EDI Payer Initiated Eligibility/Benefit Transaction (Washington State Medicaid) Additional Guides
EDI Payer Initiated Eligibility/Benefit Transaction transmission must be secure in accordance with 45 CFR Parts 160, 162, and 164 Health Insurance Reform: Security Standards.
EDI Payer Initiated Eligibility/Benefit Transaction conforms to ASC X12 Control Segments / Envelopes (ISA-IEA, GS-GE, and ST-SE) for Version 5010. Since files will be transmitted infrequently, files sizes will be large and will contain more than the usual number of records. Qualifiers to be used in the Sender Interchange ID Qualifier (ISA05) and Receiver Interchange ID Qualifier (ISA07) and identifiers to be used in Interchange Sender ID (ISA06) and Interchange Receiver ID (ISA08) will be specified in Section 9 Transaction Specific Information.
Acknowledgements and/or reports
A single positive ASC X12 acknowledgement will be sent back to payers indicating that the transmission was received. For Version 5010, an implementation acknowledgement (999) will be sent. If a positive acknowledgement is not received within 24 hours, resend the file once only. If a positive acknowledgement is still not received, contact the Washington State Medicaid EDI Customer Service. Washington State Medicaid will not reply indicating which subscribers matched the Washington State Medicaid database.
Washington State Medicaid requires that all Eligibility or Benefit Information (EB segments) that are appropriate to the plan be included in the Subscriber Eligibility or Benefit Information loop (2110C); likewise the Dependent Eligibility or Benefit Information loop (2110D) is used to provide dependent related information. Payers should provide qualifiers that are appropriate to their coverage including, but not limited to, Eligibility Benefit Information (EB01) and Service Type Code (EB03).
Washington State Medicaid requires a Subscriber Eligibility/Benefit date and Dependent Eligibility/Benefit Date (DTP segment) in the Subscriber Eligibility or Benefit Information loop (2110C) and Dependent Eligibility or Benefit Information loop (2110D) to specify actual start and end dates of coverage by subscriber or dependent. Qualifiers and dates sent in the PIE Transaction will be used by Washington State Medicaid to determine whether it is appropriate to submit a claim and may be used on 270s in the 270/271 Eligibility Transaction exchange.