1 Division of Workers’ Compensation Workers’ Compensation Information System

2 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 The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions

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4 Chapter 4.5 Division of Workers' Compensation Subchapter 1 Administrative Director-Administrative Rules Article 1.1 Workers’ Compensation Information System 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 California Code of Regulations

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

6 L.C. §138.6 Goals for WCIS Medical Data L.C. §138.6 Goals for WCIS Medical Data Assist the department to manage the workers' compensation system in an effective and efficient manner. 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. 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 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. Provide statistical data for research into specific aspects of the workers' compensation program.

7 WCIS Electronic Data Collection First Reports of Injury – March, 2000 First Reports of Injury – March, 2000 Subsequent Reports of Injury – July, 2000 Subsequent Reports of Injury – July, 2000 Medical/Bill Payment Reports – March, 2006 Medical/Bill Payment Reports – March, 2006

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

9 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 Functions 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)* The Nationally Accepted EDI Medical Data System E-Billing Regulations WCIS Regulations

10 What is EDI? Electronic Data Interchange Electronic Data Interchange Standardized electronic exchange of files/data between computers Standardized electronic exchange of files/data between computers Standard Set of Codes Standard Set of Codes Standard Set of Data Elements Standard Set of Data Elements

11 Standard Electronic File Formats American National Standards Institute (ANSI ) ANSI – 837 Health Care Claim ANSI – 837 Health Care Claim ANSI – 997 Functional Acknowledgment ANSI – 997 Functional Acknowledgment ANSI – 824 Detailed Acknowledgment ANSI – 824 Detailed Acknowledgment

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

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

14 Standard Paper Medical Bill Types UB92/HCFA1450 UB92/HCFA1450 CMS-1500 Form (formerly HCFA1500) CMS-1500 Form (formerly HCFA1500) American Dental Association American Dental Association Universal Pharmacy Form Universal Pharmacy Form Standard Medical Data Elements

15 Other Medical Data Sources Insurers Insurers Payers Payers Jurisdictional Licensing Boards Jurisdictional Licensing Boards Senders Senders

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

17 The Challenge: The Challenge: Over $5.3 billion in medical costs 2002 Over $5.3 billion in medical costs 2002 Estimated 15% goes to administration Estimated 15% goes to administration Lack of e-commerce Lack of e-commerce The Opportunity: The Opportunity: Retool tired processes Retool tired processes Chance to Reengineer processes Chance to Reengineer processes Become fitter, leaner, and ready to meet future challenges

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

19 Workgroup for Electronic Data Interchange (WEDI)

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

21 Transaction Cycle 837 Health Care Transmission Set DWC WCIS 824 & 997 Acknowledgments Trading Partners

22 Trading Partner Agreements Define exactly how to exchange transactions – Communication methods – Submitter/Receiver IDs – Delimiters – Frequency – Turnaround Expectations – Transactions to be exchanged

23 Claim Dr Smith Professional Claims Facility Dr Smith Provide r Claim Patient Claim Patient Bill Line 1 Line 2 Line 3 Line 1 Line 2 Line 3 Line 1 Line 2 Line 3 Procedure or a product 837 Health Care Claim Transmission

24 ISA*00**00***ZZ*003000*ZZ*WHY INC *020524*1718*U*00401* *0*T:~ GS*HC* *WHY INC* *1615*1*X*004010X098~ ST*837*0001~ BHT*0019*00*0001* *1645*CH~ REF*87*004010X098~ MN1*41*2*MARY SMITH CLEARINGHOUSE*****46* ~ PER*IC*MARY SMITH*TE* *FX* *ED* ~ NM!*40*2*MEDICARE PART B*****46* WHY INC~ HL*1*20*1~ MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24* ~ N3*PO BOX 1234~ N$*SALISBURY*MO* *US~ REF*1C*09876~ PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE* *FX* TE* ~ HL*2*1*22*0~ HL * SBR*P*18**MEDICARE PART B*****MB~ NM!*IL*1*BENNING*CARRIE****MI* A~ N3*PO BOX 123~ N4*NEOMA*MO*67799*US~ DMB*D8* *M~ MN1*PR*2*MEDICARE PART B*****PI*00065~ N3*1000 MAIN ST~ N$*ST LOUIS*MO*66666*US~ CLM*MEDBGOOD-MIS1*1500***11::1*Y*C*Y*Y*B******P~ RE*X4*32D ~ NTE*ADD*CLAIM NOTE TEXT~ HI*BK:3999~ NM1*DN*1*FOLLARD*BEN*J**M.D.* ~ PRV*RF*ZZ*101Y00000N~ RED*1C*B11277 NM!*82*1*TREPED*HOWARD****24* ~ PRV*PE*ZZ*101Y00000N~ RED*1C* ~ LX*1 SV1*HC:99213*15000*UN*1*11**1:::**N~ DTP*472*DB* ~ RE*X4*32D ~ SE*36*0001~ GE*1*1~ IEA*1* ~ What Your Computer Sees During an 837 Transaction

25 Technical Assistance ANSI standards can be downloaded for free at ANSI standards can be downloaded for free at the Washington Publishing Company website - IAIABC standards can be downloaded for free at the IAIABC website - IAIABC standards can be downloaded for free at the IAIABC website - California standards can be downloaded for free at California standards can be downloaded for free at the Division of Workers’ Compensation website -

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

27 Points of Impact Review existing workflows per transaction 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?

28 Do you need to changes your direct data entry 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 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 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 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? Do you have a crosswalk from standard code sets to ones used by your internal systems? Internal Systems

29 Questions to ask a software vendor Will your vendor be DWC compliant by the mandated deadlines? Will your vendor be DWC compliant by the mandated deadlines? What are your service level agreements for continued support? What are your service level agreements for continued support? – New versions – Training Will the required code sets be submitted? Will the required code sets be submitted? How much lead time is required to install and test the software? 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? What is the minimum hardware requirement for servers and workstations to run the California compliant version?

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

31 Where are you? Which of the following has gained influence over strategic decision making? SignificantIncreaseSlightIncreaseNoChange Boards60%33%7% Investors44%42%14% Government34%46%20% Rating Agencies 26%49%25% Regulators57%34%9%

32 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 25% 10-15% increase 9% 15-25% increase 5% More then 25% increase 5%

33 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%

34 DWC\WCIS Help WCIS web site ( WCIS web site ( WCIS Trading Partner Liaisons WCIS Trading Partner Liaisons WCIS WCIS WCIS Medical EDI Training WCIS Medical EDI Training

35 WCIS Trading Partner Liaisons Damon Chen Johnny Lee Elisema Cantu

36 WCIS Medical EDI Training Training Conference in Los Angels Area Training Conference in Los Angels Area Training Conference in Oakland Area Training Conference in Oakland Area Web Based step by step training Web Based step by step training Help Desk by telephone or Help Desk by telephone or