WCIS Advisory Committee 11/30/2018 Workers’ Compensation Information System WCIS Division of Workers’ Compensation Division of Workers' Compensation

California L.C. §138.6 Workers' Compensation Information System The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions

WWW.IAIABC.ORG

California Code of Regulations Chapter 4.5 Division of Workers' Compensation Subchapter 1 Administrative Director-Administrative Rules Article 1.1 Workers’ Compensation Information System 9702. Electronic Data Reporting (a) Each claims administrator shall transmit data elements, by electronic data interchange in the manner set forth in the…. California EDI Implementation Guide for Medical Bill Payment Records

Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1.0 December 2005

L.C. §138.6 Goals for WCIS Medical Data WCIS Advisory Committee 11/30/2018 L.C. §138.6 Goals for WCIS Medical Data Assist the department to manage the workers' compensation system in an effective and efficient manner. Facilitate the evaluation of the efficiency and effectiveness of the benefit delivery system. Assist in measuring how adequately the system indemnifies injured workers and their dependents Provide statistical data for research into specific aspects of the workers' compensation program. Division of Workers' Compensation

WCIS Electronic Data Collection WCIS Advisory Committee 11/30/2018 WCIS Electronic Data Collection First Reports of Injury – March, 2000 Subsequent Reports of Injury – July, 2000 Medical/Bill Payment Reports – March, 2006 Division of Workers' Compensation

Medical Data Collection Insurance Carriers Injured Worker Electronic Data Interface Electronic Data Interface DWC WCIS Medical Providers

The Nationally Accepted EDI Medical Data System Enrollment Pre-Certification & Adjudication Claims Acceptance and Reporting Requirements Claims Adjudication Accounts Payable Eligibility Verification Pre-Authorization and Referrals Service Billing Claim Submission Claims Status Inquiries Accounts Receivable (AR) Functions Providers Payers Maintain a Bona fide database of detailed medical bill payment records which corresponds to the FROI, SROI, UEF,DEU, and WCAB In California Function Jurisdictions 270 (Eligibility Inquiry) 271 (Eligibility Information) 837 (Claims Submission) 835 (HealthCare Claim Payment Advice) 837 Health Care Claim. 997 Functional Acknowledgement. 824 Detailed Acknowledgement 275 (Claims Attachment)* 276 (Claim Status Inquiry) 277 (Claim Status Response) 278 (Referral Authorization and Certification) 148 (First Report of Injury)* E-Billing Regulations WCIS Regulations

WCIS Advisory Committee What is EDI? 11/30/2018 Electronic Data Interchange Standardized electronic exchange of files/data between computers Standard Set of Codes Standard Set of Data Elements Division of Workers' Compensation

WCIS Advisory Committee 11/30/2018 Standard Electronic File Formats American National Standards Institute (ANSI) ANSI – 837 Health Care Claim ANSI – 997 Functional Acknowledgment ANSI – 824 Detailed Acknowledgment Division of Workers' Compensation

Standard Non-Medical Code Sets Place of Service Bill/Line Codes IAIABC Revenue Billed/Paid Codes Claim Adjustment Group Codes Claim Adjustment Reason Codes California Medical License Numbers California Department of Consumer Affairs California Medical Facility License Numbers California Department of Health Services

Standard Medical Code Sets HCPCS Centers for Medicare & Medicaid Services ICD_9 CPT American Medical Association NDC First databank DRG US Government printing Office Medical Provider Codes

Standard Medical Data Elements WCIS Advisory Committee 11/30/2018 Standard Medical Data Elements Standard Paper Medical Bill Types UB92/HCFA1450 CMS-1500 Form (formerly HCFA1500) American Dental Association Universal Pharmacy Form Division of Workers' Compensation

Other Medical Data Sources WCIS Advisory Committee 11/30/2018 Other Medical Data Sources Insurers Payers Jurisdictional Licensing Boards Senders Division of Workers' Compensation

Part II WHY EDI? Opportunity to modernize the sector Opportunity to lower per unit costs Opportunity to lower total medical delivery costs

Become fitter, leaner, and ready to meet future challenges WCIS Advisory Committee 11/30/2018 Become fitter, leaner, and ready to meet future challenges The Challenge: Over $5.3 billion in medical costs 2002 Estimated 15% goes to administration Lack of e-commerce The Opportunity: Retool tired processes Chance to Reengineer processes Division of Workers' Compensation

Lowering Per Unit Costs Reduced Accounts Payable/Reporting Cycle Improved Accuracy (5% data entry errors) Lower Cost Transactions Reduce/Eliminate paperwork Reduce Operational Costs (office supplies, postal costs, and telephone charges)

WCIS Advisory Committee Workgroup for Electronic Data Interchange (WEDI) 11/30/2018 Division of Workers' Compensation 10

Part III Nuts & Bolts Understanding the Transactions Cycle Trading Partner Agreement Adopted ANSI Structure Technical Assistance

Transaction Cycle

Trading Partner Agreements WCIS Advisory Committee 11/30/2018 Trading Partner Agreements Define exactly how to exchange transactions Communication methods Submitter/Receiver IDs Delimiters Frequency Turnaround Expectations Transactions to be exchanged Division of Workers' Compensation

WCIS Advisory Committee 837 Health Care Claim Transmission 11/30/2018 Claim Dr Smith Professional Claims Facility Provider Patient Bill Line 1 Line 2 Line 3 Procedure or a product A series of envelopes Division of Workers' Compensation

WCIS Advisory Committee 11/30/2018 ISA*00* *00* **ZZ*003000 *ZZ*WHY INC *020524*1718*U*00401*000000001*0*T:~ GS*HC*0003000*WHY INC*20030114*1615*1*X*004010X098~ ST*837*0001~ BHT*0019*00*0001*2003014*1645*CH~ REF*87*004010X098~ MN1*41*2*MARY SMITH CLEARINGHOUSE*****46*0003000~ PER*IC*MARY SMITH*TE*9135551234*FX*6123334567*ED*6125559876~ NM!*40*2*MEDICARE PART B*****46* WHY INC~ HL*1*20*1~ MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24*123456789~ N3*PO BOX 1234~ N$*SALISBURY*MO*660453565*US~ REF*1C*09876~ PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE*9135551234*FX* 6123334567TE* 6125559876~ HL*2*1*22*0~ HL * SBR*P*18**MEDICARE PART B*****MB~ NM!*IL*1*BENNING*CARRIE****MI*134-56-7890A~ N3*PO BOX 123~ N4*NEOMA*MO*67799*US~ DMB*D8*19330324*M~ MN1*PR*2*MEDICARE PART B*****PI*00065~ N3*1000 MAIN ST~ N$*ST LOUIS*MO*66666*US~ CLM*MEDBGOOD-MIS1*1500***11::1*Y*C*Y*Y*B******P~ RE*X4*32D1234567~ NTE*ADD*CLAIM NOTE TEXT~ HI*BK:3999~ NM1*DN*1*FOLLARD*BEN*J**M.D.*24-111223333~ PRV*RF*ZZ*101Y00000N~ RED*1C*B11277 NM!*82*1*TREPED*HOWARD****24*88899-1111~ PRV*PE*ZZ*101Y00000N~ RED*1C*2327870~ LX*1 SV1*HC:99213*15000*UN*1*11**1:::**N~ DTP*472*DB*81298399~ SE*36*0001~ GE*1*1~ IEA*1*000000001~ What Your Computer Sees During an 837 Transaction Division of Workers' Compensation

Part IV Implications for Payers Identify points of change\impact Develop internal systems Out sourcing to a vender

WCIS Advisory Committee 11/30/2018 Points of Impact Review existing workflows per transaction Can workflow be improved/automated? Can information returned be better utilized/automated? Do you use non-standard codes in these processes? Is there value in implementing transactions which you do not currently conduct electronically? Is there value in implementing transactions not currently required by the California DWC? Division of Workers' Compensation

WCIS Advisory Committee 11/30/2018 Internal Systems Do you need to changes your direct data entry systems Data content (data elements) must meet the data content portion of the California electronic standard Systems will also need to be capable of receiving data transfers from the DWC Coming soon-If provider chooses to send data electronically, payer must accept Do you have a crosswalk from standard code sets to ones used by your internal systems? Division of Workers' Compensation

Questions to ask a software vendor WCIS Advisory Committee 11/30/2018 Questions to ask a software vendor Will your vendor be DWC compliant by the mandated deadlines? What are your service level agreements for continued support? New versions Training Will the required code sets be submitted? How much lead time is required to install and test the software? What is the minimum hardware requirement for servers and workstations to run the California compliant version? Division of Workers' Compensation

WCIS Advisory Committee 11/30/2018 Part V Where are you now?  Assigned a “point person” for your office? Completed an Action Plan? Work toward completing your Gap Analysis? Communicated with vendors, billing services, or the DWC concerning 3/18/06? Test Internally? Scheduled External Testing? Staying abreast of upcoming requirements? Division of Workers' Compensation

Where are you? Which of the following has gained influence over strategic decision making? Significant Increase Slight No Change Boards 60% 33% 7% Investors 44% 42% 14% Government 34% 46% 20% Rating Agencies 26% 49% 25% Regulators 57% 9%

Where are you? What Investment in new governance-related activities will you make in the coming year? Decrease Investment 1% No change in Investment 25% 0-5% increase 30% 5-10% increase 10-15% increase 9% 15-25% increase 5% More then 25% increase

Where are you? What governance-related business activities will you increase investment in the coming year? The Compliance function 64% IT Spending 38% Internal communications 26% Instilling a culture of compliance though out the organization 42% Interaction with key stakeholders (regulators, government, lobby groups) 31%

DWC\WCIS Help WCIS web site (www.dir.ca.gov) WCIS Trading Partner Liaisons WCIS e-mail (wcis@dir.ca.gov) WCIS Medical EDI Training

WCIS Trading Partner Liaisons Damon Chen 510-286-6753 dchen@dir.ca.gov Johnny Lee 510-286-6772 jlee@dir.ca.gov Elisema Cantu 510-286-6763 ecantu@dir.ca.gov

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