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Health Insurance Exchange Code Lists

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Exchange Payment TypeLAST UPDATED 3/21/2016

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
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 (as of 2/2016).
Start: 11/01/2015
Notes: CMS Individual Market Only
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
BALBalancing Amount. Used when reporting an informational 820 to a State Based Marketplace to force the BRP02 to zero. This code does not apply to State Based Marketplace Issuers but only to the actual SBM. 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: 11/01/2015
Notes: CMS Individual Market Only
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. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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
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 current AR interest rate is 9.75% (as of 1/19/16).
Start: 11/01/2015
Notes: CMS Individual Market Only
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.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
PENPenalty charges for a debt owed by the payee. For 2016, these charges are at the rate of 6% per annum on principal amount delinquent for more than 90 days. This is a program-level code only and no enrollment group (policy) level information will be provided with this code.
Start: 11/01/2015
Notes: CMS Individual Market Only
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. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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. RMR04 will be positive.
Start: 10/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RADRisk Adjustment Default Charge or Proration Payment. RMR04 will be positive or negative.
Start: 05/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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. RMR04 will be positive.
Start: 10/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RAUFRisk Adjustment User Fee. RMR04 will be negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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
RCRisk Corridor Program payment or charge amount. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RCADJRisk Corridor Adjustment. RMR04 will be positive or negative.
Start: 01/01/2015 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RICReinsurance Contribution Amount. RMR04 will be negative.
Start: 06/01/2014 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RICADJReinsurance Contribution Adjustment. RMR04 will be positive or negative.
Start: 06/01/2014 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
RIPReinsurance Payment Amount. RMR04 will be positive.
Start: 06/01/2014 | Last Modified: 11/01/2015
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. RMR04 will be negative.
Start: 10/01/2013 | Last Modified: 11/01/2015
Notes: CMS Individual Market Only
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
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. RMR04 will be positive
Start: 11/01/2015
Notes: CMS Individual Market Only
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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