HIPAA Billing

HIPAA Billing Specific Guides For Washington State Health Care Authority

HIPAA Billing specific notes are specified for each Washington State Health Care Authority mandated 270/271 transaction. Implementation guides contain information related to:

  • Format and content of interchanges and functional groups
  • Format and content of the header, detailer and trailer segments specific to the transaction
  • Code sets and values authorized for use in the transaction
  • Allowed exceptions to specific transaction requirements

Transmission sizes are limited based on two factors:

  1. Number of Segments/Records allowed by Health Care Authority (HCA)
  2. HCA file size limitations

HCA limits the size of the transaction (ST-SE envelope) to a maximum of 5,000 repeats of Loop 2000C in the 270 transaction.

Batch Daily Maximum

HCA will limit the number of batch eligibility inquiries to a maximum of 100,000 subscribers per day per trading partner. HCA will also monitor validity of transaction submissions, and assess if inquiries are resulting in an appropriate number of corresponding Medicaid claims submissions. HCA reserves the right to terminate the Trading Partner Agreement with the Submitter if HCA determines that these stipulations have been violated by the Submitter.

Real-Time Daily Maximum

HCA limits the number of real-time eligibility inquiries to a maximum of 25,000 per day per trading partner. HCA will also monitor validity of transaction submissions, and assess if inquiries are resulting in an appropriate number of corresponding Medicaid claims submissions. HCA reserves the right to terminate the Trading Partner Agreement with the Submitter if HCA determines that these stipulations have been violated by the Submitter. HCA will continually examine the performance of the system in regards to real-time eligibility inquiries and will consider increasing the daily maximum on a monthly basis.

Data Format Delimiters

The ProviderOne will use the following delimiters on outbound transactions:

  • Data element separator – Asterisk ( * )
  • Sub-element Separator – colon ( : )
  • Segment Terminator – Tilde ( ~ )

Data Interchange Conventions HCA accepts 270 transaction files with single ISA/IEA and GS/GE envelopes. 270 transactions (with their limit of 5,000 repeats of Loop 2000C within an ST/SE envelop), can have multiple ST/SE envelops within the same GS/GE envelope.

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