Electronic Data Interchange Overview

Electronic Data Interchange (EDI)

Provider Electronic Solutions (PES)

ISA

Interchange Control Header

The ISA is a fixed-length record with fixed-length fields.

ISA05

Interchange ID (Sender) Qualifier

This field will contain a value of “ZZ” to indicate mutually defined.

ISA06

Interchange Sender ID

This field will contain “WISC_DHFS.”

ISA07

Interchange ID (Receiver) Qualifier

This field will contain a value of “ZZ” to indicate mutually defined.

ISA08

Interchange Receiver ID

This field will contain the eight-digit numeric vendor number assigned by Wisconsin Medicaid.

ISA13

Interchange Control Number

Wisconsin Medicaid will assign a number in this field to be used as a distinct tracking number.

ISA16

Component Element Separator

This field will contain a colon.

GS02

Application Sender's Code

This field will contain “WISC_TXIX” for Wisconsin Medicaid.

GS03

Application Receiver's Code

This field will contain the same value as ISA08, which is the eight-digit numeric vendor number assigned by Wisconsin Medicaid.

GS08

Version / Release / Industry Identifier Code

This field will contain a value of “004010X092A1,” which indicates the HIPAA-mandated implementation guide release for this transaction.

Note: The Implementation Guide used to create this HIPAA transaction incorporates the most recent HIPAA addenda changes.

BHT03

Reference Identification

The value in this field will be identical to the unique transaction identifier received in the BHT03 field of the 270 inquiry.

2000A

HL01

Hierarchical ID Number

This field will contain a value of “1.”

2000A

HL04

Hierarchical Child Code

This field will contain a value of “1,” indicating that additional subordinate hierarchical levels exist.

2000A

AAA

Request Validation

This segment will be used in the response if the Medicaid eligibility files were unavailable at the time of processing.

2000A

AAA03

Reject Reason Code

This field will contain “42” to indicate that Wisconsin Medicaid is unable to respond at the current time.

2000A

AAA04

Follow-up Action Code

This field will contain “P” to indicate that the inquiry must be resubmitted.

2100A

NM101

Entity Identifier Code

This field will contain “PR” to indicate payer.

2100A

NM102

Entity Type Qualifier

This field will contain “2” to indicate non-person entity.

2100A

NM103

Last Name or Organization Name

This field will contain “WI MEDICAID.”

2100A

NM108

Identification Code Qualifier

This field will contain “PI” to indicate payer identification.

2100A

NM109

Identification Code

This field will contain “WI MEDICAID.”

2100A

REF

Information Source Additional Information

This segment will not be returned.

2100A

PER

Information Source Contact Information

This segment will contain Wisconsin EDI Helpdesk information.

2100A

PER01

Contact Function Code

This field will contain “IC” to indicate information contact.

2100A

PER02

Name

This field will contain the name of the applicable Wisconsin health care program.

2100A

PER03

Communication Number Qualifier

This field will contain “TE” to indicate telephone.

2100A

PER04

Communication Number

This field will contain the telephone number for the associated entity identified in PER02.

2100A

AAA

Request Validation

This segment will be populated if an error was detected in the 2100A loop of the 270 inquiry.

2100A

AAA03

Reject Reason Code

This field will contain “79” to indicate that an invalid participant identification has been entered in loop 2100A, field NM109 of the 270 inquiry.

2100A

AAA04

Follow-up Action Code

This field will contain “C” to indicate that there was a problem with the inquiry. The inquiry must be corrected and resubmitted.

2000B

HL01

Hierarchical ID Number

This field will contain a value of “2.”

2000B

HL02

Hierarchical Parent ID Number

This field will contain a value of “1,” indicating that this hierarchical level is subordinate to the Information Source HL.

2000B

HL04

Hierarchical Child Code

This field will contain a value of “1,” indicating that additional subordinate hierarchical levels exist.

2100B

NM1

Information Receiver Name

The values returned to the receiver in this segment will be identical to the values sent by the information receiver in the 270 inquiry.

2100B

REF

Information Receiver Additional Identification

This segment will not be returned.

2100B

AAA

Request Validation

This segment will be populated if there was a problem with the inquiry's 2100B, NM1, receiver name segment.

2100B

AAA03

Reject Reason Code

This field will contain “51” to indicate that the provider is not contained in the information source's files.

2100B

AAA04

Follow-up Action Code

This field will contain “C” to indicate that there was a problem with the inquiry. The inquiry must be corrected and resubmitted.

2000C

HL01

Hierarchical ID Number

The first occurrence of this field at the 2000C level will contain a value of “3.” With each subsequent subscriber loop, this value will increment by one.

2000C

HL02

Hierarchical Parent ID Number

This field will contain a value of “2,” indicating that this hierarchical level is subordinate to the Information Receiver HL.

2000C

HL04

Hierarchical Child Code

This field will contain a value of “0” indicating that no subordinate hierarchical levels exist.

2000C

TRN

Subscriber Trace Number

This segment will be used to return the trace number received in the associated subscriber loop of the inquiry as well as to assign a unique Wisconsin Medicaid trace number.

2100C

NM101

Entity Identifier Code

This field will contain “IL” to indicate insured or subscriber.

2100C

NM102

Entity Type Qualifier

This field will contain “1” to indicate person.

2100C

NM103

Last Name or Organization Name

This field will contain the subscriber's last name.

2100C

NM104

First Name

This field will contain the subscriber's first name.

2100C

NM108

Identification Code Qualifier

This field will contain “MI” to indicate member identification number.

2100C

NM109

Identification Code

This field will contain the subscriber's member identification number. This is the Medicaid ID or MAID.

2100C

REF01

Reference Identification Qualifier

This field can contain one of the following values based upon the information received in the inquiry:

• “HJ” — Indicates that the subscriber's identity card number will be returned in REF02.
• “SY” — Indicates that the subscriber's Social Security number will be returned in REF02.

2100C

REF02

Reference Identification

This field can contain either the subscriber's identity card number or Social Security number as qualified by REF01.

2100C

N3

Subscriber Address

This segment will be used to indicate a subscriber's street address. The address will appear as it is contained in the information source's files, regardless of what is received in the inquiry.

2100C

N4

Subscriber City/State/ZIP

This segment will be used to indicate a subscriber's additional address information. The information will appear as it is contained in the information source's files, regardless of what is received in the inquiry.

2100C

PER

Subscriber Contact Information

This segment will not be returned.

2100C

AAA

Subscriber Request Validation

This segment will be used to report any errors detected in the associated 2100C loop of the inquiry.

2100C

AAA03

Reject Reason Code

This field will contain one of the following values:

• “15” — Required application data missing.
• “57” — Invalid/missing dates of service.
• “58” — Invalid date of birth.
• “60” — Date of birth follows date(s) of service.
• “61” — Date of death precedes date(s) of service.
• “62” — Date of service not within allowable inquiry period.
• “63” — Date of service in future.
• “72” — Invalid subscriber ID.
• “75” — Subscriber not found.
• “76” — Duplicate subscriber information found.

2100C

AAA04

Follow-up Action Code

This field will contain “C” to indicate that there was a problem with the inquiry. The inquiry must be corrected and resubmitted.

2100C

DMG01

Date Time Period Format Qualifier

This field will contain “D8” to indicate that a date will be expressed in the format YYYYMMDD in DMG02.

2100C

DMG02

Date Time Period

This field will contain the subscriber's date of birth in the format YYYYMMDD.

2100C

DMG03

Gender Code

• “F” — Female.
• “M” — Male.
• “U” — Unknown.

2100C

INS

Subscriber Relationship

This segment will be returned if the inquiry contains subscriber information that differs from Wisconsin Medicaid’s files. Possible discrepancies are the subscriber’s name or date of birth.

2100C

DTP

Subscriber Date

This segment will not be populated.

2110C

EB

Subscriber Eligibility or Benefit Information

Multiple EB segments may be used to communicate coverage information during the time period indicated in the related DTP segment. The following types of information will be communicated here:

• Medicaid coverage.
• Medicare coverage.
• Private insurance.
• Medicaid managed care program enrollment.
• Lock-in information.

See Attachment 1 for more information.

2110C

HSD

Health Care Services Delivery

This segment will not be returned.

2110C

REF

Subscriber Additional Information

The REF segment will occur at this level of the response in association with Medicare coverage to provide the health insurance claim (HIC) number or in association with private insurance coverage to provide the policy number and group number. Each private insurance policy will have an associated policy number and may or may not have an associated group number.

2110C

REF01

Reference Identification Qualifier

This field will contain one of the following qualifiers:

• “6P” — Group number.
• “IG” — Insurance policy number.
• “F6” — Health insurance claim (HIC) number.

2110C

REF02

Reference Identification

This field will contain the subscribers group number, policy number, or HIC number as qualified by REF01.

2110C

DTP01

Date/Time Qualifier

This field will contain “307” to indicate eligibility.

2110C

DTP02

Date Time Format Qualifier

This field will contain one of the following values:

• “D8” — Indicates that a date will be expressed in the format YYYYMMDD in DTP03.
• “RD8” — Indicates that a range of dates will be expressed in the format YYYYMMDD-YYYYMMDD in DTP03.

2110C

DTP03

Date Time Period

This field will contain the date or dates related to the eligibility or benefit information in the 2110C loop.

2110C

AAA

Subscriber Request Validation

This segment will not be returned.

2110C

MSG

Message Text

This segment can contain a number of different messages that describe a subscriber’s benefits/status:

• If the subscriber’s primary account number (PAN) shows a status of lost/stolen card, the MSG segment will contain a message indicating that status.
• In conjunction with Medicaid eligibility, the MSG segment will be used to provide a description of the subscriber’s medical status code.
• In conjunction with Medicaid eligibility, the MSG segment will contain a message if the subscriber has additional eligibility that has not been displayed.
• If the subscriber resides in a Health Personnel Shortage Area (HPSA), the MSG segment will indicate “HPSA RECIPIENT.”
• In conjunction with managed care program enrollment information, the MSG segment will contain messages associated with certain program enrollments.
• In conjunction with private insurance, the MSG segment will instruct the provider to call the carrier for coverage information.
• In conjunction with private insurance coverage, the MSG segment will contain a message if the subscriber has additional coverage that has not been displayed.

2110C

III

Subscriber Additional Information

This segment will not be returned.

2110C

LS

Loop Header

This segment will be used only when a 2120C loop will be generated.

2110C

LS01

Loop Identifier Code

This field will contain the value “2120.”

2120C

NM1

Subscriber Benefit Related Entity Name

This segment will provide identifying information regarding any lock-in providers, private insurance companies, or managed care providers identified in the EB segment.

2120C

NM101

Entity Identifier Code

This field will contain one of the following values:

• “1P” — Indicates that the 2120C loopwill contain lock-in information.
• “PRP” — Indicates that the 2120C loop will contain private insurance or managed care program information.

2120C

NM103

Last Name or Organization Name

This field will contain the name of the entity identified in NM101.

2120C

NM108

Identification Code Qualifier

When Medicaid managed care information is being returned, this field will contain “SV,” indicating service provider.

2120C

NM109

Identification Code

When Medicaid managed care information is being returned, this field will contain the managed care program’s HMO code.

2120C

N3

Subscriber Benefit Related Entity Address

This segment will be used to indicate street address information for insurance companies.

2120C

N4

Subscriber Benefit Related City/State/ZIP

This segment will be used to indicate additional address information for insurance companies.

2120C

PER

Subscriber Benefit Related Contact Information

This segment will provide telephone numbers for managed care programs and lock-in providers.

2120C

PRV

Subscriber Benefit Related Provider Information

This segment will not be returned.

2110C

LE01

Loop Identifier Code

If loop 2120C is present, this field will contain the value "2120.”

GE01

Number of Transaction Sets Included

This field will contain the number of transaction sets included in the interchange.

GE02

Control Group Number

The value in this field will be identical to the number assigned in field GS06.

IEA01

Number of Functional Groups Included in an Interchange

This field will contain the number of functional groups included in the interchange.

IEA02

Interchange Control Number

The number in this field will be identical to the number entered in ISA13.