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Health Insurance Exchange Payment Type codes Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.

About the Exchange Payment Type Codes

Exchange Payment Type codes are transm­itted in 005010­X306, loop 2300, RMR02. They identify the type and purpose for the payment amount transm­itted in ASC X12 005010­X306, loop 2300, RMR04. The pertinent ASC X12 docume­ntation is available in the ASC X12 Store.

While state-­based markets (SBM) may use any code, CMS will only use those codes designated as CMS in the notes below. Issuers in SBM states will need to work with their SBM to determine which codes are applicable to their HIX 820 business process.

CMS or SBM

APTC Advance Payment of Premium Tax Credit. RMR04 will be positive. Start: 10/01/2013 Notes: CMS
APTCADJ Advance Payment of Premium Tax Credit Adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: CMS
APTCMADJ APTC Manual Adjust­ment. Used to show APTC manual adjustment when enrollment group level inform­ation is not applic­able. RMR04 will be positive or negative and may be reversed in the future. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. Start: 10/01/2013 Notes: CMS
BAL Balancing Amount. Used when reporting an inform­ational 820 to a SBM to force the BRP02 to zero. RMR04 will be positive or negative. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. Start: 10/01/2013 | Last Modified: 5/01/2015 Notes: CMS
CSR Advance Payment of Cost Sharing Reduction. RMR04 will be positive. Start: 10/01/2013 Notes: CMS
CSRADJ Advance Payment of Cost Sharing Reduction Adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: CMS
CSRMADJ CSR Manual Adjust­ment. Used to show CSR manual adjustment when enrollment group level inform­ation is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. Start: 10/01/2013 Notes: CMS
CSRN Cost Sharing Reduction Reconc­ili­ation. RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
CSRNADJ Cost Sharing Reduction Reconc­ili­ation Adjust­ment. RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
DEBTADJ Payee's debt amount covered by an affili­ate's payment. RMR04 will be positive. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. When used to report that a prior debt was covered, RMR04 with the payment type code of BAL will also be used. Start: 10/01/2013 | Last Modified: 11/01/2014 | Stop: 05/01/2015 Notes: CMS
DEPEND­ENTPREM Dependent respon­sible premium amount. RMR04 will be positive. Start: 11/01/2014 Notes: CMS SHOP
DEPEND­ENT­PRE­MAD­JCANCEL Dependent premium amount adjustment due to cancel­lation. RMR04 will positive or negative Start: 11/01/2014 Notes: CMS SHOP
DEPEND­ENT­PRE­MADJNSF Dependent respon­sible premium amount due to non-su­ffi­cient funds. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
DEPEND­ENT­PRE­MAD­JTE­RMINATE Dependent respon­sible premium amount due to the termin­ation of a policy. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­EEPREM Employee respon­sible premium amount.RMR04 will be positive. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­EEP­REM­ADJ­CANCEL Employee respon­sible premium amount adjustment due to cancel­lation. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­EEP­REM­ADJNSF Employee respon­sible premium amount adjustment due to non-su­ffi­cient funds. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­EEP­REM­ADJ­TER­MINATE Employee respon­sible premium amount adjustment due to the termin­ation of a policy. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­ERPREM Employer respon­sible premium amount. RMR04 will be positive. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­ERP­REM­ADJ­CANCEL Employer respon­sible premium amount adjustment due to cancel­lation. RMR04 will be positive or negative Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­ERP­REM­ADJNSF Employer respon­sible premium amount adjustment due to non-su­ffi­cient funds.** RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
EMPLOY­ERP­REM­ADJ­TER­MINATE Employer respon­sible premium amount adjustment due to the termin­ation of a policy. RMR04 will be positive or negative. Start: 11/01/2014 Notes: CMS SHOP
INVOICE Used to show a total amount that will be billed or otherwise collected. Only used when BPR02 would otherwise be negative. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. Start: 10/01/2013 Notes: CMS
RA Risk Adjustment Transfer Charge or Proration amount. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 5/01/2015 Notes: CMS
RAADJ Risk Adjustment Payment or Charge Adjust­ment. RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
RAD Risk Adjustment Default Charge or Proration Payment.** RMR04 will be positive or negative. Start: 05/01/2015 Notes: CMS
RAUF Risk Adjustment User Fee. RMR04 will be negative. Start: 01/01/2015 Notes: CMS
RAUFADJ Risk Adjustment User Fee Adjust­ment.** RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
RC Risk Corridor Program payment or charge amount. RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
RCADJ Risk Corridor Adjust­ment. RMR04 will be positive or negative. Start: 01/01/2015 Notes: CMS
REDUCED Payment reduced to cover a debt owed by the payee. RMR04 will be negative. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code.** Start: 10/01/2013 | Last Modified: 5/01/2015 Notes: CMS
RIC Reinsu­rance Contri­bution Amount. RMR04 will be negative. Start: 06/01/2014 Notes: CMS
RICADJ Reinsu­rance Contri­bution Adjust­ment. RMR04 will be positive or negative. Start: 06/01/2014 Notes: CMS
RIP Reinsu­rance Payment Amount. RMR04 will be positive. Start: 06/01/2014 Notes: CMS
RIPADJ Reinsu­rance Payment Adjust­ment. RMR04 will be positive or negative. Start: 06/01/2014 Notes: CMS
SHOPUF Federa­lly­-fa­cil­itated Market­place User Fee for SHOP plans. RMR04 will be negative. Start: 10/01/2013 Notes: CMS
SHOPUFADJ Federa­lly­-fa­cil­itated Market­place User Fee Adjustment for SHOP plans. RMR04 will be positive or negative. Start: 10/01/2013 Notes: CMS
SHOPUFMADJ Federa­lly­-fa­cil­itated Market­place User Fee Manual Adjustment for SHOP Plans. Used to show user fee manual adjustment for SHOP plans when enrollment group level inform­ation is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code.
Start: 10/01/2013 Notes: CMS
UF Federa­lly­-fa­cil­itated Market­place User Fee. RMR04 will be negative. Start: 10/01/2013 Notes: CMS
UFADJ Federa­lly­-fa­cil­itated Market­place User Fee Adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013 Notes: CMS

SMB Only

UFMADJ Federa­lly­-fa­cil­itated Market­place User Fee Manual Adjust­ment. Used to show user fee manual adjustment when enrollment group level inform­ation is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a progra­m-level code only and no enrollment group (policy) level inform­ation will be provided with this code. Start: 10/01/2013
COMM Any commis­sions withheld by the Exchange. RMR04 will be negative. Start: 10/01/2013
COMMADJ Any commis­sions adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013
INTPREM Initial premium payment received by the Exchange from the customer. This amount will be the gross premium received from the customer. RMR04 will be positive. Start: 10/01/2013
MDCAID State Medicaid Subsidy. RMR04 will be positive. Start: 10/01/2013
MDCAIDADJ State Medicaid Subsidy Adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013
MISC Used to indicate miscel­laneous amounts (i.e. write-­offs, etc.). RMR04 will be positive or negative. Start: 10/01/2013
MRF Market­pla­ce-­Related Fee. This is the amount that is being paid not attrib­utable to an individual coverage but at a plan or carrier level. If negative, the fee was withheld from carrier payments. If positive, the fee was paid to the carrier. RMR04 will be positive or negative. Start: 10/01/2013
MRFADJ Adjust­ments to a previously sent MRF. The MRFADJ is not attrib­utable to an individual coverage level but at a plan or carrier level. RMR04 will be positive or negative. Start: 10/01/2013
NONPAYADJ Code use to indicate an adjustment is being made due to a NSF or stop payment. Amount will always be negative. Start: 10/01/2013
OPMUF OPM Multi-­State Plan user fee. RMR04 will be negative. Start: 10/01/2013
OPMUFADJ OPM Multi-­State Plan user fee manual adjust­ment. Used to show user fee manual adjustment when enrollment group level inform­ation is not provided. RMR04 will be positive or negative and may be reversed in the future. Start: 10/01/2013
PREM Premium payment amount received for the enrollment group for coverage (excluding APTC and Exchan­ge-­Related Fees). RMR04 will be positive. Start: 10/01/2013
PREMADJ Adjust­ments to premium payment amount received for the enrollment group for coverage (excluding APTC and Market­pla­ce-­Related Fees). RMR04 will be positive or negative. Start: 10/01/2013
PREMALL Premium payment amount received for the enrollment group for coverage (including APTC and Market­pla­ce-­Related Fees). RMR04 will be positive. Start: 10/01/2013
PREMALLADJ Adjust­ments to premium payment amount received for the enrollment group for coverage (including APTC and Market­pla­ce-­Related Fees). RMR04 will be positive or negative. Start: 10/01/2013
REFUND Total refunded amount sent back to the customer. RMR04 will be negative. Start: 10/01/2013
RETURN Total returned payment (i.e. returned due to non-su­ffi­cient funds). RMR04 will be negative. Start: 10/01/2013
SBMUF State Based Market­place User Fee. RMR04 will be negative. Start: 5/01/2015
SBMUFADJ State Based Market­place User Fee Adjust­ment.** RMR04 will be positive or negative. Start: 5/01/2015
SMAND State Mandate Benefit Subsidy. RMR04 will be positive. Start: 10/01/2013
SMANDADJ State Mandate Benefit Subsidy Adjust­ment. RMR04 will be positive or negative. Start: 10/01/2013
TPP Money paid by a third party payer as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013
TPPADJ Adjust­ments to Money paid by a third party payer as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013
TRIBE Money paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market.
Start: 10/01/2013
TRIBEADJ Adjust­ments to Money paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market. Start: 10/01/2013
WRITEOFF Write off amount. Start: 06/01/2014