Wisconsin Medicaid Companion Document to HIPAA Implementation Guide: X12 270/271 Eligibility, Coverage, or Benefit Inquiry and Response (Batch Process)

PHC 13092 (Rev. 2/06)
PDF (158 KB)
Revision Log

Companion Document Audience

Companion documents are intended for information technology and/or systems staff who will be coding billing systems or software for compliance with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Purpose of Companion Documents

The information contained in this companion document applies to Wisconsin Medicaid, BadgerCare, and SeniorCare, although the companion document only refers to Wisconsin Medicaid.

The companion documents are designed to be used with HIPAA Implementation Guides. Companion documents provide Wisconsin Medicaid-specific information that details the way to create HIPAA transactions for Wisconsin Medicaid and explains how Wisconsin Medicaid creates HIPAA transactions. Companion documents clarify the HIPAA-designated standards usage but are not intended to supercede them. The purpose of companion documents is to provide trading partners with a guide to communicate the Wisconsin Medicaid-specific information required to successfully exchange transactions electronically with Wisconsin Medicaid.

Wisconsin Medicaid will accept and process any HIPAA-compliant transaction. However, a compliant transaction that doesn’t contain Wisconsin Medicaid-specific information, though processed, may be denied for payment. For example, a compliant 837 claim created without a Wisconsin Medicaid recipient identification number will be processed by Wisconsin Medicaid, but will be denied payment.

Companion documents highlight the data elements significant for Wisconsin Medicaid. For transactions created by Wisconsin Medicaid, companion documents explain how certain data elements are processed. Please refer to the companion document first if there is a question about how Wisconsin Medicaid processes a HIPAA transaction. For further information, contact the Division of Health Care Financing (DHCF) Electronic Data Interchange (EDI) Department at (608) 221-9036.

Terminology

The term subscriber will be used as a generic term throughout the companion document. This term could refer to any one of the following depending upon the health program for which the transaction is being processed:

• Wisconsin Medicaid recipient.
• Wisconsin Chronic Disease Program (WCDP) recipient.

Search Criteria

The following are criteria upon which subscriber searches can be based. At least one of these combinations of subscriber data must be present in a 270 inquiry to support the generation of a 271 response:

1. PAN (primary account number).
2. Medicaid identification number (MAID).
3. Social Security number, date of birth.
4. Last name, first name, date of birth.
5. Last name, first name, Social Security number.

If the search for a subscriber is unsuccessful, the subscriber's identifying information such as name, birthdate, and Social Security number will be returned in the 271 response as it was received on the 270 inquiry.

If the search for a subscriber is successful, the subscriber's identifying information contained in the 271 response will be taken from the applicable eligibility file. In the case that the source data differs from the data sent in an inquiry, notification will be sent in the response that a change has been made to one or more of the fields that was received. This will be indicated in the INS segment of the 2100C loop.

Acceptable Characters

All alpha-characters used in 270 transactions must be in an uppercase format. All names on Wisconsin Medicaid’s files are stored in uppercase format. Therefore, inquiries containing lowercase characters could result in unnecessary rejections. All alpha-characters used in the 271 transactions will also be in an uppercase format.

The 270 transaction must not contain any carriage returns nor line feeds; the data must be received in one, continuous stream.

Patient Limit

Please limit the number of patient inquiries per 270 transaction set to 99. One transaction set includes all data between and including a Transaction Set Header (ST) segment and Transaction Set Trailer (SE) segment. The response system will attempt to provide one response transaction set per inquiry transaction set. However, due to size constraints, responses to unusually large inquiries may be broken into multiple response transaction sets.

Acknowledgements

An accepted 997 acknowledgement, rejected 997 acknowledgement, or rejected TA1 acknowledgement will be generated in response to all submitted files. Trading partners are responsible for retrieving acknowledgments from the EDI Web site to determine the status of their files. E-mails will be generated for trading partners with a valid e-mail address on file as a notification that a 997 reject or TA1 acknowledgement has been generated.

Companion documents for the 997 and TA1 acknowledgements are available on the Wisconsin Medicaid Web site.

271 Interpretation Guidelines

The following five types of eligibility and benefit information can be returned in Wisconsin Medicaid’s eligibility response (271 transaction):

• Wisconsin health care eligibility (Medicaid).
• Medicare coverage.
• Medicaid managed care program enrollment.
• Lock-In Status.
• Private Insurance Coverage.

It is important that all aspects of a subscriber’s eligibility and benefits are considered when reading an eligibility response. This is important because Wisconsin Medicaid is a payer of last resort. The simple fact that a subscriber is eligible for Wisconsin Medicaid does not always indicate that Wisconsin Medicaid should be billed for services rendered. If a subscriber has coverage through private insurance, Medicare, or Medicaid managed care, services should be billed accordingly. For questions regarding appropriate billing procedures, providers should refer to their Wisconsin Medicaid handbooks.

All eligibility and benefit information is accompanied by effective dates. It is important that effective dates are considered in combination with the dates of service submitted in the inquiry. If eligibility information is requested for a range of dates, it is possible that the subscriber’s coverage may vary at times throughout the range of service dates.

Version 2 Revision Log

Version 3 Revision Log

Please choose a link to view X12 270/271:

• X12 270 Eligibility Inquiry.
• X12 271 Eligibility, Benefit Response.
• Attachment 1 — 270/271 Eligibility, Benefit, or Coverage Inquiry and Response Notes.

Back to Companion Documents

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