EDI 820 X306 - Health Insurance Exchange Related Payments

Functional Group RA

X12F Finance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Payment Order/Remittance Advice Transaction Set (820) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used to make a payment, send a remittance advice, or make a payment and send a remittance advice. This transaction set can be an order to a financial institution to make a payment to a payee. It can also be a remittance advice identifying the detail needed to perform cash application to the payee's accounts receivable system. The remittance advice can go directly from payer to payee, through a financial institution, or through a third party agent.

Heading

1. 0100 · ST · 820 Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0200 · BPR · Financial Information · Max 1 · Mandatory

   To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur

   Use the BPR to address a single payment to a single issuer. The BPR contains mandatory information, even though this transaction is not being used to move funds electronically.
   See section 1.10.2.3, Balancing, for information on balancing requirements.

3. 0350 · TRN · Reassociation Trace Number · Max 1 · Mandatory

   To uniquely identify a transaction to an application

   The purpose of this segment is to uniquely identify this transaction set and aid in reassociating payment and remittance data that have been separated. See section 1.10.2.4 for more information.

4. 0500 · REF · Exchange Assigned Qualified Health Plan Identifier · Max 1 · Optional

   To specify identifying information

   Required when an exchange assigned QHP identifier was provided in the 834 enrollment transaction and all enrollees within this transaction apply to a single QHP. If not required by this implementation guide, do not send.

5. 0500 · REF · Issuer Assigned Qualified Health Plan Identifier · Max 1 · Optional

   To specify identifying information

   Required when all enrollees within this transaction apply to a single QHP and the Issuer Assigned QHP Identifier is known to the submitter. If not required by this implementation guide, do not send.

6. 0500 · REF · Exchange Assigned Employer Group Identifier · Max 1 · Optional

   To specify identifying information

   Required when an exchange assigned employer group identifier was provided in the 834 enrollment transaction and all enrollees within this transaction apply to a single employer group. If not required by this implementation guide, do not send.

7. 0500 · REF · Issuer Assigned Employer Group Identifier · Max 1 · Optional

   To specify identifying information

   Required when: all enrollees within this transaction apply to a single employer group, the issuer has assigned an identifier to that employer group, and the identifier is known to the submitter. If not required by this implementation guide, do not send.

8. 1000A Loop Mandatory Repeat 1

   1. 0700 · N1 · Payee Name · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

   2. 1100 · REF · Unique Health Plan Identifier · Max 1 · Optional

      To specify identifying information

      Required when the Payee has obtained a Unique Health Plan Identifier and that identifier is known to the submitter. If not required by this implementation guide, do not send.

9. 1000B Loop Mandatory Repeat 1

   1. 0700 · N1 · Payer's Name · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

      The "payer" in the context of this transaction is not the health plan. The payer is the entity making payment to the plan. This will be either a government entity (HHS, IRS, etc) or a Health Insurance Exchange.

   2. 1200 · PER · Payer's Administrative Contact Information · Max >1 · Optional

      To identify a person or office to whom administrative communications should be directed

      Required when specified by the terms of the trading partner agreement. If not required by this implementation guide, do not send.
      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. For example, (534)224-2525 would be represented as 5342242525.

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 0100 · ENT · Remittance Information · Max 1 · Mandatory

      To designate the entities which are parties to a transaction and specify a reference meaningful to those entities

      Each iteration of the ENT loop represents an identifiable detail payment and or adjustment(s). The detail payment or adjustment may be specific to an individual or represent an aggregate to the issuer.;Examples of individual specific detail payments include: premium payments, advance tax credit payments, advance cost share payments, etc. Examples of detail payments or adjustments that are not individual include: risk adjustments, reinsurance, tax liens, etc. When reporting a detail payment or adjustment that is not specific to an individual, Loop ID 2100 (Individual Name) is not used.

   2. 2100 Loop Optional Repeat 1

      1. 0200 · NM1 · Individual Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required when the payment and/or adjustment amounts within this iteration of Loop ID 2000 are attributed to a specific individual. If not required by this implementation guide, do not send.

      2. 0600 · REF · Exchange Assigned Qualified Health Plan Identifier · Max 1 · Optional

         To specify identifying information

         Required when the header level Exchange Assigned QHP Identifier segment is not used and an exchange assigned QHP identifier was provided to the issuer in the 834. If not required by this implementation guide, do not send.

      3. 0600 · REF · Issuer Assigned Qualified Health Plan Identifier · Max 1 · Optional

         To specify identifying information

         Required when the Issuer Assigned QHP segment in the header is not used, and the Issuer Assigned QHP Identifier is known by the submitter. If not required by this implementation guide, do not send.

      4. 0600 · REF · Exchange Assigned Employer Group Identifier · Max 1 · Optional

         To specify identifying information

         Required when the enrollment is from a SHOP exchange and the header exchange assigned employer group segment is not used. If not required by this implementation guide, do not send.

      5. 0600 · REF · Issuer Assigned Employer Group Identifier · Max 1 · Optional

         To specify identifying information

         Required when: the enrollment is from a SHOP exchange, the header issuer assigned employer group segment is not used, the issuer has assigned an identifier to that employer group, and the identifier is known to the submitter. If not required by this implementation guide, do not send.

      6. 0600 · REF · Exchange Assigned Policy Identifier · Max 1 · Mandatory

         To specify identifying information

         For the purposes of this implementation, policy is defined as the collective of enrollees constituting a family unit or household.

      7. 0600 · REF · Issuer Assigned Policy Identifier · Max 1 · Optional

         To specify identifying information

         Required when known by the submitter. If not required by this implementation guide, do not send.

      8. 0600 · REF · Exchange Assigned APTC Contributor/Tax Payer Identifier · Max 1 · Optional

         To specify identifying information

         Required when: an exchange has assigned an identifier to an ATPC contributor/Tax Payer, who is not the subscriber or a dependent of the policy, for which this payment is directed, AND the exchange/government agency manages payment information to this level of granularity, AND the identifier is permitted for use under applicable regulation. If not required by this implementation guide, do not send.

      9. 0600 · REF · Issuer Assigned APTC Contributor/Tax Payer Identifier · Max 1 · Optional

         To specify identifying information

         Required when: the issuer has assigned an identifier to an ATPC contributor/Tax Payer who is not the subscriber or a dependent of the policy for which this payment is directed, AND that identifier has been made known to the submitter, AND the exchange/government agency manages payment information to this level of granularity. If not required by this implementation guide, do not send.

      10. 0600 · REF · Exchange Assigned Dependent Identifier · Max 1 · Optional

          To specify identifying information

          Required when the associated payment for a subscriber policy is not directly attributable to the subscriber. If not required by this implementation guide, do not send.
          An example of when this would be used is as follows. When dependents of a policy file taxes separately from the subscriber, it is possible they may be eligible for an Advance payment of the Premium Tax Credit (APTC) separate from, and in addition to, any APTC of which the subscriber may qualify.

      11. 0600 · REF · Issuer Assigned Dependent Identifier · Max 1 · Optional

          To specify identifying information

          An example of when this would be used is as follows. When dependents of a policy file taxes separately from the subscriber, it is possible they may be eligible for an Advance payment of the Premium Tax Credit (APTC) separate from, and in addition to, any APTC of which the subscriber may qualify.
          Required when the associated payment for a subscriber policy is not directly attributable to the subscriber AND the issuer assigned identifier is known by the payer. If not required by this implementation guide, do not send.

      12. 0600 · REF · Issuer Assigned Subscriber Identifier · Max 1 · Optional

          To specify identifying information

          Required when the issuer assigned subscriber number is known to the payer. If not required by this implementation guide, do not send.

   3. 2300 Loop Mandatory Repeat >1

      1. 1500 · RMR · Remittance Detail · Max 1 · Mandatory

         To specify the accounts receivable open item(s) to be included in the cash application and to convey the appropriate detail

         Relays detailed health insurance exchange-related remittance information.

      2. 1700 · REF · Exchange Report Document Control Number · Max >1 · Optional

         To specify identifying information

         Required when the Exchange needs to provide supporting documentation pertaining to this payment. If not required by this implementation guide, do not send.

      3. 1800 · DTM · Individual Coverage Period · Max 1 · Mandatory

         To specify pertinent dates and times

         This segment relays the start and end dates related to the payment reported in the RMR segment.

Summary

1. 0100 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)