PIE (PAYER INITIATED ELIGIBILITY/BENEFIT): Requirements of The Deficit Reduction Act Scope (Washington State Medicaid)

PIE (Payer Initiated Eligibility/Benefit) transaction was developed to deliver membership and benefit information in one single, unsolicited transaction. The PIE (Payer Initiated Eligibility/Benefit) Transaction uses the same identifiers as the ASC X12 271 response transaction and therefore mirrors the format of the 271 transaction. The purpose of the Deficit Reduction Act (DRA) companion guidelines are to provide a standardized format for the PIE Transaction information. The information supplied on the PIE Transaction is to be as comprehensive as possible, with beginning and end dates and including other coverage, if available. The provided information will be used to match to the Medicaid databases. For this purpose, a required key data element is the Social Security Number. If the Social Security Number is not available, other key identifiers may be used.

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 Deficit Reduction Act strengthens States‘ ability to obtain payments from health insurers by requiring States to have laws in effect that require health insurers to make payment as long as the claim is submitted by the Medicaid agency within 3 years from the date on which the item or service was furnished. For this reason, Washington State Medicaid may require 3 years’ worth of data. The identifiers provided by the payers on the PIE Transaction are also used to construct HIPAA-standard eligibility inquiries as well as claims.

Washington State Medicaid will supply payers with testing details such as access to submit test transactions, procedures for confirming successful transmission and processing, and procedures for submitting production transactions.

The trading partner submits all HIPAA test files through the ProviderOne Secure File Transfer Protocol (SFTP). The trading partner downloads acknowledgements for the test file from the ProviderOne SFTP HIPAA ACK folder.

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