Payer Initiated Eligibility/Benefit

Payer Initiated Eligibility/Benefit (PIE) Within The Requirements of The Deficit Reduction Act Scope (Washington State Medicaid)

Payer Initiated Eligibility/Benefit (PIE) electronic transaction can be used by health plans to transmit eligibility and benefit information to Washington State Medicaid. basic guidelines given below are to assist State Medicaid agencies and payers in implementing the Payer Initiated Eligibility/Benefit (PIE) Transaction.

Federal law requires States to identify and obtain payment from third party entities that are legally responsible to pay claims primary to Medicaid. To enhance States‘ ability to identify legally liable third parties, the Deficit Reduction Act of 2005 (DRA) required States to pass laws imposing requirements on health plans, as a condition of doing business in the State, to provide plan eligibility information to the State. The Centers for Medicare & Medicaid Services developed the Payer Initiated Eligibility/Benefit (PIE) Transaction which can be used to meet the DRA requirements.

The DRA also clarified the definition of health insurer to include self-insured plans, managed care organizations, pharmacy benefit managers, and other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. Other parties include such entities as third party administrators, fiscal intermediaries, and managed care contractors, who administer benefits on behalf of the risk-bearing sponsor (e.g., an employer with a self-insured health plan). Health insurers will be referred to as ‘payers’ throughout this document.

The Secretary adopted the following transmission format that was developed by Accredited Standards Committee (ASC) for conducting eligibility and benefit information transactions between the Medicaid agency, or its agent, and other payers: ASC X12 270/271 Health Care Eligibility/Benefit Inquiry and Response Technical Report Type 3 Version 005010X279 (hereafter referred to as Version 5010).

The Payer Initiated Eligibility/Benefit (PIE) Transaction will be used to provide Washington State Medicaid with a listing that identifies plan members‘ eligibility for health coverage and their associated benefits.

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