Electronic Data Interchange Overview

Electronic Data Interchange (EDI)

Provider Electronic Solutions (PES)

ISA

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. This is the character that will function as a component element separator in the transaction.

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.

BTH03

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

AAA

Request validation

This segment will be used in the response to indicate that there was a problem within the header of the inquiry.

2000A

AAA03

Reject reason code

This field will contain one of the following values:

• 41 — Indicates that the entity identified in GS02 is not authorized to submit transactions for one of the applicable Wisconsin health care programs.
• 42 — Indicates that Wisconsin Medicaid is unable to respond at the current time.
• 79 — Indicates that a participant identification number provided in either GS02 or GS03 of the 270 inquiry was invalid.

2000A

AAA04

Follow-up action code

This segment will contain one of two values:

• P — Indicates that the inquiry must be resubmitted.
• C — Indicates that there was a problem with the inquiry. The inquiry must be corrected and 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 a nonperson entity.

2100A

NM103

Last name or organization name

This field will contain “Wisconsin Medicaid”.

2100A

NM108

Identification code qualifier

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

2100A

NM109

Identification code

This field will contain “Wisconsin 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 phone 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 or if the quantity of allowable transactions was exceeded.

2100A

AAA03

Reject reason code

This field will contain one of the following values:

• 04 — Indicates that the quantity of allowable transactions has been exceeded. Only one transaction is allowable per transmission in real- time.
• 79 — Indicates 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 the following value:

• C — Indicates that there was a problem with the inquiry. The inquiry must be corrected and resubmitted.

2100B

NM1

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

NM108

Identification Code Qualifier

The value “XX” will be returned if the NPI was used in the original request to indicate that the next element contains the NPI. The value “24” will be used if the next element is the provider’s tax identification number. The value “34” will be used if the next element is the provider’s SSN.

2100B

NM109

Identification Code

Either the NPI, tax ID or SSN will be returned in this field.

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 the following value:

• 51 — Indicates that the provider is not contained in the information source's files.

2100B

AAA04

Follow-up action code

This field will contain the following value:

• C — Indicates that there was a problem with the inquiry. The inquiry must be corrected and resubmitted.

2100C

TRN

Subscriber trace number

This segment will be used to return each of the TRN segments that were received in the 270 inquiry as well as to assign a unique 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.

2100C

REF01

Reference identification qualifier

This field can contain one of the following values based upon the information received in the 270 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 indicated 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 sent in the 270 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 sent in the 270 inquiry.

2100C

PER

Subscriber contact information

This segment will not be returned.

2100C

AAA

Subscriber request validation

This segment will be populated if there is a problem with the inquiry's 2100C, subscriber segment.

2100C

AAA03

Reject reason code

This field will contain a valid value from the Implementation Guide that properly indicates any errors detected in the 270 inquiry.

See Note 2 in Attachment 1.

2100C

AAA04

Follow-up action code

This field will contain the following value:

• C — Indicates 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 the following value:

• D8 — Indicates that a date will be expressed in the format YYYYDDMM in DTP03.

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 MAID, name, or date of birth.

2100C

DTP

Subscriber date

This segment will not be populated.

2110C

EB

Subscriber eligibility or benefit information

Any number of 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.
• Lock in information.

See Note 3 in Attachment 1.

2110C

HSD

Health care services delivery

This segment will not be returned.

2110C

REF

Subscriber additional information

This segment will be used for additional identifiers related to the EB loop.

See Note 4 in Attachment 1.

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 information in the associated 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 SG 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 that information.
• 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

LS01

Loop identifier code

This field will be populated only when it is necessary to identify an entity in the NM1 segment that follows. If this segment is populated, it will contain “2120.”

2120C

NM1

Subscriber benefit related entity name

This segment will provide identifying information regarding any lock-in providers, private insurance, 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 loop will contain lock-in information.
• PRP — Indicates that the 2120C loop will contain private insurance or managed care program information.

2120C

NM103

Name last or organization name

This field will contain the name of the entity identified in NM101 which will be further identified in the 2120C loop.

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 the entity identified in NM103.

2120C

N4

Subscriber benefit related city/state/ZIP

This segment will be used to indicate additional address information for the entity identified in NM103.

2120C

PER

Subscriber benefit related contact information

This segment will provide information to assist in contacting the entity identified in NM103.

2120C

PRV

Subscriber benefit related provider information

This segment will not be returned.

2110C

LE01

Loop identifier code

If field LS01 was populated, this field will contain “2120.”

GE01

Number of transaction sets included

This field will contain a value of “1” for all real-time transactions.

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

The number in this field is a count of the GS records created. This will always be a value of “1” for real time-transactions.

IEA02

Interchange control number

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