Electronic Data Interchange Overview

Electronic Data Interchange (EDI)

Provider Electronic Solutions (PES)

Loop/Segment Revised

Page(s) Revised

Text Revised

None / ISA06

5

This element is populated with "WISC_DHCF."

None / TRN02

6

This is the check number. If there is no check number issued, Wisconsin Medicaid populates this element with the phrase "NO CHECK" followed by the Remittance Advice number.

None / DTM

6

This segment is populated with the first date of coverage and the last date of coverage for this remittance report(s).

1000A / N104

6

This is the nine-digit payee provider number (Federal Tax ID).

1000B / N102

6

This is the name of the payer, Wisconsin Medicaid and BadgerCare.

1000B / N403

6

This is the ZIP code of the payer, 53784.

2000B / ENT

7

Note: ENT Segments are created for each new recipient. In order to reconcile with the paper Remittance and Status Reports, all "claims" are reported before cash transactions are reported.

2000B / ENT03

7

This element is populated with "ZZ" to indicate mutually defined.

2000B / ENT04

7

This is the Medicaid identification number for that recipient.

Note: For Acquired Immune Deficiency Syndrome/Ventilator (AIDS/Vent) payments, this element will be populated with "AIDSVENT." For Summary Payments, this element will be populated with "SUMMARY PAYMENT."

2100B / NM103

7

This is the recipient’s last name.

Note: For AIDS/Vent Payments, this element will be populated with "AIDS/VENT PAYMENT." For Summary Payments, this element will be populated with "SUMMARY PAYMENT."

2300B / RMR01

7

This element will be populated with "IK" to indicate that the RMR02 will be reporting from an internal Medicaid claim.

2300B / RMR02

8

This element is populated with the procedure code for non-cash transactions (where available) followed by "/," followed by the two most significant three-digit EOB codes (if any), followed by "/," followed by the internal control number.

Note: This element will only take the first two significant EOB codes. For Reversal recoupments, the phrase "REVERSAL" will replace the two most significant EOB codes along with the procedure code and the ICN. For AR recoupments, this element will have "AR" followed by "/," followed by the EOB code, followed by "/," followed by the internal control number. For AIDS/Vent payments, this element will have "/" followed by "AIDSVENT TRANSACTION," followed by "/," followed by the Cash Control Number.

Removed: If the first two characters are "AR" followed by "/," this is informational data. It reports a future accounts receivable (AR) transaction. The value after "/" is the detail (Medicaid "claim") affected by the A/R logic.

2300B / RMR05

8

Payment or recoupment before adjustment but only present if different from RMR04.

2320B / ADX01

8

This element reports the difference between the original amount (RMR05) and the final amount (RMR04).

2320B / ADX02

9

This element will contain one of the following adjustment reason codes to indicate the reason for payment or recoupment:

• "52" — Recoupment.
• "53" — Payout.
• "J3" — Partial recoupment because funds were not available to fully recoup.

Removed: If ADX02 equals "J3," ADX01 is informational and exists to reconcile the associated informational "AR" RMR Segment.

Loop

Element

Name

Instruction

None

ISA

Interchange Control Header

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

None

ISA05

Interchange ID (Sender) Qualifier

This element contains a value of "ZZ" to indicate that they are mutually defined.

None

ISA06

Interchange Sender ID

This element is populated with "WISC_DHCF."

None

ISA07

Interchange ID (Receiver) Qualifier

This element contains a value of "ZZ" to indicate that they are mutually defined.

None

ISA08

Interchange Receiver ID

This element is populated with the eight-digit numeric vendor number assigned by Wisconsin Medicaid.

None

ISA13

Interchange Control Number

This element contains a distinct tracking number for this file.

None

GS02

Application Sender’s Code

This element is populated with "WISC_TXIX."

None

GS03

Application Receiver’s Code

This element is populated with the same value as ISA08, the eight-digit numeric vendor number assigned by Wisconsin Medicaid.

None

GS08

Version/Release/ Industry Identifier Code

This element contains a value of "004010X061A1," 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.

None

ST02

Transaction Set Control Number

This element will contain a unique transaction set control number assigned by Wisconsin Medicaid.

None

BPR01

Transaction Handle Code

This element is populated with "I," indicating that the 820 is sent separately from the check.

None

BPR02

Total Premium Payment Amount

This is the total amount of the check.

None

BPR04

Payment Method Code

This element is populated with "CHK," indicating that a check is being sent.

None

BPR16

Check Issue Date

This is the date on the check.

None

TRN02

Check Number

This is the check number. If there is no check number issued, Wisconsin Medicaid populates this element with the phrase "NO CHECK" followed by the Remittance Advice number.

None

TRN03

Originating Company Identifier

This is the number "1" followed by the Wisconsin Medicaid tax identification number.

None

REF02

Premium Receiver Reference Identification

This is the eight-digit payee provider number assigned by Wisconsin Medicaid.

None

DTM

Coverage Period

This segment is populated with the first date of coverage and the last date of coverage for this remittance report(s).

1000A

N102

Information Receiver Last Name or Organization Name

This is the payee provider’s name.

1000A

N104

Receiver Identifier

This is the nine-digit payee provider number (Federal Tax ID).

1000A

N301

Receiver Address Line

This is the address of the payee provider.

1000A

N401

Information Receiver City Name

This is the city of the payee provider.

1000A

N402

Information Receiver State Code

This is the state of the payee provider.

1000A

N403

Information Receiver Postal Zone or ZIP Code

This is the ZIP code of the payee provider.

1000B

N102

Premium Payer Name

This is the name of the payer, Wisconsin Medicaid and BadgerCare.

1000B

N104

Premium Payer Identifier

This is Wisconsin Medicaid’s tax identification number.

1000B

N301

Premium Payer Address Line

This is the address of the payer, 6406 Bridge Road.

1000B

N401

Premium Payer City

This is the city of the payer, Madison.

1000B

N402

Premium Payer State Code

This is the state of the payer, Wisconsin.

1000B

N403

Premium Payer Postal Zone or ZIP Code

This is the ZIP code of the payer, 53784.

2000B

ENT

Organization Summary Remittance

Note: ENT Segments are created for each new recipient. In order to reconcile with the paper Remittance and Status Reports, all "claims" are reported before cash transactions are reported.

2000B

ENT02

Entity Identifier Code

This element is populated with "2J" to indicate an individual.

2000B

ENT03

Identification Code Qualifier

This element is populated with "ZZ" to indicate mutually defined.

2000B

ENT04

Identification Code

This is the Medicaid identification number for that recipient.

Note: For Acquired Immune Deficiency Syndrome/Ventilator (AIDS/Vent) payments, this element will be populated with "AIDSVENT." For Summary Payments, this element will be populated with "SUMMARY PAYMENT."

2100B

NM103

Individual Last Name

This is the recipient’s last name.

Note: For AIDS/Vent Payments, this element will be populated with "AIDS/VENT PAYMENT." For Summary Payments, this element will be populated with "SUMMARY PAYMENT."

2100B

NM104

Individual First Name

This is the recipient’s first name.

2100B

NM105

Individual Middle Name

This is the recipient’s middle initial.

2300B

NM108

Identification Code Qualifier

This element is populated with "N" to indicate the recipient’s unique identification number.

2300B

NM109

Individual Identifier

This element is populated with the recipient’s Medicaid identification number.

2300B

RMR01

Reference Identification Number

This element will be populated with "IK" to indicate that the RMR02 will be reporting from an internal Medicaid claim.

2300B

RMR02

Insurance Remittance Reference Number

This element is populated with the procedure code for non-cash transactions (where available) followed by "/," followed by the two most significant three-digit EOB codes (if any), followed by "/," followed by the internal control number.

Note: This element will only take the first two significant EOB codes. For Reversal recoupments, the phrase "REVERSAL" will replace the two most significant EOB codes along with the procedure code and the ICN. For AR recoupments, this element will have "AR" followed by "/," followed by the EOB code, followed by "/," followed by the internal control number. For AIDS/Vent payments, this element will have "/" followed by "AIDSVENT TRANSACTION," followed by "/," followed by the Cash Control Number.

2300B

RMR04

Detail Premium Payment Amount

This is the total premium amount paid or recouped by Wisconsin Medicaid for the individual.

2300B

RMR05

Detail Premium Billed Amount

Payment or recoupment before adjustment but only present if different from RMR04.

2320B

DTM

Coverage Period

This segment is populated with the coverage period of the individual associated with the premium payment (Not present for cash payments).

2320B

ADX01

Adjustment Amount

This element reports the difference between the original amount (RMR05) and the final amount (RMR04).

2320B

ADX02

Adjustment Reason Code

This element will contain one of the following adjustment reason codes to indicate the reason for payment or recoupment:

• "52" — Recoupment.
• "53" — Payout.
• "J3" — Partial recoupment because funds were not available to fully recoup.

None

SE02

Transaction Set Control Number

This element will contain a unique transaction set control number assigned by Wisconsin Medicaid. This value is the same value indicated in ST02.