Electronic Data Interchange Overview

Electronic Data Interchange (EDI)

Provider Electronic Solutions (PES)

None

ISA06

Interchange sender ID

This element is populated with "WISC_DHCF."

None

ISA08

Interchange receiver ID

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

None

GS02

Application sender's code

This element is populated with "WISC_TXIX" for Wisconsin Medicaid.

None

GS03

Application receiver's code

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

None

ST02

Transaction set control number

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

None

BGN02

Reference identification

This element will contain the following information:

• Positions 1-7, Report ID, valid values are "INITIAL" or "FINAL."
• Positions 8-8, Space.
• Positions 9-14, Enrollment month in a CCYYMM format.
• Positions 15-15, Space.
• Position 16-19, Sequence number of the transaction set indicating the order that the transaction sets are created and the order in which the transaction sets are to be processed.

Note: Positions 1-7 will contain a value of "INITIAL" when the transaction sets are created mid-month for the initial enrollment cycle. Two or more transaction sets will be created during the initial cycle. The first transaction set(s) will contain only recipients who have changes in their enrollment status such as new and terminated recipients or recipients with changes in other information. The value of BGN08 will be "2" to indicate that this transaction set contains only recipients with changes. The transaction set(s) with changes will be followed by one or more transaction sets where the value in BGN08 will be "4" to indicate that this is a full file audit/compare. The full file audit/compare transaction set(s) will contain all new recipients and all recipients in a continue or pending status effective for the current enrollment month.

Positions 1-7 will contain a value of "FINAL" when the transaction set(s) is created at the end of the month for the final enrollment cycle. The value in BGN08 will be "2" to indicate that this transaction set contains only recipients who have changes to their enrollment status or other information.

For example, in the October 2003 initial enrollment report, the value of BGN02 would be "INITIAL 200310 0001."

None

BGN08

Action code

This element will contain the following values:

• 2 — change (update)
  Used to indicate that this transaction set contains only recipients who have changes in their enrollment status or other information.
• 4 — verify
  Used when the transaction set is created mid-month (initial enrollment cycle). The transaction set(s) will contain all new recipients and all recipients in a continue or pending status effective for the current enrollment month.

None

REF

Header — transaction set policy number

This segment will be created for every transaction set, and the following elements will be populated.

None

REF01

Reference identification qualifier

This element will contain a value of "38," which is the master policy number.

None

REF02

Reference identification

This element will contain the 8-character Wisconsin Medicaid payee provider number.

None

DTP

File Effective Date

This segment will be created during the initial enrollment cycle when the value in BGN08 is "4" to indicate that this is a full file audit/compare.

None

DPT01

Date/Time Qualifier

This element will contain a value of "007" to indicate that the date that follows applies to all recipients in the file.

None

DTP03

Date time period status information effective date

This element will contain a file effective date indicating the first day of the current enrollment month.

1000A

N1

Sponsor name

This segment will be created for every transaction set, and the following elements will be populated.

1000A

N101

Entity identifier code

This element will contain a value of "P5," which is the plan sponsor.

1000A

N103

Identification code qualifier

This element will have a value of "FI," which is the federal taxpayer’s identification number.

1000A

N104

Identification code
sponsor identifier

This element will contain the Wisconsin Medicaid federal tax ID.

1000B

N1

Payer name

This segment will be created for every transaction set, and the following elements will be populated.

1000B

N101

Entity identifier code

This element will contain a value of "IN," which is the insurer.

1000B

N103

Identification code qualifier

This element will have a value of "FI," which is the federal tax ID.

1000B

N104

Identification code insurer identification code

This element will contain the federal tax ID associated with the 8-character Wisconsin Medicaid payee provider number identified in the transaction set policy number REF02.

2000

INS

Member level detail

This segment is required for each Wisconsin Medicaid recipient being reported.

2000

INS01

Insured indicator

This element will have a value of "Y," which indicates the insured is a subscriber.

2000

INS02

Individual relationship code

This element will have a value of "18," which indicates self.

2000

INS03

Maintenance type code

The value of this element used in conjunction with maintenance reason code (INS04) and employment status code (INS08) will indicate the recipient's enrollment status. See Attachment 1 for a cross-reference between the MMIS enrollment status and the INS03, INS04, and INS08.

The following values will be sent in the initial and final enrollment cycle transaction set(s) when the value of BGN08 is equal to "2":

• "001" — change
  During the initial enrollment cycle, this value indicates an enrollment status of "CONTINUE" or "PEND" when there is a change in recipient information to report.
  During the final enrollment cycle, this value will identify recipients previously reported as "PEND" who have changed their enrollment status to "CONTINUE," as well as recipients with a change in recipient information with no change in enrollment status.
  During either the initial or final enrollment cycle, this value will be used when a second 2300 HD loop is present.
• "021" — addition
  Indicates an enrollment status of "ADD/NEW."
• "024" — cancellation or termination
  Indicates an enrollment status of "DISENROLL" or "DISENROLL/RCP."
• "025" — reinstatement
  Indicates an enrollment status of "ADD/RS."

The following value will be sent in the initial enrollment cycle full file audit transaction set(s) when the value of BGN08 is equal to "4":

• "030" — audit or compare
  This value will only be used with the initial enrollment cycle full file audit transaction set(s). All recipients in a "PEND," "CONTINUE," or "ADD enrollment status effective for the current enrollment month will be reported.

2000

INS04

Maintenance reason code

This element further describes the recipient’s enrollment status.

The following values will be sent in the initial and final enrollment cycle change transaction set(s) when the value of BGN08 is equal to "2":

• "07" — termination of benefits
  When used with a maintenance type code (INS03) with a value of "024," this indicates that the recipient is being terminated from the managed care organization (MCO).
• "27" — pre-enrollment
  When used with a maintenance type code (INS03) with a value of "021," this indicates that the recipient is a newborn.
• "28" — initial enrollment
  When used with a maintenance type code (INS03) with a value of "021," this indicates that the recipient is a new enrollee but not a newborn.
• "41" — re-enrollment
  When used with a maintenance type code (INS03) with a value of "025," this indicates that the recipient is being re-instated in the MCO.

The following maintenance reason codes will be used with a maintenance type code (INS03) with a value of "001."

• "43" — change of location
  Indicates the recipient's address information has changed.
• "33" — personal data
  Indicates a change in recipient information such as medical status code.
• "25" — change in identifying data elements
  Indicates the recipient's name, date of birth, or gender code has changed.
• "AI" — no reason given
  During either the initial or final enrollment cycle, this value will be used when a second 2300 HD loop is present.
  When used during the initial enrollment cycle, "AI" indicates that recipient information that does not fit into the other reason codes has changed.
  When used during the final enrollment cycle, "AI" indicates that the recipient's enrollment status has changed from "PEND" to "CONTINUE," or recipient information that does not fit into the other reason codes has changed.
  

Note: The value of the maintenance reason code will be established in the order listed above; however, the transaction may include more than one type of change. For example, the recipient could have a maintenance reason code of "43" to indicate a change in the address information but could also include a change to the date of birth.

The following value will be sent in the initial enrollment cycle full file audit transaction set(s) when the value of BGN08 is equal to "4":

• "XN" — notification only
  Used with a maintenance type code (INS03) with a value of "030" to indicate that the recipient’s enrollment status for the current enrollment month is "ADD," "CONTINUE," or "PEND."

2000

INS05

Benefit status code

This element will have a value of "A," which indicates active.

2000

INS08

Employment status code

This element further describes the recipient’s enrollment status.

The following values will be sent:

• "FT" — full-time
  Indicates that the recipient is in a "CONTINUE" or "ADD" enrollment status. The maintenance type code (INS03) and maintenance reason code (INS04) should be interrogated to determine if the recipient is in a "CONTINUE" or "ADD" enrollment status.
• "TE" — terminated
  When used with the maintenance type code (INS03) with a value of "001" or "030," the recipient is in a "PEND" enrollment status.
  When used with the maintenance type code (INS03) with a value of "024," the recipient is in a "DISENROLL" or "DISENROLL/RCP" enrollment status.

2000

INS12

Date time period

The recipient's date of death will be reported in this element when available. This information was not available in the proprietary Wisconsin Medicaid managed care enrollment file.

2000

REF

Subscriber number

The subscriber number segment is required and will identify the Wisconsin Medicaid recipient.

2000

REF01

Reference identification qualifier

This element will contain a value of "0F," which indicates the subscriber number.

2000

REF02

Reference identification

This element will contain the 10-character Wisconsin Medicaid recipient ID.

2000

REF

Member identification number

The following member identification number segment will be created for each Wisconsin Medicaid recipient being reported.

2000

REF01

Reference identification qualifier

This element will contain a value of "17," which is the client reporting category.

2000

REF02

Reference identification subscriber supplemental identifier

This element will contain the 2-character Wisconsin Medicaid medical status code.

2000

REF

Member identification number

The following member identification number segment will be created for each Wisconsin Medicaid recipient being reported.

2000

REF01

Reference identification qualifier

This element will contain a value of "3H," which is the case number.

2000

REF02

Reference identification subscriber supplemental identifier

This element will contain the 10-character Wisconsin Medicaid case number.

2000

REF

Member identification number

The following member identification number segment be will only be created when the Medicaid recipient ID has changed since the last reported transaction set.

2000

REF01

Reference identification qualifier

This element will contain a value of "Q4," which indicates the prior identification number.

2000

REF02

Reference identification subscriber supplemental identifier

This element will contain the 10-character previously reported Medicaid recipient ID.

2000

DTP

Member level dates

When the value of BGN08 is "2," the member level dates segment will be created for each INS segment in this transaction set. This segment will not be present when the value of BGN08 is "4."

2000

DTP01

Date/time qualifier

This element will contain the following values:

• "303" — maintenance effective
  The date that follows applies to recipients currently reported as a "CONTINUE," "PEND," or demographic change only enrollment status. This value is also used when there is an assigned provider change reported in the 2300 HD loop.
• "356" — eligibility begin
  The date that follows applies to recipients currently reported as an "ADD" enrollment status.
• "357" — eligibility end
  The date that follows applies to recipients currently reported as a "DISENROLL" or a "DISENROLL/RCP" enrollment status.
  The date reported in DTP03 will reflect the true eligibility end effective date.
  
  Note: Multiple disenrollment effective dates will not be sent to reflect each possible month of retroactive disenrollment.

2000

DTP03

Date time period status information effective date

This element will contain the status information effective date associated with the previous DTP01 value.

2100A

NM1

Member name

The member name segment will be created for each INS segment created, and the following elements will be populated.

2100A

NM101

Entity identifier code

This element will contain the following values:

• "74" — corrected insured
  Indicates that the values in NM103, NM104, or NM105 have changed since last reported.
• "IL" — insured or subscriber
  Indicates that the values in NM103, NM104, or NM105 have not changed since last reported.

2100A

NM102

Entity type qualifier

This element will contain a value of "1," which indicates a person.

2100A

NM103

Name last or organization name

This element will contain the last name of the Wisconsin Medicaid recipient.

2100A

NM104

Name first

This element will contain the first name of the Wisconsin Medicaid recipient.

2100A

NM105

Name middle

This element will contain the middle initial (if present) of the Wisconsin Medicaid recipient.

2100A

PER

Member communication numbers

The member communication numbers segment will be created when the recipient’s telephone number is available.

2100A

PER01

Contact function code

This element will contain a value of "IP," which indicates the insured party

2100A

PER03

Communication number qualifier

This element will contain a value of "TE," which indicates telephone number.

2100A

PER04

Communication number

This element will contain the Wisconsin Medicaid recipient’s telephone number.

2100A

N3

Member resident street address

The member resident street address segment will be created for each INS segment created.

2100A

N4

Member residence city, state, & ZIP code

The member resident city, state, & ZIP code segment will be created for each INS segment created.

2100A

N405

Location qualifier

This element will contain a value of "CY," which indicates county/parish.

2100A

N406

Location identifier

This element will contain the Wisconsin Medicaid recipient’s residence two-character county code.

2100A

DMG

Member demographic information

The member demographic information segment will be created for each INS segment created. Only elements DMG01, DMG02, and DMG03 will be populated.

2100A

HLH

Member health information

This segment will be created for each INS segment with the value of "021" or "025" in the maintenance type code (INS03) to indicate an enrollment status of "ADD."

2100A

HLH01

Health related code

This element will contain a value of "U," which indicates unknown.

2100B

NM1

Incorrect member name

The incorrect member name segment will only be created when there is a change to the recipient's previously supplied name, date of birth, or gender code. When present, the following elements will be populated.

Note: If only the date of birth or gender code is changing, then the information in NM103, NM104, and NM105 will be identical in this loop and loop 2100A.

2100B

NM101

Entity identifier code

This element will contain a value of "70," which indicates prior incorrect insured.

2100B

NM102

Entity type qualifier

This element will contain a value of "1," which indicates a person.

2100B

NM103

Name last or organization name

If NM101 in loop 2100A contains a value of "74," this element will contain the prior last name of the Wisconsin Medicaid recipient.

If NM101 in Loop 2100A contains a value of "IL," this element will contain the current last name of the Wisconsin Medicaid recipient.

2100B

NM104

Name first

If NM101 in Loop 2100A contains a value of "74," this element will contain the prior first name of the Wisconsin Medicaid recipient.

If NM101 in Loop 2100A contains a value of "IL," this element will contain the current first name of the Wisconsin Medicaid recipient.

2100B

NM105

Name middle

If NM101 in Loop 2100A contains a value of "74," this element will contain the prior middle initial (if present) of the Wisconsin Medicaid recipient.

If NM101 in Loop 2100A contains a value of "IL," this element will contain the current middle initial (if present) of the Wisconsin Medicaid recipient.

2100B

DMG

Incorrect member demographics

This segment will only be created when there is a change to the recipient's previously supplied date of birth or gender code.

2100B

DMG02

Prior incorrect insured birth date

If there is a change to the recipient’s previously supplied date of birth, this element will contain the previously supplied date of birth; otherwise, this element will contain the current date of birth.

2100B

DMG03

Prior incorrect insured gender code

If there is a change to the recipient’s previously supplied gender, this element will contain the previously supplied gender; otherwise, this element will contain the current gender.

2100G

NM1

Responsible person

The responsible person segment will be created for each INS segment where the responsible person information is available (ie case head). When present, the following elements will be populated.

2100G

NM101

Entity identifier code

This element will contain a value of "QD," which indicates responsible party.

2100G

NM102

Entity type qualifier

This element will contain a value of "1," which indicates person.

2100G

NM103

Name last or organization name

This element will contain the last name of the responsible person.

2100G

NM104

Name first

This element will contain the first name of the responsible person.

2100G

NM105

Name middle

This element will contain the middle initial (if present) of the responsible person.

2300

HD

Health coverage

One 2300 health coverage loop will be created for each INS segment where the maintenance type code (INS03) does not equal "024" — termination of benefits (currently reported as a "DISENROLL" or a "DISENROLL/RCP" enrollment status).

A second 2300 health coverage loop will be created when there is an assigned provider change in the current month and the assigned provider base (first six digits) has changed or when the assigned provider change is retroactive. The first 2300 HD loop will reflect the new assigned provider, the second HD loop will reflect the previously assigned provider.

Note: Some special managed care programs, such as Family Care and Pace Partnership, may receive a second 2300 health coverage loop to reflect changes in level of care or mid-month changes to dates of enrollment or disenrollment.

2300

HD01

Maintenance type code

The following values will be sent in the initial and final enrollment cycle change transaction set(s) when the value of BGN08 is equal to "2:"

• "021" — addition
  Indicates that the information that follows applies to a recipient who is in an enrollment status that is currently reported as an "ADD/NEW" enrollment status.
• "024" — cancellation or termination
  The information that follows reports the disenrollment from an assigned provider. This also applies to special managed care programs, such as Family Care and Pace Partnership, to reflect changes in level of care, or mid-month changes to dates of enrollment or disenrollment.
• "025" — reinstatement
  Indicates that the information that follows applies to a recipient who is in an enrollment status that is currently reported as an "ADD/RS" enrollment status.

The following value will be sent in the initial enrollment cycle full file audit transaction set(s) when the value of BGN08 is equal to "4:"

• "030" — audit/compare
  Used with a maintenance type code (INS03) with a value of "030" to indicate that the recipient’s enrollment status for the current enrollment month is an "ADD," "CONTINUE," or "PEND."

2300

HD03

Insurance line code

This element will contain a value of "HMO," which indicates Health Maintenance Organization or managed care program.

2300

HD04

Plan coverage description

This element will contain the Wisconsin Medicaid 2-character managed care program code.

2300

HD05

Coverage level code

This element will contain a value of "IND," which indicates individual.

2300

DTP

Health coverage dates

One health coverage dates segment will be created for each 2300 HD segment created.

2300

DTP01

Date/time qualifier

This element will contain the following values:

• "303" — maintenance effective
  The date that follows applies to recipients currently reported as a "CONTINUE," "PEND," or demographic change only enrollment status.
• "348" — benefit begin
  The date that follows applies to recipients currently reported as an "ADD" enrollment status.
• "349" — benefit end
  The date that follows reflects the effective end date of the previously reported assigned provider when there is an assigned provider change. This also applies to special managed care programs, such as Family Care and Pace Partnership, to reflect changes in level of care or mid-month changes to dates of enrollment or disenrollment.


Note: Multiple disenrollment effective dates will not be sent to reflect each possible month of retroactive disenrollment as currently reported.

2300

DTP03

Date time period coverage period

This element will contain the coverage period effective date associated with the previous DTP01 value.

2310

LX

Provider information

One provider information segment will be created for each loop 2300 HD created.

2310

NM1

Provider name

One provider name segment will be created for each loop 2300 HD created.

2310

NM101

Entity identifier code

This element will contain a value of "Y2," which indicates managed care organization.

2310

NM102

Entity type qualifier

This element will contain a value of "2," which indicates non-person entity.

2310

NM103

Name last or organization name

This element will contain the name of the managed care program.

2310

NM108

Identification code qualifier

This element will contain a value of "SV," which indicates service provider.

2310

NM109

Identification code
provider identifier

This element will contain the 8-character Wisconsin Medicaid provider number of the recipient’s assigned provider.

2310

NM110

Entity relationship code

This element will contain the following values:

• "25" — established patient.
• "26" — not established patient.

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.