1 THE DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING WCIS Medical Data Collection

2 Division of Workers’ Compensation Workers’ Compensation Information System

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

Page 34 California Implementation Guide Table of Contents EDI service providers EDI service providers Events that trigger required medical EDI reports Events that trigger required medical EDI reports Required medical data elements Required medical data elements Data edits Data edits System specifications System specifications IAIABC information IAIABC information Code lists and state license numbers Code lists and state license numbers Medical EDI glossary and acronyms Medical EDI glossary and acronyms Standard medical forms Standard medical forms

5 Section M Data edits Page 81

Pages IAIABC Detailed Data Edits Mandatory field not present Must be numeric (0-9) Must be a valid date (CCYYMMDD) Must be A-Z, 0-9, or spaces Must be a valid time (HHMMSS) Must be <= date of injury Must be >= date of injury No match on database All digits cannot be the same Must be <= current date Duplicate transmission/transaction Code/ID invalid Event table criteria not met Invalid event sequence/relationship Invalid data relationship Must be>= date payer received bill Must be >= from date of service Must be <= thru service date

Page TR = Transaction Rejected Error Code MessageExample 001Mandatory field not presentClaims Administrator Claim Number 028Must be numeric (0-9)Zip Code 029 Must be a valid date (CCYYMMDD)Date of Injury 030 Must be A-Z, 0-9, or spacesCity of Oakland 031 Must be a valid time (HHMMSS)Header (Time Transmission sent) 033 Must be <= date of injuryNever occurs 034 Must be >= date of injuryEvery Date reported 039No match on databaseNo FROI received; (DOI <= Jan 1, 2002) 040 All digits cannot be the sameFEIN 041 Must be <= current dateDate of injury 057 Duplicate transmission/transactionBatch Control Number 058 Code/ID invalidJurisdictional paid procedure code 061 Event table criteria not metReport date > 90 after bill was paid 063 Invalid event sequence/relationshipReceive a “01” before receiving “00” 064 Invalid data relationshipConditional relationships 073 Must be>= date payer received billDate payer paid bill 074 Must be >= from date of serviceDate payer paid bill 075 Must be <= thru service dateProcedure date

8 824 with an Error *00* *00**ZZ* *ZZ* *051122*1202*U*00401* *0*P*~ ISA*00* *00**ZZ* *ZZ* *051122*1202*U*00401* *0*P*~ GS*01* * * *1202*68*X*004010~ ST*824*0015~ BGN*11*MED01* *1202~N1*10**FI* ~N4*** ~N1*40**FI* ~N4*** ~ OTI*TR*55*00001*** *1627***837~ DTM*009* *153124~LM*IB~ LQ*FZ*040~ RED~..RED~ SE*11*0015~ GE*1*68~ IEA*1* ~

Page 889 California Specific Data Edits Must be numeric (error code = 028) Must be numeric (error code = 028) DWC specifies an more exact numerical valueDWC specifies an more exact numerical value Postal CodesPostal Codes Units (days, minutes, number of pills etc)Units (days, minutes, number of pills etc) Social security numberSocial security number Lines numbersLines numbers Code/ID invalid (error code = 058)Code/ID invalid (error code = 058) DWC specifies exact IAIABC values in a lookup tableDWC specifies exact IAIABC values in a lookup table Bill Submission Reason Code (00 or 01 or 05)Bill Submission Reason Code (00 or 01 or 05) Billing Format Code ( A or B)Billing Format Code ( A or B) Billing Type Code ( DM or MO or RX)Billing Type Code ( DM or MO or RX) Diagnosis Pointer (1 or 2 or 3 or 4)Diagnosis Pointer (1 or 2 or 3 or 4) Service Adjustment Group Code ( CO or MA or OA or PI or PR)Service Adjustment Group Code ( CO or MA or OA or PI or PR)

10 Section N System Specifications Page 69

Page 9011 Bill Submission Sequencing Bill submission reason codes (BSRC) Bill submission reason codes (BSRC) 00 Original00 Original 01 Cancellation01 Cancellation 05 Replace05 Replace 00 must be used with the initial medical bill payment report sent. 00 must be used with the initial medical bill payment report sent. 01must be preceded by the initial (00) medical bill payment report. 01must be preceded by the initial (00) medical bill payment report. 05must be preceded by the initial (00) medical bill payment report. 05must be preceded by the initial (00) medical bill payment report.

Page 9112 Application Acknowledgment Codes 824 detailed acknowledgment824 detailed acknowledgment inform the Trading partner of the accepted or rejected status of each 837 transmissioninform the Trading partner of the accepted or rejected status of each 837 transmission – TA Transaction accepted Transaction accepted – No Errors – TR Transaction rejected Transaction rejected – At least one error – TE Transaction accepted with errors Transaction accepted with errors – No Claim Administrator Claim Number in the WCIS Database

13 DWC Automated Processes Corrected data elementCorrected data element (BSRC=00)(ACC=TR)(BSRC=00)(ACC=TR) Corrected medical billCorrected medical bill (BSRC=01)(ACC=TA)(BSRC=01)(ACC=TA) Replacement of a claims administrator claim numberReplacement of a claims administrator claim number (BSRC=05)(ACC=TA)(BSRC=05)(ACC=TA)

Page 9114 Corrected data element process (BSRC=00)(ACC=TR) 1. Sender transmits original bill, including all lines, utilizing a BSRC "00". 2. DWC sends a “TR” 824 acknowledgement with errors to sender. 3. Sender corrects errors in the original bill. 4. Sender transmits the corrected bill, including all lines, as an original BSRC "00". 5. DWC sends a 997 and a “TA” 824 acknowledgement to sender.

Page 9115 Corrected medical bill process (BSRC=01)(ACC=TA) 1. Sender transmits original bill, including all lines, utilizing a BSRC "00". 2. DWC sends a 997 and a “TA” 824 acknowledgement to sender. 3. Sender changes the value of data elements on the original bill. 4. Sender cancels incorrect original bill by transmitting a BSRC "01". 5. DWC sends a 997 and a “TA” 824 acknowledgement to sender. 6. Sender transmits the updated bill, including all lines, as a BSRC "00". 7. DWC sends a 997 and “TA” 824 acknowledgement to sender.

Page 9216 Replacement of a claims administrator claim number process (BSRC=05)(ACC=TA) 1. Sender transmits original bill, including all lines, utilizing a BSRC "00". 2. DWC sends a 997 and a “TA” 824 acknowledgement to sender. 3. Sender changes the claims administrator claim number on the original bill. 4. Sender notifies the DWC\WCIS of the new claims administrator claim number by transmitting a BSRC "05" with the old and new claims administrator claim number.

Page 9217 Duplicate transmissions, transactions, and medical bills Transmission duplicatesTransmission duplicates ISA or GE functional groups contain the same key header informationISA or GE functional groups contain the same key header information Transaction duplicatesTransaction duplicates ST-SE transaction sets contain the same header information (DN532)ST-SE transaction sets contain the same header information (DN532) Bill duplicatesBill duplicates ST-SE transaction sets from the same sender, contain the same information on the claim administrator FEIN, claim administrator claim number, and unique bill identification number.ST-SE transaction sets from the same sender, contain the same information on the claim administrator FEIN, claim administrator claim number, and unique bill identification number.

Page 9318 Detailed Segment Detailed Segment Detailed Segment DWC 837 format ISA-IEA (Interchange) contains control information and identifies the sender and receiver. GS-GE (Functional Group) identifies the business purpose of multi-functional transaction sets. ST-SE (Transaction Set) provides the business document contents.

Page 9319 WCIS matching rulesPrimary: 1.Jurisdiction claim number Secondary match for medical bill payment reports to the FROI: 2a.Claim administrator claim number Insurer FEIN (match on insurer FEIN if provided, otherwise match on claim administrator FEIN) 2b.Employee social security number 2c.Date of injury Employee last name Employee middle name Employee first name

Page Unmatched Transactions (BSRC=00)(ACC=TE) 1.The DWC retains the transmission and continuously searches for a match (FROI). 2.If no match (FROI) or BSRC = 01 the DWC sends an 824 acknowledgment indicating transaction accepted with errors (TE). The error code will be 039_nomatch on database. 3.The DWC continues to retain the transmission and searches for a match (FROI). 4.The DWC plans to produce data quality reports within 30 days to send to all trading partners.

21 Section O IAIABC Information Page 95

Pages Introduction History of the IAIABC and EDI What is EDI? Standards Software Communications IAIABC Information

23 Section P Code lists and State license numbers Page 99

24 Standard Code Sets Facility/Place of Service Codes (page 102)Facility/Place of Service Codes (page 102) IAIABCIAIABC Place of Service Bill/Line Codes (page 103)Place of Service Bill/Line Codes (page 103) IAIABCIAIABC Revenue Billed/Paid Codes (page 104)Revenue Billed/Paid Codes (page 104) IAIABCIAIABC Claim Adjustment Group Codes (page 116)Claim Adjustment Group Codes (page 116) IAIABCIAIABC Claim Adjustment Reason Codes ( )Claim Adjustment Reason Codes ( ) IAIABCIAIABC California Medical License Numbers (page 116)California Medical License Numbers (page 116) California Department of Consumer AffairsCalifornia Department of Consumer Affairs California Medical Facility License NumbersCalifornia Medical Facility License Numbers California Department of Health ServicesCalifornia Department of Health Services

25 Standard Code Sets Zip Codes (page 100)Zip Codes (page 100) US Postal ServiceUS Postal Service HCPCS (page 100)HCPCS (page 100) Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services ICD_9 (page 100)ICD_9 (page 100) Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services CPT (page 101)CPT (page 101) American Medical AssociationAmerican Medical Association NDC (page 101)NDC (page 101) First databankFirst databank DRG (101)DRG (101) US Government printing OfficeUS Government printing Office Medical Provider Codes (page 102)Medical Provider Codes (page 102) Washington Publishing CompanyWashington Publishing Company

26 Chapter 4.5 Division of Workers' Compensation Subchapter 1 Administrative Director-Administrative Rules  Article 5.3__Official Medical Fee Schedule  §§  § through §  Article 5.5__Application of Official Medical Fee Schedule  §§  §9790. through §  Article 5.6__ Medical-legal Expenses and Comprehensive Medical-Legal Evaluations  §§9795  §9793. through §9795  Article 5.7__ Fees for Interpreter Services  §§  § through § California DWC Code Sets

27 California DWC Code Sets Official Medical Fee ScheduleOfficial Medical Fee Schedule – Evaluation and Management – Anesthesiology – – Surgery10040 – – Radiology70010 – – Pathology and Laboratory80002 – – Medicine Official Hospital Fee ScheduleOfficial Hospital Fee Schedule –§ –§ PharmacyPharmacy –§ –§ Durable Medical EquipmentDurable Medical Equipment –§ –§

28 DWC/WCIS Medical Code Contact David Henderson WCIS Research Unit Research Program Specialist II (Medical Data) Division of Workers' Compensation 1515 Clay Street, 18th floor Oakland, CA Tel: Fax:

29 Form HCFA-1500 or CMS-1500

30 Form HCFA-1450 or UB-92

31 American Dental Association Claim Form

32 NCDPD Universal Claim Form