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Health Insurance Exchange Code Lists

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Exchange Payment TypeLAST UPDATED 5/1/2017

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.

Note:
Catastrophic is included in Individual Market and Merged is Individual and Small Group Markets combined.
All markets include both on and off exchange issuers.
Exchange markets include Individual/Small Group/Catastrophic/Merged.
Specific transaction detail may be provided in the Document Control Number in the payment reports effective July 2017.

CMS or SBM
ADMAdministrative Fees used for a debt owed by the payee. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. The Administrative Fee is $15. Negative Amounts Only
Start: 11/01/2015 | Last Modified: 05/01/2017
Notes: CMS All Programs and Relevant Markets
APTCAdvance Payment of Premium Tax Credit. RMR04 will be positive.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
APTCADJAdvance Payment of Premium Tax Credit Adjustment. RMR04 will be positive or negative.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
APTCMADJAPTC 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 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
BALWhen an AR invoice is split between multiple HIX 820 reports, this adjustment balances the reports. Negative Amounts & Positive Amounts
Start: 10/01/2013 | Last Modified: 05/01/2017
Notes: CMS All Programs and Relevant Markets
CSRAdvance Payment of Cost Sharing Reduction. RMR04 will be positive.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
CSRADJAdvance Payment of Cost Sharing Reduction Adjustment. RMR04 will be positive or negative.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
CSRMADJCSR 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 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
CSRNCost Sharing Reduction Reconciliation. Negative Amounts & Positive Amounts
Start: 01/01/2015 | Last Modified: 05/01/2017
Notes: CMS Exchange Markets
CSRNADJCost Sharing Reduction Reconciliation Adjustment. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
DEBTADJPayee'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
DEPENDENTPREMDependent responsible premium amount. RMR04 will be positive.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
DEPENDENTPREMADJCANCELDependent premium amount adjustment due to cancellation. RMR04 will positive or negative
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
DEPENDENTPREMADJNSFDependent responsible premium amount due to non-sufficient funds. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
DEPENDENTPREMADJTERMINATEDependent responsible premium amount due to the termination of a policy. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYEEPREMEmployee responsible premium amount. RMR04 will be positive.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYEEPREMADJCANCELEmployee responsible premium amount adjustment due to cancellation. RMR04 will be positive or negative
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYEEPREMADJNSFEmployee responsible premium amount adjustment due to non-sufficient funds. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYEEPREMADJTERMINATEEmployee responsible premium amount adjustment due to the termination of a policy. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYERPREMEmployer responsible premium amount. RMR04 will be positive.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYERPREMADJCANCELEmployer responsible premium amount adjustment due to cancellation. RMR04 will be positive or negative
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYERPREMADJNSFEmployer responsible premium amount adjustment due to non-sufficient funds. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EMPLOYERPREMADJTERMINATEEmployer responsible premium amount adjustment due to the termination of a policy. RMR04 will be positive or negative.
Start: 11/01/2014 | Last Modified: 11/01/2015
Notes: CMS SHOP Market Only
EXTLOANPayment Offsets For Co-op Loan. Negative Amounts Only
Start: 10/18/2016
Notes: CMS Co-ops Only
INTInterest charges for a debt owed by the payee. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. The Secretary of Treasury certifies and updates an interest rate on a quarterly basis. Negative Amounts Only
Start: 11/01/2015 | Last Modified: 05/01/2017
Notes: CMS All Programs and Relevant Markets
INVOICEUsed 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. Negative Amounts Only
Start: 10/01/2013 | Last Modified: 05/01/2017
Notes: CMS All Programs and Relevant Markets
PENPenalty charges for a debt owed by the payee. The Treasury will add additional administrative fees of up to 30 percent and accrue the required penalty charge of 6 percent per year on any amount outstanding. Interest will continue to accrue. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Negative Amounts Only
Start: 11/01/2015 | Last Modified: 05/01/2017
Notes: CMS All Programs and Relevant Markets
RARisk Adjustment Transfer Charge or Proration amount. If RA is the Payment Type Code, a corresponding Report Type Code of RARPT will also be included. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts
Start: 01/01/2015 | Last Modified: 05/01/2017
Notes: All Markets
RAADJRisk Adjustment Payment or Charge Adjustment. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RAARRisk Adjustment Administration Fee Refund. A Risk Adjustment Admin Fee is only charged if an Issuer does not pay their RA Charges within 30 days. Positive Amounts Only
Start: 10/01/2015 | Last Modified: 05/01/2017
Notes: All Markets
RACRRisk Adjustment Refund For Prior Fiscal Years. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RADRisk Adjustment Default Charge or Proration Payment. (Invoice Number and specific detail may be provided in the Document Control Number in the payment reports effective July 2017). Negative Amounts & Positive Amounts
Start: 05/01/2015 | Last Modified: 05/01/2017
Notes: All Markets
RAIRRisk Adjustment Interest Charge Refund. A Risk Adjustment Interest Charge is only assessed if an Issuer does not pay their RA Charges within 30 days. Negative Amounts & Positive Amounts
Start: 10/01/2015 | Last Modified: 05/01/2017
Notes: All Markets
RAREFRisk Adjustment Refund For Current Fiscal Year. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RAUFRisk Adjustment User Fee. Negative Amounts Only
Start: 01/01/2015 | Last Modified: 05/01/2017
Notes: All Markets
RAUFADJRisk Adjustment User Fee Adjustment. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RAUFARRisk Adjustment User Fee Refund of admin charge. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RAUFIRRisk Adjustment User Fee Refund of interest charge. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RAUFRRisk Adjustment User Fee Refund. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RAUFR2PYRisk Adjustment User Fee Refund. Positive Amounts Only
Start: 10/18/2016
Notes: All Markets
RAUFREFRisk Adjustment User Fee refund for current fiscal year. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RAUFRNRisk Adjustment User Fee Refund. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RCRisk Corridor Program payment or charge amount. Negative Amounts & Positive Amounts
Start: 01/01/2015 | Last Modified: 05/01/2017
Notes: CMS Exchange Markets
RC15Risk Corridors Charges. Negative Amounts Only
Start: 10/18/2016
Notes: CMS Exchange Markets
RCADJRisk Corridor Adjustment. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RCARRisk Corridors Refund Of Admin Charge. Positive Amounts Only
Start: 10/18/2016
Notes: CMS Exchange Markets
RCCR15Risk Corridors Refund For Prior Fiscal Years. Positive Amounts Only
Start: 10/18/2016
Notes: CMS Exchange Markets
RCCR16Risk Corridors Refund For Current Fiscal Year. Positive Amounts Only
Start: 10/18/2016
Notes: CMS Exchange Markets
RCIRRisk Corridors Refund Of Interest Charge. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
RCREFRisk Corridors Refund For Current Fiscal Year. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
REDUCEDPayment 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. Negative Amounts Only
Start: 10/01/2013 | Last Modified: 05/01/2017
Notes: CMS Exchange Markets
RICReinsurance Contribution Amount. Negative Amounts & Positive Amounts
Start: 06/01/2014 | Last Modified: 05/01/2017
Notes: All Markets
RICADJReinsurance Contribution Adjustment. RMR04 will be positive or negative.
Start: 06/01/2014 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RICARReinsurance Contribution Refund Of Admin Charge. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RICIRReinsurance Contribution Refund Of Interest Charge. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RICRReinsurance Contribution Refund For Prior Fiscal Years. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RICREFReinsurance Contribution Refund For Current Fiscal Year. Positive Amounts Only
Start: 05/01/2015
Notes: All Markets
RIPReinsurance Payment Amount. Negative Amounts & Positive Amounts
Start: 06/01/2014 | Last Modified: 05/01/2017
Notes: CMS Individual Market Only
RIPADJReinsurance Payment Adjustment. RMR04 will be positive or negative.
Start: 06/01/2014 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
SHOPUFFederally-facilitated Marketplace User Fee for SHOP plans. (SHOP HIX 820 Trace Number may be provided in the Document Control Number in the payment reports). Negative Amounts & Positive Amounts
Start: 10/01/2013 | Last Modified: 05/01/2017
Notes: CMS SHOP Market
SHOPUFADJFederally-facilitated Marketplace User Fee Adjustment for SHOP plans. RMR04 will be positive or negative. This code will not be used.
Start: 10/01/2013 | Last Modified: 11/01/2015 | Stop: 11/01/2015
Notes: CMS Individual Market Only
SHOPUFMADJFederally-facilitated Marketplace User Fee Manual Adjustment for SHOP Plans.
Start: 10/01/2013 | Last Modified: 11/01/2015 | Stop: 11/01/2015
Notes: CMS Individual Market Only
UFFederally-facilitated Marketplace User Fee. RMR04 will be negative.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
UFADJFederally-facilitated Marketplace User Fee Adjustment. RMR04 will be positive or negative.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
UFARFFM User Fee refund of admin charges. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
UFIRFFM User Fee Refund of interest charges. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
UFMADJFederally-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 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
UFRFederally-facilitated Marketplace User Fee Adjustment related to providing contraceptive care coverage. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. Positive Amounts Only
Start: 11/01/2015 | Last Modified: 05/01/2017
Notes: CMS Exchange Markets
UFR2PYFFM User Fee Refund. Positive Amounts Only
Start: 10/18/2016
Notes: CMS Exchange Markets
UFRPFFM User Fee Refund. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
UFRPNFFM User Fee Refund. Positive Amounts Only
Start: 05/01/2015
Notes: CMS Exchange Markets
SBM Only
COMMAny commissions withheld by the Exchange. RMR04 will be negative.
Start: 10/01/2013
Notes: SBM Only
COMMADJAny commissions adjustment. RMR04 will be positive or negative.
Start: 10/01/2013
Notes: SBM Only
DEDUCTDeductible amount due to the Payer. RMR04 will be positive or negative.
Start: 10/01/2015
Notes: SBM Only
INTPREMInitial 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
Notes: SBM Only
MDCAIDState Medicaid Subsidy. RMR04 will be positive.
Start: 10/01/2013
Notes: SBM Only
MDCAIDADJState Medicaid Subsidy Adjustment. RMR04 will be positive or negative.
Start: 10/01/2013
Notes: SBM Only
MISCUsed to indicate miscellaneous amounts (i.e. write-offs, etc.) RMR04 will be positive or negative.
Start: 10/01/2013
Notes: SBM Only
MRFMarketplace-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
Notes: SBM Only
MRFADJAdjustments 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
Notes: SBM Only
NONPAYADJCode use to indicate an adjustment is being made due to a NSF or stop payment. Amount will always be negative.
Start: 10/01/2013
Notes: SBM Only
OPMUFOPM Multi-State Plan user fee. RMR04 will be negative.
Start: 10/01/2013
Notes: SBM Only
OPMUFADJOPM 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
Notes: SBM Only
PREMPremium payment amount received for the enrollment group for coverage (excluding APTC and Exchange-Related Fees). RMR04 will be positive.
Start: 10/01/2013
Notes: SBM Only
PREMADJAdjustments 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
Notes: SBM Only
PREMALLPremium payment amount received for the enrollment group for coverage (including APTC and Marketplace-Related Fees). RMR04 will be positive.
Start: 10/01/2013
Notes: SBM Only
PREMALLADJAdjustments 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
Notes: SBM Only
REFUNDTotal refunded amount sent back to the customer. RMR04 will be negative.
Start: 10/01/2013
Notes: SBM Only
RETURNTotal returned payment (i.e. returned due to non-sufficient funds). RMR04 will be negative.
Start: 10/01/2013
Notes: SBM Only
SBMUFState Based Marketplace User Fee. RMR04 will be negative.
Start: 05/01/2015
Notes: SBM Only
SBMUFADJState Based Marketplace User Fee Adjustment. RMR04 will be positive or negative.
Start: 05/01/2015
Notes: SBM Only
SMANDState Mandate Benefit Subsidy. RMR04 will be positive.
Start: 10/01/2013
Notes: SBM Only
SMANDADJState Mandate Benefit Subsidy Adjustment. RMR04 will be positive or negative.
Start: 10/01/2013
Notes: SBM Only
TPPMoney paid by a third party payer as a subsidy to Subscriber coverage in the individual market.
Start: 10/01/2013
Notes: SBM Only
TPPADJAdjustments to Money paid by a third party payer as a subsidy to Subscriber coverage in the individual market.
Start: 10/01/2013
Notes: SBM Only
TRIBEMoney paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market.
Start: 10/01/2013
Notes: SBM Only
TRIBEADJAdjustments to Money paid by a registered Tribe as a subsidy to Subscriber coverage in the individual market.
Start: 10/01/2013
Notes: SBM Only
WRITEOFFWrite off amount
Start: 06/01/2014
Notes: SBM Only
 

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