| Loop |
Element |
Name |
Instruction |
|
ISA |
Interchange Control Header |
The ISA is a fixed-length record with fixed length fields.
Note: Deviating from the standard's ISA element sizes will cause the interchange to be rejected. |
|
ISA05 |
Interchange ID (Sender) Qualifier |
Enter the value “ZZ,” which is mutually defined. |
|
ISA06 |
Interchange Sender ID |
Enter the eight-digit numeric vendor number assigned by Wisconsin Medicaid. |
|
ISA07 |
Interchange ID (Receiver) Qualifier |
Enter the value “ZZ,” which is mutually defined. |
|
ISA08 |
Interchange Receiver ID |
Enter “WISC_DHFS.” |
|
ISA13 |
Interchange Control Number |
The interchange control number assigned in ISA13 must be identical to the value in IEA02. If these numbers do not match, the transaction will not be processed. |
|
ISA16 |
Component Element Separator |
Wisconsin Medicaid recommends the use of a colon “:” in this field. |
|
GS02 |
Application Sender's Code |
Enter the same value as ISA06, the eight-digit numeric vendor number assigned by Wisconsin Medicaid. |
|
GS03 |
Application Receiver's Code |
Enter “WISC_TXIX” for Wisconsin Medicaid. |
|
GS06 |
Group Control Number |
The group control number assigned in GS06 must be identical to the value in GE02. If these numbers do not match, the interchange will not be processed. |
|
GS08 |
Version / Release / Industry Identifier Code |
Enter the value “004010X092A1” to indicate the HIPAA-mandated implementation guide release for this transaction.
Note: This code represents the HIPAA Implementation Guide with the most recent addenda changes. Using an earlier guide, without the most recent addenda changes, does not comply with the HIPAA rule and will cause the transaction to be rejected. |
|
ST02 |
Transaction Set Control Number |
The transaction set control number assigned in ST02 must be identical to the value in SE02. If these numbers do not match, the transaction will not be processed. Start with a number, for example “0001,” and increment with each subsequent transaction set. This number must be unique within an interchange, but can repeat in other interchanges. |
|
BHT03 |
Reference Identification |
Make this identifier unique to a single transaction (ST to SE envelope). Repeating a value will cause the transaction to be rejected. It is recommended that a value with an easily identifiable pattern is used to aid research (e.g., “ANY_GROUP_PRACTICE_20031016” or “ANY GROUP PRACTICE #00001”). |
2100A |
NM101 |
Entity Identifier Code |
Enter “PR” to indicate payer. |
2100A |
NM102 |
Entity Type Qualifier |
Enter “2” to indicate a non-person entity. |
2100A |
NM108 |
Identification Code Qualifier |
Enter “PI” to indicate payer identification. |
2100A |
NM109 |
Identification Code |
Enter “WISC_TXIX” for Wisconsin Medicaid. |
2100B |
NM108 |
Identification Code Qualifier |
Enter “SV” to indicate the service provider number. |
2100B |
NM109 |
Identification Code |
Enter the information receiver’s Wisconsin Medicaid provider identification number. |
2100B |
REF |
Information Receiver Additional Information |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100B |
N3 |
Information Receiver Address |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100B |
N4 |
Information Receiver City/State/ZIP |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100B |
PER |
Information Receiver Contact Info |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100B |
PRV |
Provider Segment |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2000C |
TRN |
Subscriber Trace Number |
This segment may be used to assign a trace number to a transaction. 271 responses will contain as many TRN segments as were present on the received 270 inquiry as well as an additional segment originated by the information source. |
2000C |
TRN02 |
Reference Identification |
Use this field to assign a unique trace or reference number for this transaction. |
2000C |
TRN03 |
Originating Company Identifier |
Use this field for an identification number of the entity that originated the reference identification in TRN02. |
2100C |
NM101 |
Entity Identifier Code |
Enter “IL” to indicate insured or subscriber. |
2100C |
NM102 |
Entity Type Qualifier
| Enter “1” to indicate person. |
2100C |
NM103 |
Last Name or Organization Name |
Enter the subscriber's last name. |
2100C |
NM104 |
First Name |
Enter the subscriber's first name. |
2100C |
NM108 |
Identification Code Qualifier |
Enter “MI” to indicate member identification number. |
2100C |
NM109 |
Identification Code |
Enter the subscriber's member identification number. |
2100C |
REF |
Subscriber Additional Information |
The REF segment can be used to return either the subscriber’s Social Security number or the subscriber’s PAN number. The REF segment can be repeated if both numbers will be sent. |
2100C |
REF01 |
Reference Identification Qualifier |
If providing the subscriber’s Social Security number, use “SY.” If providing the subscriber’s PAN number, use “HJ.” |
2100C |
REF02 |
Reference Identification |
Enter either the subscriber's identification card number or Social Security number as qualified by field REF01. |
2100C |
N3 |
Subscriber Address |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100C |
N4 |
Subscriber City/State/ZIP |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100C |
PRV |
Provider Information |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100C |
DMG |
Subscriber Demographic Information |
The DMG segment should only be used if the subscriber’s date of birth is to be provided. |
2100C |
DMG01 |
Date Time Period Format Qualifier |
Enter “D8” to indicate a single date. |
2100C |
DMG02 |
Date Time Period |
Enter the subscriber's date of birth in the format YYYYMMDD. |
2100C |
INS |
Subscriber Relationship |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2100C |
DTP |
Subscriber Date |
The DTP segment can be used to specify a date or range of dates for which eligibility will be verified. If no DTP segment is present, the recipient’s eligibility will be provided for the date the transaction is processed. |
2100C |
DTP01 |
Date Time Qualifier |
Enter “307” to indicate eligibility. |
2100C |
DTP02 |
Date Time Period Qualifier |
Enter one of the following values:
- “D8” — Indicates that DTP03 will contain a single date.
- “RD8” — Indicates that DTP03 will contain a range of dates.
|
2100C |
DTP03 |
Date Time Period |
Enter the date(s) of inquiry for the subscriber’s benefits. |
2110C |
EQ01 |
Service Type Code |
Enter “30” to indicate health benefit plan coverage. |
2110C |
AMT |
Subscriber Spenddown Amount |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2110C |
III |
Subscriber Eligibility or Benefit Additional Inquiry Information |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2110C |
REF |
Subscriber Additional Information |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2110C |
DTP |
Subscriber Eligibility/Benefit Date |
It is not necessary to submit any data in this segment as it is irrelevant for Wisconsin Medicaid’s purposes. Any data submitted in this segment will not be used in processing the inquiry. |
2000D |
|
Dependent Level |
Because each subscriber and each of his/her dependents is assigned a unique identification number, dependents are treated as subscribers in the Wisconsin Medicaid system. Thus, there is no need to submit any data at the dependent level. Any data submitted at the dependent level will not be used in processing the inquiry. |
|
GE01 |
Number of Transaction Sets Included |
Enter the number of transaction sets included in the interchange. |
|
GE02 |
Control Group Number |
The value in this field must be identical to the number assigned in field GS06. |
|
IEA01 |
Number of Included Functional Groups Included in an Interchange |
The number in this field is a count of the “GS” records created. This must always be a value of “1.” |
|
IEA02 |
Interchange Control Number |
The number in this field must be identical to the number entered in ISA13. |
