ASC X12 Version: 008030 | Transaction Set: 820 | TR3 ID: 008030X334
Example 02: Payment Subscriber and Dependent
Situation - Jayne Doe is the subscriber and is enrolled in a medical and vision plan effective 1/1/2024. She also has a dependent enrolled in the medical and vision plan. The premium payer received a member level bill where the premium amount due represents a separate subscriber and dependent payment amount. This payment is for January 2024.
Transmission Explanation
Table 1
ST*820*0001*008030X334~
Used to indicate the start of a transaction set and to specify a transaction set control number.
BPR*
Indicates the total premium payment amount and remittance detail are sent together for this remittance advice.
TRN*1*362436*1030449999~
Indicates transaction trace number for this payment.
REF*14*12345~
Indicates the Master Account number.
DTM*009*20231217~
Indicates the premium payer process date.
DTM*035*20231218~
Indicates the premium payment delivery date.
DTM*582****RD8*20240101-20240131~
Indicates the premium payment for a coverage period.
DTM*097*20231218~
Indicates the premium payment creation date.
Loop 1000A - Premium Receiver's Name
N1*PE**FI*012222222~
Indicates the premium payment receivers identifier.
Loop 1000B - Premium Payer's Name
N1*PR**FI*030449999~
Indicates the premium payers identifier.
Table 2 - Member Level Detail
Loop 8000 - Member Level Detail
INS*Y*18~
Indicates the member as a subscriber.
NM1*IL*1*DOE*JAYNE~
Indicates the member name.
REF*0F*234567890~
Indicates the subscriber identifier.
REF*1L*W12345567~
Indicates the member policy number.
REF*17*1000~
Indicates the member supplemental identifier, 17 - client reporting category.
DTP*356*D8*20240101~
Indicates the member eligibility begin date.
Loop 8200 - Health Coverage
HD*021**HLT*PPOX0001*FAM~
Indicates enrollment for health plan with family coverage.
DTP*348*D8*20240101~
Indicates the benefit begin dates.
Loop 8210 - Member Premium Detail
RMR*AZ*123456**1500~
Indicates the premium payment amount.
REF*18*223456~
Indicates the plan number.
DTM*582*****RD8*20240101-20240131~
Indicates the premium for Individual Coverage period.
Loop 8200 - Health Coverage
HD*021**VIS*VIS00001*FAM~
Indicates enrollment for vision with family coverage.
DTP*348*D8*20240101~
Indicates the benefit begin dates.
Loop 8210 - Member Premium Detail
RMR*AZ*2223456**15~
Indicates the premium payment amount.
REF*18*22445556~
Indicates the plan number.
DTM*582*****RD8*20240101-20240131~
Indicates the premium for Individual Coverage period.
Table 2 - Member Level Detail
Loop 8000 - Member Level Detail
INS*N*19~
Indicates the member as a dependent child.
NM1*IL*1*DOE*ANDREW~
Indicates the member name.
REF*0F*234567890~
Indicates the subscriber identifier.
REF*1L*W12345567~
Indicates the member policy number.
REF*17*1000~
Indicates the member supplemental identifier, 17 - client reporting category.
DTP*356*D8*20240101~
Indicates the member eligibility begin date.
Loop 8200 - Health Coverage
HD*021**HLT*PPOX0001*FAM~
Indicates enrollment for health plan with family coverage.
DTP*348*D8*20240101~
Indicates the benefit begin dates.
Loop 8210 - Member Premium Detail
RMR*AZ*123456**1500~
Indicates the premium payment amount.
REF*18*223456~
Indicates the plan number.
DTM*582*****RD8*20240101-20240131~
Indicates the premium for Individual Coverage period.
Loop 8200 - Health Coverage
HD*021**VIS*VIS00001*FAM~
Indicates enrollment for vision with family coverage.
DTP*348*D8*20240101~
Indicates the benefit begin dates.
Loop 8210 - Member Premium Detail
RMR*AZ*2223456**15~
Indicates the premium payment amount.
REF*18*22445556~
Indicates the plan number.
DTM*582*****RD8*20240101-20240131~
Indicates the premium for Individual Coverage period.
Table 3
SE*43*0001~
Used to indicate the end of transaction set. 43 segments were sent and the control number in the ST segment is 0001.