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Electronic Data Interchange Overview
The following HIPAA information is for Wisconsin Medicaid
providers and
Wisconsin
Health Care Trading Partners.
The Administrative Simplification provisions of the
Health Insurance Portability and Accountability Act of 1996
(HIPAA), commonly referred to as the "HIPAA standards,"
require the Secretary of the federal Department of Health
and Human Services (HHS) to adopt national standards for:
- The electronic transmission of administrative and
financial health care information (e.g., claims) and code
sets (e.g., diagnosis codes, procedure codes, procedure
code modifiers).
- Unique health care identification numbers for
providers, health plans, employers, and individuals.
- Privacy and security of individually identifiable
health care information.
- Electronic submission of claims attachments.
- Enforcement of the components of HIPAA.
Although federal HIPAA legislation is targeted at
standardizing electronic health care transactions, HIPAA
will also affect many aspects of paper billing, such as
coding structures and required data elements.
Wisconsin
Health Care Trading Partners and providers participating in health care programs administered by the
Wisconsin Department of Health and Family Services (DHFS),
Division of Health Care Financing, such as Wisconsin
Medicaid, BadgerCare, SeniorCare, Wisconsin Chronic Disease Program (WCDP),
Wisconsin Well Woman Program (WWWP) should check back to
this site for additional materials as they become
available.
Trading Partners
The DHCF defines a trading partner as a covered entity
that exchanges electronic health care transactions as
mandated by HIPAA. (Refer to Section III of the Trading
Partner Profile for a listing of electronic health care
transactions.) Therefore, the DHCF considers the following
covered entities to be its trading partners:
- Billing providers who exchange electronic transactions
directly with the DHCF.
- Billing services and clearinghouses that exchange
electronic transactions directly with the DHCF on behalf
of a billing provider.
|
Covered Entity |
Complete
Trading Partner Agreement? |
Complete
Trading Partner Profile? |
Testing required? |
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Billing providers who do not use a third party to
exchange electronic transactions, including providers who use the free
claims submission software. |
Yes. |
Yes. |
Yes. |
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Billing providers who use a third party (billing
services and clearinghouses) to exchange electronic transactions. |
Yes. |
No, billing providers should have their third party
complete and return the Trading Partner Profile to the DHCF EDI
Department. |
No, billing providers should coordinate testing with
their third party. |
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Billing services and clearinghouses, including those
that use the free claims submission software that are authorized by
providers to exchange electronic transactions on a provider's behalf. |
No. |
Yes. |
Yes. |
Mandated transactions
The Electronics Transactions standard has the most impact
on the interaction between Wisconsin health care programs
and its trading partners. The electronic transactions listed
in the table below are mandated as part of the standard.
| Transaction |
Description |
| X12 270/271 |
Health Care Eligibility Benefit Inquiry/Response |
| X12 276/277 |
Health Care Claim Status Request/Response |
| X12 278 |
Health care Services Review/Request for Response |
| X12 820 |
Payroll Deducted and Other Group Premium Payment for
Insurance Products |
| X12 834 |
Benefit Enrollment and Maintenance |
| X12 835 |
Health Care Claim Payment/Advice |
| X12 837 |
Health Care Claim: Dental, Professional,
Institutional |
| NCPDP |
Telecommunication Standard for Retail Pharmacy
Claims |
Companion
documents for these transactions.
EDI Helpdesk. |
