[X12 HIPAA] 820 Payroll Deducted and Other Group Premium Payment For Insurance Products Examples (X218)

ST*820*0001*005010X218~
BPR*C*19000*C*ACH*CTX*01*999999992*DA*12345678*1030449999**01*199999999*DA*98765*20070516~
TRN*1*12345*1030449999~
REF*14*12345~
N1*PE*DEF HEALTH CARE INC.*FI*012222222~
N1*PR*ABC PLASTICS*FI*123456789~
ENT*1*2L*FI*123456789~
RMR*IK*970501001*PI*16500~
IT1*1~
SLN*1**O*5*IE~
SLN*2**O*75*10~
RMR*IK*970501002*PI*250~
IT1*1~
SLN*1**O*25*IE~
SE*15*0001~


Example 1: Summary Bill Payment

ST*820*0001*005010X218~
BPR*C*255*C*ACH*CTX*01*999999992*DA*12345678*1345678901**01*199999999*DA*98765*20071103~
TRN*1*78905*1345678901~
REF*14*0011001~
N1*PE*BATA INSURANCE CO.*FI*012222222~
N1*PR*ALFA MEDAL CO*FI*123456789~
ENT*1*2J*34*030440099~
NM1*EY*1*DOE*JOHN****EI*777222~
RMR*IG*555666**30~
RMR*IG*555667**35~
ENT*2*2J*34*029500563~
NM1*EY*1*FIRSTONE*EMILY****EI*777333~
RMR*IG*555777**45~
ENT*3*2J*34*029480664~
NM1*EY*1*MIDDLEONE*JULIE****EI*777444~
RMR*IG*544477**50~
ENT*4*2J*34*030498099~
NM1*EY*1*NEWONE*KELLY****EI*777111~
RMR*IG*551166**45~
RMR*IG*558766**50~
SE*21*0001~


Example 2: List Bill Payment

ST*820*0002*005010X218~
BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~
TRN*3*12345*1231555555~
REF*14*673001~
REF*2F*0004369123~
N1*PE*DEF HEALTHCARE CO*FI*998216353~
N1*PR*ABC PLASTICS*FI*1231555555~
ENT*1*2L*FI*000057811~
RMR*IK*0004369123*PI*20000~
IT1*1~
SLN*1**O*100*IE~
SLN*2**O*75*PR~
SLN*3**O*125*10~
SE*14*0002~


Example 3: Summary Bill

ST*820*0002*005010X218~
BPR*U*20000*C*ACH*CCP*01*934257813*DA*1234587*1231555555**01*025677833*DA*99887766*20070620~
TRN*3*12345*1231555555~
REF*14*673001~
REF*2F*0004369123~
N1*PE*DEF HEALTHCARE CO*FI*998216353~
N1*PR*ABC PLASTICS*FI*000057811~
ENT*1*2J*34*190206123~
NM1*EY*1*SMITH*JOHN****EI*123456~
RMR*CT*190206123**7000~
ENT*2*2J*34*163910163~
NM1*EY*1*JONES*MARY****EI*793016~
RMR*CT*163910163**10000*11000~
ADX*-1000*52~
ENT*3*2J*34*179203456~
NM1*EY*1*JOHNSON*JOE****EI*934213~
RMR*CT*179203456**3000*3100~
ADX*-100*52~
SE*19*0002~


Example 4: List Bill

ST*820*0001*005010X218~
BPR*C*255*C*ACH*CTX*01*999999992*DA*12345678*1345678901**01*199999999*DA*98765*20071103~
TRN*1*78905*1345678901~
REF*14*0011001~
N1*PE*Oscar Health,Inc.*FI*012222222~
N3*75 Varick Street~
N4*New York*NY*10013*US~
N1*PR*Thatch Health,Inc*FI*123456789~
N3*353 Kearny St.~
N4*San Francisco*CA*94108*US~
ENT*1*2J*34*030440099~
NM1*EY*1*Doe*John****EI*777222~
RMR*IG*555666**30~
RMR*IG*555667**35~
ENT*2*2J*34*029500563~
NM1*EY*1*FirstOne*Emily****EI*777333~
RMR*IG*555777**45~
ENT*3*2J*34*029480664~
NM1*EY*1*MiddleOne*Julie****EI*777444~
RMR*IG*544477**50~
ENT*4*2J*34*030498099~
NM1*EY*1*NewOne*Kelly****EI*777111~
RMR*IG*551166**45~
RMR*IG*558766**50~
SE*25*0001~


List Bill Payment Sample

ST*820*0001*005010X218~
BPR*C*19000*C*ACH*CTX*01*999999992*DA*12345678*1030449999**01*199999999*DA*98765*20070516~
TRN*1*12345*1030449999~
REF*14*12345~
N1*PE*Oscar Health,Inc.*FI*012222222~
N3*75 Varick Street~
N4*New York*NY*10013*US~
N1*PR*Thatch Health,Inc*FI*123456789~
N3*353 Kearny St.~
N4*San Francisco*CA*94108*US~
ENT*1*2L*FI*123456789~
RMR*IK*970501001*PI*16500~
IT1*1~
SLN*1**O*5*IE~
SLN*2**O*75*10~
RMR*IK*970501002*PI*250~
IT1*1~
SLN*1**O*25*IE~
SE*19*0001~


X12 820 [X12 HIPAA] 820 Payroll Deducted and Other Group Premium Payment For Insurance Products Examples (X218)