X12 820 Health Insurance Exchange Related Payments (X306)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

ISA-01 · I01 · Authorization Information Qualifier · Required · Identifier (ID)

• 00: No Authorization Information Present (No Meaningful Information in I02)

ISA-02 · I02 · Authorization Information · Required · String (AN) · Min 10 Max 10

ISA-03 · I03 · Security Information Qualifier · Required · Identifier (ID)

• 00: No Security Information Present (No Meaningful Information in I04)

ISA-04 · I04 · Security Information · Required · String (AN) · Min 10 Max 10

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

ISA-09 · I08 · Interchange Date · Required · Date (DT) · YYMMDD format

ISA-10 · I09 · Interchange Time · Required · Time (TM) · HHMM format

ISA-11 · I65 · Repetition Separator · Required · String (AN) · Min 1 Max 1

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

• 00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• RA: Payment Order/Remittance Advice (820)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 15

GS-04 · 373 · Date · Required · Date (DT) · CCYYMMDD format

GS-05 · 337 · Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

GS-06 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X306

Heading

0100 Heading > ST

ST 820 Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 820: Payment Order/Remittance Advice

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Implementation Convention Reference · Required · String (AN)

005010X306

0200 Heading > BPR

BPR Financial Information

Required · Max use 1

If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiving Depository Financial Institution (DFI) Identifier (BPR-13) is present, then the other is required

If Account Number Qualifier (BPR-14) is present, then Receiver Bank Account Number (BPR-15) is required

BPR-01 · 305 · Transaction Handling Code · Required · Identifier (ID)

• I: Remittance Information Only

BPR-02 · 782 · Total Payment Amount · Required · Decimal number (R) · Min 1 Max 15

BPR-03 · 478 · Credit or Debit Flag Code · Required · Identifier (ID)

• C: Credit

BPR-04 · 591 · Payment Method Code · Required · Identifier (ID)

• ACH: Automated Clearing House (ACH)
• CHK: Check
• FWT: Federal Reserve Funds/Wire Transfer - Nonrepetitive
• NON: Non-Payment Data

BPR-05 · 812 · Payment Format Code · Optional · Identifier (ID)

• CCP: Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)

BPR-12 · 506 · Depository Financial Institution (DFI) Identification Number Qualifier · Optional · Identifier (ID)

• 01: ABA Transit Routing Number Including Check Digits (9 digits)
• 02: Swift Identification (8 or 11 characters)
• 04: Canadian Bank Branch and Institution Number

BPR-13 · 507 · Receiving Depository Financial Institution (DFI) Identifier · Optional · String (AN) · Min 3 Max 12

BPR-14 · 569 · Account Number Qualifier · Optional · Identifier (ID)

• DA: Demand Deposit
• SG: Savings

BPR-15 · 508 · Receiver Bank Account Number · Optional · String (AN) · Min 1 Max 35

BPR-16 · 373 · Check Issue or EFT Effective Date · Required · Date (DT) · CCYYMMDD format

0350 Heading > TRN

TRN Reassociation Trace Number

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 3: Financial Reassociation Trace Number

TRN-02 · 127 · Check or EFT Trace Number · Required · String (AN) · Min 1 Max 50

0500 Heading > REF

REF Exchange Assigned Qualified Health Plan Identifier

Optional · Max use 1

Variants (all may be used)

REFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 38: Master Policy Number

REF-02 · 127 · Exchange Assigned Qualified Health Plan Identifier · Required · String (AN) · Min 1 Max 50

0500 Heading > REF

REF Issuer Assigned Qualified Health Plan Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• TV: Line of Business

REF-02 · 127 · Issuer Assigned Qualified Health Plan Identifier · Required · String (AN) · Min 1 Max 50

0500 Heading > REF

REF Exchange Assigned Employer Group Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFIssuer Assigned Employer Group Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 18: Plan Number

REF-02 · 127 · Exchange Assigned Employer Group Identifier · Required · String (AN) · Min 1 Max 50

0500 Heading > REF

REF Issuer Assigned Employer Group Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number

REF-02 · 127 · Issuer Assigned Employer Group Identifier · Required · String (AN) · Min 1 Max 50

1000A Payee Name Loop Required Max 1

Variants (all may be used)

Payer's Name Loop

0700 Heading > Payee Name Loop > N1

N1 Payee Name

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PE: Payee

N1-02 · 93 · Payee Organization Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• FI: Federal Taxpayer's Identification Number

N1-04 · 67 · Payee's Tax Identification Number · Required · String (AN) · Min 2 Max 80

1100 Heading > Payee Name Loop > REF

REF Unique Health Plan Identifier

Optional · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• ABY: Centers for Medicare and Medicaid Services PlanID

REF-02 · 127 · Unique Health Plan Identifier · Required · String (AN) · Min 1 Max 50

1000B Payer's Name Loop Required Max 1

Variants (all may be used)

Payee Name Loop

0700 Heading > Payer's Name Loop > N1

N1 Payer's Name

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• RM: Party that remits payment

N1-02 · 93 · Payer Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 58: Originating Company Number

N1-04 · 67 · Payer Identifier · Required · String (AN) · Min 2 Max 80

1200 Heading > Payer's Name Loop > PER

PER Payer's Administrative Contact Information

Optional · Max use >1

If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-02 · 93 · Premium Payer Contact Name · Required · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone

PER-04 · 364 · Communication Number · Required · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-06 · 364 · Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-08 · 364 · Communication Number · Optional · String (AN) · Min 1 Max 256

Detail

2000 Remittance Information Loop Required Max >1

0100 Detail > Remittance Information Loop > ENT

ENT Remittance Information

Required · Max use 1

ENT-01 · 554 · Assigned Number · Required · Numeric (N0) · Min 1 Max 6

2100 Individual Name Loop Optional Max 1

0200 Detail > Remittance Information Loop > Individual Name Loop > NM1

NM1 Individual Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Individual Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Individual First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Individual Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-06 · 1038 · Individual Name Prefix · Optional · String (AN) · Min 1 Max 10

NM1-07 · 1039 · Individual Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• C1: Insured or Subscriber

NM1-09 · 67 · Exchange Assigned Subscriber Identifier · Required · String (AN) · Min 2 Max 80

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Exchange Assigned Qualified Health Plan Identifier

Optional · Max use 1

Variants (all may be used)

REFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 38: Master Policy Number

REF-02 · 127 · Exchange Assigned Qualified Health Plan Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned Qualified Health Plan Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• TV: Line of Business

REF-02 · 127 · Issuer Assigned Qualified Health Plan Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Exchange Assigned Employer Group Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 18: Plan Number

REF-02 · 127 · Exchange Assigned Employer Group Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned Employer Group Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number

REF-02 · 127 · Issuer Assigned Employer Group Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Exchange Assigned Policy Identifier

Required · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• POL: Policy Number

REF-02 · 127 · Exchange Assigned Policy Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned Policy Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• AZ: Health Insurance Policy Number

REF-02 · 127 · Issuer Assigned Policy Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Exchange Assigned APTC Contributor/Tax Payer Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 4A: Personal Identification Number (PIN)

REF-02 · 127 · Exchange Assigned APTC Contributor/Tax Payer Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned APTC Contributor/Tax Payer Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 23: Client Number

REF-02 · 127 · Issuer Assigned APTC Contributor/Tax Payer Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Exchange Assigned Dependent Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6O: Cross Reference Number

REF-02 · 127 · Exchange Assigned Dependent Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned Dependent Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Subscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1W: Member Identification Number

REF-02 · 127 · Issuer Assigned Dependent Identifier · Required · String (AN) · Min 1 Max 50

0600 Detail > Remittance Information Loop > Individual Name Loop > REF

REF Issuer Assigned Subscriber Identifier

Optional · Max use 1

Variants (all may be used)

REFExchange Assigned Qualified Health Plan IdentifierREFIssuer Assigned Qualified Health Plan IdentifierREFExchange Assigned Employer Group IdentifierREFIssuer Assigned Employer Group IdentifierREFExchange Assigned Policy IdentifierREFIssuer Assigned Policy IdentifierREFExchange Assigned APTC Contributor/Tax Payer IdentifierREFIssuer Assigned APTC Contributor/Tax Payer IdentifierREFExchange Assigned Dependent IdentifierREFIssuer Assigned Dependent Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0F: Subscriber Number

REF-02 · 127 · Issuer Assigned Subscriber Identifier · Required · String (AN) · Min 1 Max 50

2300 Remittance Detail Loop Required Max >1

1500 Detail > Remittance Information Loop > Remittance Detail Loop > RMR

RMR Remittance Detail

Required · Max use 1

RMR-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• ZZ: Mutually Defined

RMR-02 · 127 · Exchange Payment Type · Required · String (AN) · Min 1 Max 50

RMR-04 · 782 · Payment Amount · Required · Decimal number (R) · Min 1 Max 15

1700 Detail > Remittance Information Loop > Remittance Detail Loop > REF

REF Exchange Report Document Control Number

Optional · Max use >1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0N: Attached To

REF-02 · 127 · Exchange-related Report Type · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Exchange Report Document Control Number · Required · String (AN) · Min 1 Max 80

1800 Detail > Remittance Information Loop > Remittance Detail Loop > DTM

DTM Individual Coverage Period

Required · Max use 1

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 582: Report Period

DTM-05 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

DTM-06 · 1251 · Coverage Period · Required · String (AN) · Min 1 Max 35

Summary

0100 Summary > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Example 1: Different Types of Payment Made by the HIX

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1259*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*125918*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*220*C*ACH*CCP*******01*199999999*DA*98765*20140604~
TRN*3*78905~
REF*38*123456~
REF*TV*12565496~
N1*PE*BATA INSURANCE CO.*FI*012222222~
N1*RM*GOVERNMENT AGENCY*58*123ABC~
ENT*1~
NM1*IL*1*DOE*JOHN****C1*777222~
REF*POL*1232456~
REF*AZ*12565496~
REF*0F*555666~
RMR*ZZ*APTC**35~
DTM*582****RD8*20120501-20140531~
ENT*2~
NM1*IL*1*FIRSTONE*EMILY****C1*777333~
REF*POL*1232457~
REF*AZ*12565497~
REF*0F*555777~
RMR*ZZ*APTC**35~
DTM*582****RD8*20120501-20140531~
ENT*3~
NM1*IL*1*MIDDLEONE*JULIE****C1*777444~
REF*POL*1232458~
REF*AZ*12565498~
REF*0F*544477~
RMR*ZZ*APTC**-350~
DTM*582****RD8*20140101-20140331~
ENT*4~
NM1*IL*1*NEWONE*KELLY****C1*777111~
REF*POL*1232459~
REF*AZ*12565499~
RMR*ZZ*APTC**450~
DTM*582****RD8*20140501-20140531~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140501-20140531~
SE*37*0001~
GE*1*000000001~
IEA*1*000000001~

Example 10: Debt Amount Covered by an Affiliate’s Payment — Initial (Optional)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1348*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*134856*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140210~
TRN*3*123456789123385~
N1*PE*NATIONAL EAST*FI*121231244~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*HOPE*AMY****C1*777339~
REF*38*12345MD000011500~
REF*POL*4599~
REF*AZ*PLAN2~
REF*0F*SUB1234~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-35~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*APTCADJ**-450~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*APTCADJ**100~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*RENEE*JENNIFER****C1*777335~
REF*38*12346MD000011501~
REF*POL*5678~
REF*AZ*PLAN4~
REF*0F*SUB2348~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-40~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*BAL**125~
DTM*582****RD8*20140201-20140228~
SE*38*0001~
GE*1*000000001~
IEA*1*000000001~

Example 11: Current Month Debt Amount Covered by an Affiliate’s Payment — Final

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1404*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*140425*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*0*C*NON************20140228~
TRN*3*12345678945678~
N1*PE*NATIONAL EAST*FI*121231244~
N1*RM*CMS*58*CMS~
PER*IC*EXCHANGE OPERATIONS CENTER*EM*CMS_FEPS@cms.hhs.gov*TE*8002671515~
ENT*1~
NM1*IL*1*HOPE*AMY****C1*777339~
REF*38*12345MD000011501~
REF*POL*4599~
REF*AZ*PLAN2~
REF*0F*SUB1234~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-35~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*APTCADJ**-450~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*APTCADJ**100~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*RENEE*JENNIFER****C1*777335~
REF*38*12346MD000011501~
REF*POL*5674~
REF*AZ*PLAN4~
REF*0F*SUB2348~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-40~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*DEBTADJ**125~
REF*0N*AFFRPT*5551202-123456789123459~
DTM*582****RD8*20140201-20140228~
SE*39*0002~
GE*1*000000001~
IEA*1*000000001~

Example 12: CSR Manual Adjustment — Optional

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1405*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*140549*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140210~
TRN*3*123456789123456~
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*777222~
REF*38*12345MD000011221~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-35~
DTM*582****RD8*20140201-20140228~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*777223~
REF*38*12346MD000011232~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-40~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*BAL**-125~
DTM*582****RD8*20140201-20140228~
SE*30*0001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Payments Exceed Charges — Initial Payment (Optional)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1259*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*125902*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140110~
TRN*3*123456789123456~
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*777222~
REF*38*12345MD000011221~
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*777223~
REF*38*12346MD000011232~
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~
ENT*3~
RMR*ZZ*BAL**-1110~
DTM*582****RD8*20140101-20140131~
SE*34*0001~
GE*1*000000001~
IEA*1*000000001~

Example 3: Payments Exceed Charges — Final Payment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1331*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*133138*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*777222~
REF*38*12345MD000011221~
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*777223~
REF*38*12346MD000011232~
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~

Example 4: Charges Exceed Payments (SHOP) — Initial Payment (Optional)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1335*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*133549*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140110~
TRN*3*123456789123457~
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*777222~
REF*38*12346MD000011222~
REF*1L*987654~
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*777223~
REF*38*12346MD000011237~
REF*1L*678910~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140101-20140131~
ENT*3~
RMR*ZZ*BAL**40~
DTM*582****RD8*20140101-20140131~
SE*28*0001~
GE*1*000000001~
IEA*1*000000001~

Example 5: Charges Exceed Payments (SHOP) — Final Payment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1338*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*133811*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*777222~
REF*38*12345MD000011222~
REF*1L*987654~
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*777223~
REF*38*12346MD000011237~
REF*1L*678910~
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*28*0002~
GE*1*000000001~
IEA*1*000000001~

Example 6: APTC Adjustments — Initial (Optional)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1342*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*134200*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140210~
TRN*3*123456789123456~
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*777222~
REF*38*12345MD000011221~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*APTC**500~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*APTCADJ**-600~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*APTCADJ**500~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*777223~
REF*38*12346MD000011232~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*BAL**-910~
DTM*582****RD8*20140201-20140228~
SE*38*0001~
GE*1*000000001~
IEA*1*000000001~

Example 7: APTC Adjustments — Final Payment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1343*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*134329*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*910*C*ACH*CCP*******01*000000001*DA*123456772123*20140228~
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*777222~
REF*38*12345MD000011221~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*APTC**500~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*APTCADJ**-600~
DTM*582****RD8*20140101-20140131~
RMR*ZZ*APTCADJ**500~
DTM*582****RD8*20140101-20140131~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*777223~
REF*38*12346MD000011232~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140201-20140228~
SE*35*0002~
GE*1*000000001~
IEA*1*000000001~

Example 8: Outstanding Debt Owed by the Payee or their Affiliates — Initial (Optional)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1345*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*134520*000000001*X*005010X306~
ST*820*0001*005010X306~
BPR*I*0*C*NON************20140210~
TRN*3*1234512345098~
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*777222~
REF*38*12345MD000011221~
REF*POL*4567~
REF*AZ*PLAN1~
REF*0F*SUB123~
RMR*ZZ*APTC**600~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**100~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140201-20140228~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*777223~
REF*38*12346MD000011232~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-1~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*BAL**-1100~
DTM*582****RD8*20140201-20140228~
SE*34*0001~
GE*1*000000001~
IEA*1*000000001~

Example 9: Outstanding Debt Owed by the Payee or their Affiliates — Final Payment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1347*^*00501*000000001*0*T*>~
GS*RA*SENDERGS*RECEIVERGS*20240221*134721*000000001*X*005010X306~
ST*820*0002*005010X306~
BPR*I*985*C*ACH*CCP*******01*000000001*DA*123456772123*20140228~
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*777222~
REF*38*12345MD000011221~
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*20140201-20140228~
RMR*ZZ*UF**-25~
DTM*582****RD8*20140201-20140228~
ENT*2~
NM1*IL*1*DOE*JOHN****C1*777223~
REF*38*12346MD000011232~
REF*POL*5678~
REF*AZ*PLAN2~
REF*0F*SUB234~
RMR*ZZ*APTC**400~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*CSR**50~
DTM*582****RD8*20140201-20140228~
RMR*ZZ*UF**-15~
DTM*582****RD8*20140201-20140228~
ENT*3~
RMR*ZZ*REDUCED**-125~
REF*0N*AFFRPT*5551201-12345678945678~
DTM*582****RD8*20140201-20140228~
SE*35*0002~
GE*1*000000001~
IEA*1*000000001~