~
SE*47*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for the February 2017 payment month. The Payment Type Code: REDUCED is used to show a reduction in payment to cover an outstanding debt amount owed by a payee.

Scenario 8: Outstanding Debt Owed by the Payee (REDUCED)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240225*1757*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240225*175725*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*3288.89*C*ACH*CCP*******01*066033492*DA*123456789123456000*20170121~
TRN*3*1234567890~
N1*PE*NATIONAL*FI*121231233~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
RMR*ZZ*APTCMADJ**1500.54~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20162131~
ENT*2~
RMR*ZZ*CSRMADJ**700.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*3~
RMR*ZZ*UFMADJ**-321.85~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20161201-20161231~
ENT*4~
RMR*ZZ*RC**200.10~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20170101-20170131~
ENT*5~
RMR*ZZ*UFR**100~
REF*0N*ISSUERIDRPT*29497~
DTM*582****RD8*20170101-20170131~
ENT*6~
NM1*IL*1*KNOWLESDE*LUCILLE*R**IV*C1*0000074370~
REF*38*29497DE006000602~
REF*POL*000018209074370~
REF*AZ*000018209074370~
REF*0F*0000074370~
RMR*ZZ*APTC**600~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**100~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-25~
DTM*582****RD8*20170101-20170131~
ENT*7~
NM1*IL*1*LANGLEYDE*DAVID****C1*0000074371~
REF*38*29497DE006000603~
REF*POL*000018210174371~
REF*AZ*000018210174371~
REF*0F*0000074371~
RMR*ZZ*APTC**400~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*CSR**50~
DTM*582****RD8*20170101-20170131~
RMR*ZZ*UF**-15~
DTM*582****RD8*20170101-20170131~
SE*51*0002~
GE*1*000000001~
IEA*1*000000001~

This scenario is for FFE issuers who participated in 2016 and 2017. This means the Payee Group does not have any SBE issuers in their payee group. Included in this example are the 2016 Restatements from the Manual Process as Program-Level Amounts (2300 Only) with a 12/1/2016-12/31/2016 coverage date as well as a new REF Report Type Code of ISSUERIDRPT. In the document control number is the 5-digit HIOS Issuer ID. CMS PPR –Issuers with Risk Corridors Payment and Contraceptive User Fee Adjustment


This scenario also reflects a user fee reduction related to contraceptive care coverage and a Risk Corridors payment. These codes can apply to any type of issuer expecting these payments.

X12 820 820 Health Insurance Exchange Related Payments (X306)