Example 03: Summary Bill

Transmission Explanation

Table 1

ST*820*0002*005010X218~

Beginning of an 820 transaction set. Control number = 0002.

BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~

Financial institution to send the payment of $20,000 separate from the remittance information.The payment will use an ACH CCP format.The premium payer's bank transit routing number is 934257813 and their bank account number is 1234587. The premium receiver's bank transit routing number is 025677833 and their bank account number is 99887766. The effective date of the payment is June 20, 2007.

TRN*3*12345*1231555555~

Since the remittance and dollars travel on separate paths, the financial reassociation trace number of 12345 will be used to reassociate the remittance information with the payment. The Federal Tax ID, 231555555, identifies the premium payer.

REF*14*673001~

The premium payer's master account number is 673001.

REF*2F*0004369123~

The consolidated invoice number is 0004369123.

N1*PE*DEF HEALTHCARE CO*FI*998216353~

The premium receiver's name and Federal Tax ID Number.

N1*PR*ABC PLASTICS*FI*1231555555~

The premium payer's name and Federal Tax ID Number.

Table 2

ENT*1*2L*FI*000057811~

Start of detail loop for first individual. Identifying this is an individual John Doe's remittance items (list bill payment). The individual'sStart of the detail loop. This identifies the premium payer as a corporation and lists their Federal Tax ID Number.

RMR*IK*0004369123*PI*20000~

Details the invoice and the amount being paid on that invoice.

IT1*1~

Start of required member counts under a summary RMR item.

SLN*1**O*100*IE~

One hundred employees have individual coverage.

SLN*2**O*75*PR~

Seventy-five employees have two party coverage.

SLN*3**O*125*10~

One hundred twenty-five employees have family coverage.

Table 3

SE*14*0002~

Transaction Set Trailer.