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

X12 270/271 V5
PHC 13045 (4/08)
PDF (178 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 Plus, and SeniorCare, although the companion document only refers to Wisconsin Medicaid.

Companion documents are designed to be used with HIPAA Implementation Guides. Companion documents provide 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 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 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.

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.

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. Last name, first name, date of birth.
4. Last name, first name, Social Security number.
5. Social Security number, date of birth.

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.

As recommended in the 270/271 Implementation Guide, only one patient inquiry per transaction will be supported in the real time system. Therefore, loop 2110C of the 270 must occur only one time per inquiry.

Each 270, eligibility, coverage, or benefit inquiry transaction must be preceded by the four digit transaction identification “WTPG.”

VERSION 5 REVISION LOG

Companion Document: 270/271
Approved: 4/23/08
Modified by: SKR

Wisconsin Medicaid will begin accepting and reporting the National Provider Identifier (NPI) on May 19, 2008. The provider’s NPI must be on file with Wisconsin Medicaid in order for requests to process appropriately utilizing the NPI. Confirmation letters were sent to providers once their NPI was reported and entered into the Wisconsin Medicaid system. Wisconsin Medicaid will continue to accept and report the eight-digit Medicaid provider number if received.

Wisconsin Medicaid has identified personal care only providers, specialized medical vehicle providers, blood banks, and Community Care Organizations as providers of non-healthcare services which makes them exempt from the NPI requirement. These are the only providers required to continue indicating their Medicaid provider number on standard electronic transactions. Transactions submitted by these providers with an NPI will be denied.

Version 4 Revision Log

Companion Document: 270/271
Approved: 02/10/06
Modified by: EMS

Version 3 Revision Log

Companion Document: 270/271
Approved: 09/09/03
Modified by: EMS

Version 2 Revision Log

Companion Document: 270/271
Approved: 08/26/03
Modified by: EMS

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Protecting and promoting the health and safety of the people of Wisconsin