Electronic Data Interchange Overview

Electronic Data Interchange (EDI)

Provider Electronic Solutions (PES)

Electronic Data Interchange (EDI) Information

Trading Partner Enrollment — Companion Documents

HIPAA companion documents will provide software firms, billing services/clearinghouses, and computer processing staff who manage the technical component (e.g., telecommunication, exchange file creation, and translation) of electronic transactions, from here on referred to as "trading partners," with useful technical information on Wisconsin Medicaid’s standards for HIPAA-compliant transactions. The Wisconsin Medicaid HIPAA Companion Documents complement national HIPAA Implementation Guidelines. 

The Companion Documents will not include instructions for billing staff. Companion Documents will not contain policy information or claim form instructions, but will help those who create the electronic formats for electronic data exchange. Wisconsin Medicaid will publish changes to Medicaid policy information and paper claim instructions that will result from HIPAA in future Wisconsin Medicaid and BadgerCare Updates and HIPAA inSights.

The HIPAA Companion Documents will highlight information that trading partners will need to successfully exchange HIPAA-compliant electronic transactions with Wisconsin Medicaid, including general topics such as:

• Methods of exchanging electronic information (e.g., exchange interfaces, transaction administration, and data preparation).
• Instructions for constructing the technical component of submitting or receiving electronic transactions (e.g., claims, remittance advice, and eligibility inquiries).

Companion Documents will cover the following specific subjects:

• Getting started (e.g., identification information, testing, and exchange preparation).
• Delivery mechanisms (e.g., Bulletin Board Software [BBS] Dial-Up Access, Internet File Transfer Protocol [FTP], and Magnetic Cartridges).
• Transaction administration (e.g., tracking claims submissions, contacting the Division of Health Care Financing Electronic Data Interchange [EDI] Help Desk).
• Transaction formats such as:
  • Retail pharmacy transactions.
  • Health care claims/adjustments for dental, professional, and institutional providers.
  • Enrollment and disenrollment in a health plan.
  • Eligibility inquiry and response.
  • Remittance advice.
  • Health plan premium payments.
  • Health claim status inquiry and response.
  • Referral certification and authorization (prior authorization).

Format of Companion Documents

Wisconsin Medicaid will notify trading partners in the monthly Wisconsin Medicaid and BadgerCare Update Summary when the HIPAA Companion Documents are available. Wisconsin Medicaid will offer multiple options for obtaining Companion Documents including accessing them from the Internet.

Companion Documents may be updated as a result of changes to federal requirements. When this occurs, trading partners will be notified.