5010 820X Health Insurance Exchange Related Payments [S5]


Loop Qualifiers
xx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy / yyy - Loop Value Qualifier
xxyy / xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date/TimeDate
05GSHDR_GS05_TMTimeTime
06GSHDR_GS06_GCNIntegerGroup Control Number
07GSHDR_GS07_RESP_AGNCY_CDStringResponsible Agency Code
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_IMP_GUID_VERS_NMStringImplementation Guide Version Name
STHDRBPRFinancial Information
02STHDR_BPR02_TOT_PMT_AMTDecimalTotal Payment Amount
04STHDR_BPR04_PMT_METHD_CDStringPayment Method Code
05STHDR_BPR05_PMT_FMT_CDStringPayment Format Code
10STHDR_BPR10_ORG_CO_IDStringOriginating Company Identifier
11STHDR_BPR11_ORG_CO_SUPP_CDStringOriginating Company Supplemental Code
13STHDR_BPR13_ABA_RT_NRStringABA Transit Routing Number Including Check Digits (9 digits)
13STHDR_BPR13_SWIFT_IDStringSwift Identification (8 or 11 characters)
13STHDR_BPR13_CAN_BNK_NRStringCanadian Bank Branch and Institution Number
15STHDR_BPR15_DEMND_DEPSTStringDemand Deposit
15STHDR_BPR15_SAVNGSStringSavings
16STHDR_BPR16_CHK_EFT_EFDT_D8Date/TimeCheck Issue or EFT Effective Date
STHDRTRNReassociation Trace Number
02STHDR_TRN02_CHK_EFT_TRC_NRStringCheck or EFT Trace Number
STHDRREFExchange Assigned Qualified Health Plan Identifier
02STHDR_REF_MSTR_PLCY_NRStringMaster Policy Number
STHDRREFIssuer Assigned Qualified Health Plan Identifier
02STHDR_REF_LOBStringLine of Business
STHDRREFExchange Assigned Employer Group Identifier
02STHDR_REF_PLAN_NRStringPlan Number
STHDRREFIssuer Assigned Employer Group Identifier
02STHDR_REF_GRP_POLCY_NRStringGroup or Policy Number
L1000A - PAYEE NAME
L1000AN1Payee Name
02L1000A_N102_PAYEE_ORG_NMStringPayee Organization Name
04L1000A_N104_PAYEE_TAX_IDStringPayees Tax Identification Number
L1000AREFUnique Health Plan Identifier
02L1000A_REF_MDCR_MDCD_PLANIDStringCenters for Medicare and Medicaid Services Plan ID
L1000B - PAYERS NAME
L1000BN1Payers Name
02L1000B_N102_PYR_NMStringPayer Name
04L1000B_N104_PYR_IDStringPayer Identifier
L1000BPERPayers Administrative Contact Information Iterated: [01-99]
02L1000B_nnPER02_PREM_PYR_CON_NMStringPremium Payer Contact Name
04L1000B_nnPER04_EMAILStringElectronic Mail
04L1000B_nnPER04_FAXStringFacsimile
04L1000B_nnPER04_PHN_NRStringTelephone
06L1000B_nnPER06_EMAILStringElectronic Mail
06L1000B_nnPER06_PHN_EXTStringTelephone Extension
06L1000B_nnPER06_FAXStringFacsimile
06L1000B_nnPER06_PHN_NRStringTelephone
08L1000B_nnPER08_EMAILStringElectronic Mail
08L1000B_nnPER08_PHN_EXTStringTelephone Extension
08L1000B_nnPER08_FAXStringFacsimile
08L1000B_nnPER08_PHN_NRStringTelephone
L2000 - REMITTANCE INFORMATION
L2000ENTRemittance Information
01L2000_ENT01_ASSGD_NRIntegerAssigned Number
L2100 - INDIVIDUAL NAME
L2100NM1Individual Name
03L2100_NM103_IND_LNMStringIndvidual Last Name
04L2100_NM104_IND_FNMStringIndividual First Name
05L2100_NM105_IND_MNMStringIndividual Middle Name
06L2100_NM106_IND_PFXStringIndividual Name Prefix
07L2100_NM107_IND_SFXStringIndividual Name Suffix
09L2100_NM109_XCHG_ASSG_SBR_IDStringExchange Assigned Subscriber Identifier
L2100REFExchange Assigned Qualified Health Plan Identifier
02L2100_REF_MSTR_PLCY_NRStringMaster Policy Number
L2100REFIssuer Assigned Qualified Health Plan Identifier
02L2100_REF_LOBStringLine of Business
L2100REFExchange Assigned Employer Group Identifier
02L2100_REF_PLAN_NRStringPlan Number
L2100REFIssuer Assigned Employer Group Identifier
02L2100_REF_GRP_POLCY_NRStringGroup or Policy Number
L2100REFExchange Assigned Policy Identifier Segment Suffix:
02L2100_REFB_POLCY_NRStringPolicy Number
L2100REFIssuer Assigned Policy Identifier
02L2100_REF_HLTH_INS_PLCYStringHealth Insurance Policy Number
L2100REFExchange Assigned APTC Contributor/Tax Payer Identifier
02L2100_REF_PINStringPersonal Identification Number (PIN)
L2100REFIssuer Assigned APTC Contributor/Tax Payer Identifier
02L2100_REF_CLNT_NRStringClient Number
L2100REFExchange Assigned Dependent Identifier
02L2100_REF_XREF_NRStringExchange Assigned Dependent Identifier
L2100REFIssuer Assigned Dependent Identifier
02L2100_REF_MEM_IDStringMember Identification Number
L2100REFIssuer Assigend Subscriber Identifier
02L2100_REF_SUB_NRStringSubscriber Number
L2300 - REMITTANCE DETAIL
L2300RMRRemittance Detail
02L2300_RMR02_XCHG_PMT_TYPStringExchange Payment Type
04L2300_RMR04_PMT_AMTDecimalPayment Amount
L2300REFExchange Report Document Control Number Iterated: [01-99]
02L2300_nnREF_ATCHD_TOStringAttached To
03L2300_nnREF03_DESCRStringDescription
L2300DTMIndividual Coverage Period
02L2300_DTM02_REPT_PERD_D8Date TimestampReport Period

STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number

GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number