Health Insurance Exchange Related Payments (X306)

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 1: Different Types of Payment Made by the HIX

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

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

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 12: CSR Manual Adjustment — 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 2: Payments Exceed Charges — Initial Payment (Optional)

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 3: Payments Exceed Charges — Final Payment

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

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 5: Charges Exceed Payments (SHOP) — Final Payment

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 6: APTC Adjustments — Initial (Optional)

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 7: APTC Adjustments — Final Payment

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

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~

X12 820 Health Insurance Exchange Related Payments (X306)