X12 820 820 Health Insurance Exchange Related Payments (X306)
This X12 Transaction Set contains the format and establishes the data contents of the Payment Order/Remittance Advice Transaction Set (820) for use within the context of an Electronic Data Interchange (EDI) environment.
The transaction set can be used to make a payment, send a remittance advice, or make a payment and send a remittance advice.
This transaction set can be an order to a financial institution to make a payment to a payee. It can also be a remittance advice identifying the detail needed to perform cash application to the payee's accounts receivable system. The remittance advice can go directly from payer to payee, through a financial institution, or through a third party agent.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- RA
- Payment Order/Remittance Advice (820)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X306
Heading
820 Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 820
- Payment Order/Remittance Advice
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- The value in ST03 must be the same as the value in GS08.
- 005010X306
Financial Information
To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur
- Use the BPR to address a single payment to a single issuer. The BPR contains mandatory information, even though this transaction is not being used to move funds electronically.
- See section 1.10.2.3, Balancing, for information on balancing requirements.
Code designating the action to be taken by all parties
- I
- Remittance Information Only
Indicates to the payee that the remittance detail is moving separately from the payment. This also includes when the resulting payment would be zero.
Monetary amount
- BPR02 specifies the payment amount.
- Use BPR02 for the total payment amount for this 820. The total payment amount for this 820 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 820 cannot be issued for less than zero dollars.
Code indicating whether amount is a credit or debit
- This indicates a credit to the payee's account, and a debit to the Payer's account.
- C
- Credit
Code identifying the method for the movement of payment instructions
- ACH
- Automated Clearing House (ACH)
Use this code to notify the issuer that an ACH transfer was requested. When this code is used, see BPR05 and BPR12 through BPR15 for additional requirements.
- NON
- Non-Payment Data
Use this code when BPR02 equals 0 (zero) indicating no dollars are to be paid.
Code identifying the payment format to be used
- CCP
- Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)
Use the CCD+ format to move money. The addenda must contain a copy of the TRN segment.
Code identifying the type of identification number of Depository Financial Institution (DFI)
- BPR12 and BPR13 relate to the receiving depository financial institution (RDFI).
- BPR12 THROUGH BPR15 relate to the receiver's bank account.
- 01
- ABA Transit Routing Number Including Check Digits (9 digits)
ABA is a unique number identifying every bank in the United States.
Depository Financial Institution (DFI) identification number
- This is the identifying number of the Receiving Depository Financial Institution receiving the transaction into the ACH network.
Code indicating the type of account
- BPR14 is a code identifying the type of bank account or other financial asset.
- BPR14 identifies the type of account in BPR15.
- DA
- Demand Deposit
- SG
- Savings
Account number assigned
- BPR15 is the account number of the receiving company to be debited or credited with the payment order.
- This is the premium receiver's bank account at the Receiving Depository Financial Institution.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date).
- For check payment, this data element specifies the check issuance date.
- For payments other than check this data element specifies the date the originator (premium payer) intends to provide funds to the receiver (premium receiver).
- When the remittance detail contained in this transaction results in a Total Payment Amount (BPR02) of $0.00, the date reported here must equal the date the remittance was created.
Reassociation Trace Number
To uniquely identify a transaction to an application
- The purpose of this segment is to uniquely identify this transaction set and aid in reassociating payment and remittance data that have been separated. See section 1.10.2.4 for more information.
Code identifying which transaction is being referenced
- 3
- Financial Reassociation Trace Number
The payment and remittance information have been separated and need to be reassociated by the receiver.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This number must be unique within the sender/receiver relationship. The number is assigned by the sender.
If payment is made by check, this must be the check number.
If payment is made by EFT, this is the payer assigned reference number for this payment, to be passed through the EFT clearing system to the payment receiver (This is NOT the ACH Trace number assigned by the originating depository financial institution).
If this is a non-payment 820, this must be a unique remittance advice identification number. - This field is used to reassociate the payment and remittance information.
Exchange Assigned Employer Group Identifier
To specify identifying information
- Required when an exchange assigned employer group identifier was provided in the 834 enrollment transaction and all enrollees within this transaction apply to a single employer group. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 18
- Plan Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Exchange Assigned Qualified Health Plan Identifier
To specify identifying information
- Required when an exchange assigned QHP identifier was provided in the 834 enrollment transaction and all enrollees within this transaction apply to a single QHP. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 38
- Master Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Employer Group Identifier
To specify identifying information
- Required when:
all enrollees within this transaction apply to a single employer group,
the issuer has assigned an identifier to that employer group,
and the identifier is known to the submitter.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Qualified Health Plan Identifier
To specify identifying information
- Required when all enrollees within this transaction apply to a single QHP and the Issuer Assigned QHP Identifier is known to the submitter. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- TV
- Line of Business
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payee Name
To identify a party by type of organization, name, and code
Code identifying an organizational entity, a physical location, property or an individual
- PE
- Payee
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
Unique Health Plan Identifier
To specify identifying information
- Required when the Payee has obtained a Unique Health Plan Identifier and that identifier is known to the submitter. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- ABY
- Centers for Medicare and Medicaid Services PlanID
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer's Name
To identify a party by type of organization, name, and code
- The "payer" in the context of this transaction is not the health plan. The payer is the entity making payment to the plan. This will be either a government entity (HHS, IRS, etc) or a Health Insurance Exchange.
Code identifying an organizational entity, a physical location, property or an individual
- RM
- Party that remits payment
Free-form name
- CMS
For Use with All Exchange Issuers
- CMSSHOP
For Use with Small Business Health Option Issuers (SHOP)
Code designating the system/method of code structure used for Identification Code (67)
- 58
- Originating Company Number
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
- The identifier reported here identifies the government agency or Health Insurance Exchange making the payment. Its value is established by trading partner agreement.
- CMS
- CMS
Payer's Administrative Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when specified by the terms of the trading partner agreement. If not required by this implementation guide, do not send.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. For example, (534)224-2525 would be represented as 5342242525.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Detail
Remittance Information
To designate the entities which are parties to a transaction and specify a reference meaningful to those entities
- Each iteration of the ENT loop represents an identifiable detail payment and or adjustment(s). The detail payment or adjustment may be specific to an individual or represent an aggregate to the issuer.;Examples of individual specific detail payments include: premium payments, advance tax credit payments, advance cost share payments, etc.
Examples of detail payments or adjustments that are not individual include: risk adjustments, reinsurance, tax liens, etc.
When reporting a detail payment or adjustment that is not specific to an individual, Loop ID 2100 (Individual Name) is not used.
Number assigned for differentiation within a transaction set
- The first ENT01 within each ST-SE envelope must begin with "1", and be incremented by one each time an ENT is used in the transaction.
Individual Name
To supply the full name of an individual or organizational entity
- Required when the payment and/or adjustment amounts within this iteration of Loop ID 2000 are attributed to a specific individual. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- C1
- Insured or Subscriber
Code identifying a party or other code
- This is the subscriber's Exchange assigned identifier.
Exchange Assigned APTC Contributor/Tax Payer Identifier
To specify identifying information
- Required when:
an exchange has assigned an identifier to an ATPC contributor/Tax Payer, who is not the subscriber or a dependent of the policy, for which this payment is directed,
AND
the exchange/government agency manages payment information to this level of granularity,
AND
the identifier is permitted for use under applicable regulation.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 4A
- Personal Identification Number (PIN)
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Exchange Assigned Dependent Identifier
To specify identifying information
- Required when the associated payment for a subscriber policy is not directly attributable to the subscriber.
If not required by this implementation guide, do not send.
- An example of when this would be used is as follows. When dependents of a policy file taxes separately from the subscriber, it is possible they may be eligible for an Advance payment of the Premium Tax Credit (APTC) separate from, and in addition to, any APTC of which the subscriber may qualify.
Code qualifying the Reference Identification
- 6O
- Cross Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Exchange Assigned Employer Group Identifier
To specify identifying information
- Required when the enrollment is from a SHOP exchange and the header exchange assigned employer group segment is not used. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 18
- Plan Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Exchange Assigned Policy Identifier
To specify identifying information
- For the purposes of this implementation, policy is defined as the collective of enrollees constituting a family unit or household.
Code qualifying the Reference Identification
- POL
- Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Exchange Assigned Qualified Health Plan Identifier
To specify identifying information
- Required when the header level Exchange Assigned QHP Identifier segment is not used and an exchange assigned QHP identifier was provided to the issuer in the 834. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 38
- Master Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned APTC Contributor/Tax Payer Identifier
To specify identifying information
- Required when:
the issuer has assigned an identifier to an ATPC contributor/Tax Payer who is not the subscriber or a dependent of the policy for which this payment is directed,
AND
that identifier has been made known to the submitter,
AND
the exchange/government agency manages payment information to this level of granularity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 23
- Client Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Dependent Identifier
To specify identifying information
- An example of when this would be used is as follows. When dependents of a policy file taxes separately from the subscriber, it is possible they may be eligible for an Advance payment of the Premium Tax Credit (APTC) separate from, and in addition to, any APTC of which the subscriber may qualify.
- Required when the associated payment for a subscriber policy is not directly attributable to the subscriber AND the issuer assigned identifier is known by the payer.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1W
- Member Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Employer Group Identifier
To specify identifying information
- Required when:
the enrollment is from a SHOP exchange,
the header issuer assigned employer group segment is not used,
the issuer has assigned an identifier to that employer group,
and the identifier is known to the submitter.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Policy Identifier
To specify identifying information
- Required when known by the submitter. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- AZ
- Health Insurance Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Qualified Health Plan Identifier
To specify identifying information
- Required when the Issuer Assigned QHP segment in the header is not used, and the Issuer Assigned QHP Identifier is known by the submitter.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- TV
- Line of Business
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Issuer Assigned Subscriber Identifier
To specify identifying information
- Required when the issuer assigned subscriber number is known to the payer.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0F
- Subscriber Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Remittance Detail
To specify the accounts receivable open item(s) to be included in the cash application and to convey the appropriate detail
- Relays detailed health insurance exchange-related remittance information.
Code qualifying the Reference Identification
- Parties using this segment should agree on the content of RMR01 and RMR02 prior to initiating communication.
- ZZ
- Mutually Defined
Exchange-Payment Type
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- This code identifies the type or purpose for the payment amount identified in RMR04.
Codification and Definitions can be found on the CMS Health Insurance Exchange web site.
Monetary amount
- RMR04 is the amount paid.
- The Payment Amount must be greater than or less than zero. Zero "0" is not an acceptable value for this element.
- This is the amount being paid on this remittance item.
Exchange Report Document Control Number
To specify identifying information
- Required when the Exchange needs to provide supporting documentation pertaining to this payment.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0N
- Attached To
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- This element defines the type of report being described. Examples include Risk Adjustment Supporting Documentation, Reinsurance Supporting Documentation, etc. Codification and Definitions can be found on the CMS Health Insurance Exchange web site.
A free-form description to clarify the related data elements and their content
- This is the Document Control Number assigned to the supplemental report which details how the payment amount reported in RMR04 was calculated.
Individual Coverage Period
To specify pertinent dates and times
- This segment relays the start and end dates related to the payment reported in the RMR segment.
Code specifying type of date or time, or both date and time
- 582
- Report Period
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Summary
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Multiple scenarios
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~
Scenario 1: New 2017 FFE Issuers
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~
Scenario 10: Financial Change in Circumstances (CIC) Partial Month
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~
Scenario 11: 2016 SBE State Transitioning to FFE for 2017
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~
Scenario 2: New 2017 SBE-only Issuers
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~
Scenario 3: PBP Issuers Only
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~
Scenario 4: Final HIX 820 – Payments Exceed Charges
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~
Scenario 5: Charges Exceed Payments (Net Zero HIX 820 with an Invoice line) – FFE SADP with no APTC
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~
Scenario 6: Final HIX 820 – Charges Exceed Payments - FFE User Fees
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~
Scenario 7: FFE and SBE Issuers in Same Payee Group
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~
Scenario 8: Outstanding Debt Owed by the Payee (REDUCED)
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~
Scenario 9: Issuers with Risk Corridors Payment and Contraceptive User Fee Adjustment
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~
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.