X12 820 Payroll Deducted and Other Group Premium Payment For Insurance Products Examples (X218)

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)

005010X218

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)

005010X218

0200 Heading > BPR

BPR Financial Information

Required · Max use 1

If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Originating Depository Financial Institution (DFI) Identifier (BPR-07) is present, then the other is required

If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required

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)

• C: Payment Accompanies Remittance Advice
• D: Make Payment Only
• I: Remittance Information Only
• P: Prenotification of Future Transfers
• U: Split Payment and Remittance
• X: Handling Party's Option to Split Payment and Remittance

BPR-02 · 782 · Total Premium 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)
• BOP: Financial Institution Option
• CHK: Check
• FWT: Federal Reserve Funds/Wire Transfer - Nonrepetitive
• NON: Non-Payment Data
• SWT: Society for Worldwide Interbank Financial Telecommunications (S.W.I.F.T.)

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

• CCP: Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)
• CTX: Corporate Trade Exchange (CTX) (ACH)

BPR-06 · 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-07 · 507 · Originating Depository Financial Institution (DFI) Identifier · Optional · String (AN) · Min 3 Max 12

BPR-08 · 569 · Account Number Qualifier · Optional · Identifier (ID)

• ALC: Agency Location Code (ALC)
• DA: Demand Deposit

BPR-09 · 508 · Sender Bank Account Number · Optional · String (AN) · Min 1 Max 35

BPR-10 · 509 · Payer Identifier · Required · String (AN) · Min 10 Max 10

BPR-11 · 510 · Originating Company Supplemental Code · Optional · String (AN) · Min 9 Max 9

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)

• 1: Current Transaction Trace Numbers
• 3: Financial Reassociation Trace Number

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

TRN-03 · 509 · Originating Company Identifier · Optional · String (AN) · Min 10 Max 10

TRN-04 · 127 · Originating Company Supplemental Code · Optional · String (AN) · Min 1 Max 50

0400 Heading > CUR

CUR Foreign Currency Information

Optional · Max use 1

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

• 2B: Third-Party Administrator
• PR: Payer

CUR-02 · 100 · Currency Code · Required · Identifier (ID) · Min 3 Max 3

0500 Heading > REF

REF Premium Receivers Identification Key

Optional · Max use >1

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

• 2F: Consolidated Invoice Number
• 14: Master Account Number
• 17: Client Reporting Category
• 18: Plan Number
• 38: Master Policy Number
• 72: Schedule Reference Number
• LB: Lockbox

REF-02 · 127 · Premium Receiver Reference Identifier · Required · String (AN) · Min 1 Max 50

0600 Heading > DTM

DTM Process Date

Optional · Max use 1

Variants (all may be used)

DTMDelivery DateDTMCoverage PeriodDTMCreation Date

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

• 009: Process

DTM-02 · 373 · Payer Process Date · Required · Date (DT) · CCYYMMDD format

0600 Heading > DTM

DTM Delivery Date

Optional · Max use 1

Variants (all may be used)

DTMProcess DateDTMCoverage PeriodDTMCreation Date

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

• 035: Delivered

DTM-02 · 373 · Premium Delivery Date · Required · Date (DT) · CCYYMMDD format

0600 Heading > DTM

DTM Coverage Period

Optional · Max use 1

Variants (all may be used)

DTMProcess DateDTMDelivery DateDTMCreation Date

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

0600 Heading > DTM

DTM Creation Date

Optional · Max use 1

Variants (all may be used)

DTMProcess DateDTMDelivery DateDTMCoverage Period

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

• 097: Transaction Creation

DTM-02 · 373 · Date · Required · Date (DT) · CCYYMMDD format

1000A Premium Receiver's Name Loop Required Max 1

Variants (all may be used)

Premium Payer's Name LoopIntermediary Bank Information Loop

0700 Heading > Premium Receiver's Name Loop > N1

N1 Premium Receiver's Name

Required · Max use 1

At least one of Premium Receiver's Last or Organization Name (N1-02) or Identification Code Qualifier (N1-03) is required

If either Identification Code Qualifier (N1-03) or Premium Receiver's Identification Code (N1-04) is present, then the other is required

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

• PE: Payee

N1-02 · 93 · Premium Receiver's Last or Organization Name · Optional · String (AN) · Min 1 Max 60

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

• 1: D-U-N-S Number, Dun & Bradstreet
• 9: D-U-N-S+4, D-U-N-S Number with Four Character Suffix
• EQ: Insurance Company Assigned Identification Number
• FI: Federal Taxpayer's Identification Number
• XV: Centers for Medicare and Medicaid Services PlanID

N1-04 · 67 · Premium Receiver's Identification Code · Optional · String (AN) · Min 2 Max 80

0800 Heading > Premium Receiver's Name Loop > N2

N2 Premium Receiver Additional Name

Optional · Max use 1

N2-01 · 93 · Premium Receiver's Additional Name · Required · String (AN) · Min 1 Max 60

0900 Heading > Premium Receiver's Name Loop > N3

N3 Premium Receiver's Address

Optional · Max use 1

N3-01 · 166 · Premium Receiver's Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Premium Receiver's Address Line · Optional · String (AN) · Min 1 Max 55

1000 Heading > Premium Receiver's Name Loop > N4

N4 Premium Receiver's City, State, and ZIP Code

Optional · Max use 1

Only one of Premium Receiver's State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Premium Receiver's City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Premium Receiver's State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Premium Receiver's Postal Zone or Zip Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1300 Heading > Premium Receiver's Name Loop > RDM

RDM Premium Receiver's Remittance Delivery Method

Optional · Max use 1

RDM-01 · 756 · Remittance Delivery Method Code · Required · Identifier (ID)

• BM: By Mail
• EM: E-Mail
• FT: File Transfer
• FX: By Fax
• IA: Electronic Image
• OL: On-Line

RDM-02 · 93 · Premium Receiver's Last or Organization Name · Optional · String (AN) · Min 1 Max 60

RDM-03 · 364 · Premium Receiver's Communication Number · Optional · String (AN) · Min 1 Max 256

1000B Premium Payer's Name Loop Required Max 1

Variants (all may be used)

Premium Receiver's Name LoopIntermediary Bank Information Loop

0700 Heading > Premium Payer's Name Loop > N1

N1 Premium Payer's Name

Required · Max use 1

At least one of Premium Payer Name (N1-02) or Identification Code Qualifier (N1-03) is required

If either Identification Code Qualifier (N1-03) or Premium Payer Identifier (N1-04) is present, then the other is required

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

• PR: Payer

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

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

• 1: D-U-N-S Number, Dun & Bradstreet
• 9: D-U-N-S+4, D-U-N-S Number with Four Character Suffix
• 24: Employer's Identification Number
• 75: State or Province Assigned Number
• EQ: Insurance Company Assigned Identification Number
• FI: Federal Taxpayer's Identification Number
• PI: Payor Identification

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

0800 Heading > Premium Payer's Name Loop > N2

N2 Premium Payer Additional Name

Optional · Max use 1

N2-01 · 93 · Premium Payer Additional Name · Required · String (AN) · Min 1 Max 60

0900 Heading > Premium Payer's Name Loop > N3

N3 Premium Payer's Address

Optional · Max use 1

N3-01 · 166 · Premium Payer Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Premium Payer Address Line · Optional · String (AN) · Min 1 Max 55

1000 Heading > Premium Payer's Name Loop > N4

N4 Premium Payer's City, State, ZIP Code

Optional · Max use 1

Only one of Premium Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Premium Payer City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Premium Payer State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Premium Payer Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1200 Heading > Premium Payer's Name Loop > PER

PER Premium Payer's Administrative Contact

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

1000C Intermediary Bank Information Loop Optional Max 14

Variants (all may be used)

Premium Receiver's Name LoopPremium Payer's Name Loop

0700 Heading > Intermediary Bank Information Loop > N1

N1 Intermediary Bank Information

Required · Max use 1

At least one of Intermediary Bank Name (N1-02) or Identification Code Qualifier (N1-03) is required

If either Identification Code Qualifier (N1-03) or Intermediary Bank Identifier (N1-04) is present, then the other is required

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

• 0B: Interim Funding Organization
• 04: Asset Account Holder
• 8W: Payment Address
• AK: Party to Whom Acknowledgment Should Be Sent
• BE: Beneficiary
• BK: Bank
• C1: In Care Of Party no. 1
• C2: In Care Of Party no. 2
• IAT: Party Executing and Verifying
• MJ: Financial Institution
• RB: Receiving Bank
• Z6: Transferring Party
• ZB: Party to Receive Credit
• ZL: Party Passing the Transaction

N1-02 · 93 · Intermediary Bank Name · Optional · String (AN) · Min 1 Max 60

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

• 31: Bank Identification Code
• 57: Department
• 94: Code assigned by the organization that is the ultimate destination of the transaction set
• A3: Assigned by Third Party
• A4: Assigned by Clearinghouse
• A6: Financial Identification Numbering System (FINS) Number
• CF: Canadian Financial Institution Routing Number
• G: Payee Identification Number
• PA: Secondary Agent Identification

N1-04 · 67 · Intermediary Bank Identifier · Optional · String (AN) · Min 2 Max 80

0800 Heading > Intermediary Bank Information Loop > N2

N2 Intermediary Bank Additional Name

Optional · Max use 1

N2-01 · 93 · Intermediary Bank Additional Name · Required · String (AN) · Min 1 Max 60

0900 Heading > Intermediary Bank Information Loop > N3

N3 Intermediary Bank's Address

Optional · Max use 1

N3-01 · 166 · Intermediary Bank Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Intermediary Bank Address Line · Optional · String (AN) · Min 1 Max 55

1000 Heading > Intermediary Bank Information Loop > N4

N4 Intermediary Bank's City, State, ZIP Code

Optional · Max use 1

Only one of Intermediary Bank State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Intermediary Bank City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Intermediary Bank State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Intermediary Bank Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1200 Heading > Intermediary Bank Information Loop > PER

PER Intermediary Bank's Administrative Contact

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 · Intermediary Bank 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

2000A Organization Summary Remittance Loop Optional Max 1

Variants (all may be used)

Individual Remittance Loop

0100 Detail > Organization Summary Remittance Loop > ENT

ENT Organization Summary Remittance

Required · Max use 1

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

ENT-02 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 2L: Corporation
• AG: Agent/Agency
• NH: Association
• RGA: Responsible Government Agency
• UN: Union

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

• 1: D-U-N-S Number, Dun & Bradstreet
• 9: D-U-N-S+4, D-U-N-S Number with Four Character Suffix
• 24: Employer's Identification Number
• FI: Federal Taxpayer's Identification Number

ENT-04 · 67 · Organization Identification Code · Required · String (AN) · Min 2 Max 80

2200A Organization Summary Remittance Level Adjustment for Previous Payment Loop Optional Max >1

0800 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Level Adjustment for Previous Payment Loop > ADX

ADX Organization Summary Remittance Level Adjustment for Previous Payment

Required · Max use 1

ADX-01 · 782 · Premium Payment Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

ADX-02 · 426 · Premium Payment Adjustment Reason · Required · Identifier (ID)

• 52: Credit for Overpayment
• 53: Remittance for Previous Underpayment
• 80: Overpayment
• 81: Credit as Agreed
• 86: Duplicate Payment
• BJ: Insurance Charge
• H1: Information Forthcoming
• H6: Partial Payment Remitted
• RU: Interest
• WO: Overpayment Recovery
• WW: Overpayment Credit

2300A Organization Summary Remittance Detail Loop Required Max >1

1500 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > RMR

RMR Organization Summary Remittance Detail

Required · Max use 1

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

• 1L: Group or Policy Number
• 11: Account Number
• CT: Contract Number
• IK: Invoice Number

RMR-02 · 127 · Contract, Invoice, Account, Group, or Policy Number · Required · String (AN) · Min 1 Max 50

RMR-03 · 482 · Payment Action Code · Optional · Identifier (ID)

• PA: Payment in Advance
• PI: Pay Item
• PO: Payment on Account
• PP: Partial Payment

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

RMR-05 · 782 · Billed Premium Amount · Optional · Decimal number (R) · Min 1 Max 15

1700 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > REF

REF Reference Information

Optional · Max use >1

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

• 2F: Consolidated Invoice Number
• 14: Master Account Number
• 17: Client Reporting Category
• 18: Plan Number
• 38: Master Policy Number
• E9: Attachment Code
• LB: Lockbox
• LU: Location Number
• ZZ: Mutually Defined

REF-02 · 127 · Organizational Reference Identifier · Required · String (AN) · Min 1 Max 50

1800 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > DTM

DTM Organizational Coverage Period

Optional · Max use 1

At least one of Date (DTM-02) or Date Time Period Format Qualifier (DTM-05) is required

If either Date Time Period Format Qualifier (DTM-05) or Coverage Period (DTM-06) is present, then the other is required

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

• 582: Report Period
• AAG: Due Date

DTM-02 · 373 · Date · Optional · Date (DT) · CCYYMMDD format

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

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

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

2310A Summary Line Item Loop Optional Max 1

1900 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > Summary Line Item Loop > IT1

IT1 Summary Line Item

Required · Max use 1

IT1-01 · 350 · Line Item Control Number · Required · String (AN) · Min 1 Max 20

2312A Service, Promotion, Allowance, or Charge Information Loop Optional Max 4

2020 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > Summary Line Item Loop > Service, Promotion, Allowance, or Charge Information Loop > SAC

SAC Service, Promotion, Allowance, or Charge Information

Required · Max use 1

SAC-01 · 248 · Allowance or Charge Indicator · Required · Identifier (ID)

• C: Charge

SAC-02 · 1300 · Service, Promotion, Allowance, or Charge Code · Required · Identifier (ID)

• A172: Administrative
• B680: Contract Service Charge
• D940: Insurance Premium
• G740: Service Charge

SAC-05 · 610 · Amount · Required · Numeric (N2) · Min 1 Max 15

2315A Member Count Loop Optional Max 3

2040 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > Summary Line Item Loop > Member Count Loop > SLN

SLN Member Count

Required · Max use 1

SLN-01 · 350 · Line Item Control Number · Required · String (AN) · Min 1 Max 20

SLN-03 · 662 · Information Only Indicator · Required · Identifier (ID)

• O: Information Only

SLN-04 · 380 · Head Count · Required · Decimal number (R) · Min 1 Max 15

SLN-05 · C001 · Composite Unit of Measure · Required Max use 1 · To identify a composite unit of measure (See Figures Appendix for examples of use)

C001-01 · 355 · Unit or Basis for Measurement Code · Required · Identifier (ID)

• 10: Group
• IE: Person
• PR: Pair

2320A Organization Summary Remittance Level Adjustment for Current Payment Loop Optional Max >1

2100 Detail > Organization Summary Remittance Loop > Organization Summary Remittance Detail Loop > Organization Summary Remittance Level Adjustment for Current Payment Loop > ADX

ADX Organization Summary Remittance Level Adjustment for Current Payment

Required · Max use 1

ADX-01 · 782 · Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

ADX-02 · 426 · Adjustment Reason Code · Required · Identifier (ID)

• 20: Balance Due Declined
• 52: Credit for Overpayment
• 53: Remittance for Previous Underpayment
• AA: Prepaid Benefit or Advances
• AX: Person No Longer Employed
• H1: Information Forthcoming
• H6: Partial Payment Remitted
• IA: Invoice Amount Does Not Match Account Analysis Statement
• J3: Promised Adjustment Not Received

2000B Individual Remittance Loop Optional Max >1

Variants (all may be used)

Organization Summary Remittance Loop

0100 Detail > Individual Remittance Loop > ENT

ENT Individual Remittance

Required · Max use 1

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

ENT-02 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 2J: Individual

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

• 34: Social Security Number
• EI: Employee Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States

ENT-04 · 67 · Receiver's Individual Identifier · Required · String (AN) · Min 2 Max 80

2100B Individual Name Loop Optional Max >1

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

NM1 Individual Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Individual Identifier (NM1-09) is present, then the other is required

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

• DO: Dependent Name
• EY: Employee Name
• IL: Insured or Subscriber
• QE: Policyholder

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 · Optional · Identifier (ID)

• 34: Social Security Number
• EI: Employee Identification Number
• N: Insured's Unique Identification Number

NM1-09 · 67 · Individual Identifier · Optional · String (AN) · Min 2 Max 80

2200B Individual Premium Adjustment for Previous Payment Loop Optional Max >1

0800 Detail > Individual Remittance Loop > Individual Premium Adjustment for Previous Payment Loop > ADX

ADX Individual Premium Adjustment for Previous Payment

Required · Max use 1

ADX-01 · 782 · Premium Payment Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

ADX-02 · 426 · Premium Payment Adjustment Reason · Required · Identifier (ID)

• 52: Credit for Overpayment
• 53: Remittance for Previous Underpayment
• 80: Overpayment
• 81: Credit as Agreed
• 86: Duplicate Payment
• BJ: Insurance Charge
• H1: Information Forthcoming
• H6: Partial Payment Remitted
• RU: Interest
• WO: Overpayment Recovery

2300B Individual Premium Remittance Detail Loop Required Max >1

1500 Detail > Individual Remittance Loop > Individual Premium Remittance Detail Loop > RMR

RMR Individual Premium Remittance Detail

Required · Max use 1

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

• 9J: Pension Contract
• 11: Account Number
• AZ: Health Insurance Policy Number
• B7: Life Insurance Policy Number
• CT: Contract Number
• ID: Insurance Certificate Number
• IG: Insurance Policy Number
• IK: Invoice Number
• KW: Certification

RMR-02 · 127 · Insurance Remittance Reference Number · Required · String (AN) · Min 1 Max 50

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

RMR-05 · 782 · Billed Premium Amount · Optional · Decimal number (R) · Min 1 Max 15

1700 Detail > Individual Remittance Loop > Individual Premium Remittance Detail Loop > REF

REF Reference Information

Optional · Max use >1

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

• 2F: Consolidated Invoice Number
• 14: Master Account Number
• 18: Plan Number
• 38: Master Policy Number
• E9: Attachment Code
• LU: Location Number
• ZZ: Mutually Defined

REF-02 · 127 · Organizational Reference Identifier · Required · String (AN) · Min 1 Max 50

1800 Detail > Individual Remittance Loop > Individual Premium Remittance Detail Loop > DTM

DTM Individual Coverage Period

Optional · Max use 1

At least one of Date (DTM-02) or Date Time Period Format Qualifier (DTM-05) is required

If either Date Time Period Format Qualifier (DTM-05) or Coverage Period (DTM-06) is present, then the other is required

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

• 582: Report Period
• AAG: Due Date

DTM-02 · 373 · Date · Optional · Date (DT) · CCYYMMDD format

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

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

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

2320B Individual Premium Adjustment for Current Payment Loop Optional Max >1

2100 Detail > Individual Remittance Loop > Individual Premium Remittance Detail Loop > Individual Premium Adjustment for Current Payment Loop > ADX

ADX Individual Premium Adjustment for Current Payment

Required · Max use 1

ADX-01 · 782 · Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

ADX-02 · 426 · Adjustment Reason Code · Required · Identifier (ID)

• 20: Balance Due Declined
• 52: Credit for Overpayment
• 53: Remittance for Previous Underpayment
• AA: Prepaid Benefit or Advances
• AX: Person No Longer Employed
• H1: Information Forthcoming
• H6: Partial Payment Remitted
• IA: Invoice Amount Does Not Match Account Analysis Statement
• J3: Promised Adjustment Not Received

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: Summary Bill Payment

ST*820*0001*005010X218~
BPR*C*19000*C*ACH*CTX*01*999999992*DA*12345678*1030449999**01*199999999*DA*98765*20070516~
TRN*1*12345*1030449999~
REF*14*12345~
N1*PE*DEF HEALTH CARE INC.*FI*012222222~
N1*PR*ABC PLASTICS*FI*123456789~
ENT*1*2L*FI*123456789~
RMR*IK*970501001*PI*16500~
IT1*1~
SLN*1**O*5*IE~
SLN*2**O*75*10~
RMR*IK*970501002*PI*250~
IT1*1~
SLN*1**O*25*IE~
SE*15*0001~

Example 2: List Bill Payment

ST*820*0001*005010X218~
BPR*C*255*C*ACH*CTX*01*999999992*DA*12345678*1345678901**01*199999999*DA*98765*20071103~
TRN*1*78905*1345678901~
REF*14*0011001~
N1*PE*BATA INSURANCE CO.*FI*012222222~
N1*PR*ALFA MEDAL CO*FI*123456789~
ENT*1*2J*34*030440099~
NM1*EY*1*DOE*JOHN****EI*777222~
RMR*IG*555666**30~
RMR*IG*555667**35~
ENT*2*2J*34*029500563~
NM1*EY*1*FIRSTONE*EMILY****EI*777333~
RMR*IG*555777**45~
ENT*3*2J*34*029480664~
NM1*EY*1*MIDDLEONE*JULIE****EI*777444~
RMR*IG*544477**50~
ENT*4*2J*34*030498099~
NM1*EY*1*NEWONE*KELLY****EI*777111~
RMR*IG*551166**45~
RMR*IG*558766**50~
SE*21*0001~

Example 3: Summary Bill

ST*820*0002*005010X218~
BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~
TRN*3*12345*1231555555~
REF*14*673001~
REF*2F*0004369123~
N1*PE*DEF HEALTHCARE CO*FI*998216353~
N1*PR*ABC PLASTICS*FI*1231555555~
ENT*1*2L*FI*000057811~
RMR*IK*0004369123*PI*20000~
IT1*1~
SLN*1**O*100*IE~
SLN*2**O*75*PR~
SLN*3**O*125*10~
SE*14*0002~

Example 4: List Bill

ST*820*0002*005010X218~
BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~
TRN*3*12345*1231555555~
REF*14*673001~
REF*2F*0004369123~
N1*PE*DEF HEALTHCARE CO*FI*998216353~
N1*PR*ABC PLASTICS*FI*000057811~
ENT*1*2J*34*190206123~
NM1*EY*1*SMITH*JOHN****EI*123456~
RMR*CT*190206123**7000~
ENT*2*2J*34*163910163~
NM1*EY*1*JONES*MARY****EI*793016~
RMR*CT*163910163**10000*11000~
ADX*-1000*52~
ENT*3*2J*34*179203456~
NM1*EY*1*JOHNSON*JOE****EI*934213~
RMR*CT*179203456**3000*3100~
ADX*-100*52~
SE*19*0002~