1 CALIFORNIA 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 EDI service providers Section J EDI service providers Page 60

6 EDI service providers Providers of consultation Providers of consultation Technical support Technical support VAN service VAN service Software products Software products Organizations providing data collection services Organizations providing data collection services

7 Section K Events that trigger required medical EDI reports Page 66

8 California Event Table Bill Submission Reason CodesBill Submission Reason Codes OO is a Original OO is a Original Within 90 days of date paidWithin 90 days of date paid Daily, Weekly, Monthly, QuarterlyDaily, Weekly, Monthly, Quarterly O1 is a Cancellation (Reversal of an '00' transaction ) O1 is a Cancellation (Reversal of an '00' transaction ) within 90 days of the original submissionwithin 90 days of the original submission ImmediatelyImmediately O5 is a Replacement O5 is a Replacement Replacement of a claim administrator claim number previously submitted.Replacement of a claim administrator claim number previously submitted. immediatelyimmediately

9 California Event Table EVENT PRODUCTION LEVEL IND. IMPLEMENTATION DATE REPORT TRIGGER CRITERIA REPORT TRIGGER VALUE EFFECTIVE DATE REPORT DUE BILL SUBMISSION REASON REPORT TYPE SUBMISSION DESCRIPTION REASONFROMTOFROM TOTO CRITERIAVALUE OOOriginal T = Test P=Production Periodic TBD by Trading Partners Within 90 days of date paid Daily Weekly Monthly Quarterly O1Cancellation Bill submission '00' sent to jurisdiction in error Reversal of an '00' transaction immediate within 90 days of the original submission Must be greater than date of '00' O5Replace Bill submission code '00' has been sent to jurisdiction Replacement of a claim administrator claim number previously submitted. immediate Must be greater than date of '00'

10 Section L Required medical data elements Page 69

11 Data Dictionaries IAIABC EDI Implementation Guide for Medical Bill Payment Records – – Section 9.1 Medical Bill Payment Records – – Section 9.2 Medical Bill Payment Records System California medical bill payment dictionary – – Subset of the IAIABC Data Dictionaries 125 Data Elements – – Combination of System and Data Elements 15 System Data Elements 110 medical Data Elements

12 UB92/HCFA1450 /CMS 1500 CMS-1500 Form (formerly HCFA1500) Insurers Payers Health Care Provider Jurisdictional Licensing Boards Senders Sources of Medical Data Elements

13 Sources of Data for 837 Sender Professional Bills 837 Medical Bill Payment Records File Legacy Files Jurisdiction Licensing Boards Pharmaceutical Bills UB92 Medical Bills Insurer Dental Bills Payer/ Accounts payable DME Bills Look-up Tables Claims

14 Section L 70 – 73 Source Table California EDI Implementation Guide For Medical Bill Payment Records December, 2005

15 Medical data element requirement table M = Mandatory The data element must be sent and all edits applied to it must be passed successfully or the entire transaction will be rejected. C = Conditional The data element becomes mandatory under conditions established by the Mandatory Trigger. O = Optional The data element is sent if available. If the data element is sent the data edits are applied to the data element. Mandatory Trigger: The trigger which makes a conditional data element mandatory.

16 Section L 74 – 80 Element Requirement Table California EDI Implementation Guide For Medical Bill Payment Records December, 2005

17 Mandatory Data Elements (BSRC = 00) Loop IDLoop DescriptionSegment Number and descriptionData Elements Pag e BHT Beginning of Hierarchical Transaction532 Batch control Number 74 BHT Beginning of Hierarchical Transaction100 Date Transmission Sent 74 BHT Beginning of Hierarchical Transaction101 Time Transmission Sent ASender InformationNM1 Identification Code98 Sender FEIN ASender InformationN4 Identification Code98 Sender Postal Code BReceiver InformationNM1 Identification Code99 Receiver FEIN BReceiver InformationN4 Identification Code99 Receiver Postal Code ASource of Hierarchical LevelDTP Date/Time Period615 Reporting Period Code AAInsurer/SI/CA InfoNM1 Name7 Insurer Name AAInsurer/SI/CA InfoNM1 Name6 Insurer FEIN CClaimant Hierarchical InfoDT Date of injury31 Date of Injury CAClaimant Info DescriptionNM1 Claimant Information43 Employee Last Name CAClaimant Info DescriptionNM1 Claimant Information44 Employee First Name CAClaimant Info DescriptionNM1 Claimant Information 42 Employee SSN CAClaimant Info DescriptionREF Claimant Claim Number 15 Claim Administrator Claim Number 75

18 Mandatory Data Elements (BSRC = 00) Loop ID Loop DescriptionSegment Number and descriptionData ElementsPage 2300 Billing InformationCLM Billing information501 Total Charge per Bill Billing InformationCLM Billing information503 Billing Format Code Billing InformationCLM Billing information507 Provider Agreement Code Billing InformationCLM Billing information508 Bill Submission Reason Code Billing InformationDTP Date Insurer Received Bill511 Date Insurer Received Bill Billing InformationDTP Date Insurer Paid Bill512 Date Insurer Paid Bill Billing InformationREF Unique Bill Identification Number500 Unique Bill ID Billing InformationREF Transaction Tracking Number266 Transaction Tracking Number B Rendering Bill ProviderNM1 Rendering Bill Provider Info 638 Rendering Bill Provider Group/Last Name B Rendering Bill ProviderNM1 Rendering Bill Provider Info 642 Rendering Bill Provider FEIN BRendering Bill ProviderPRV Rendering Bill Provider Specialty651 Rendering Bill Provider Specialty Code BRendering Bill Provider N4 Rendering Bill Provider City, State and Postal code 656 Rendering Bill Provider Postal Code BRendering Bill Provider REF Rendering Bill Provider Secondary Id Number 643 Rendering Bill Provider State License Number Service Line InformationLX Service Line Information547 Line Number 79

19 BHT*0080*00*0123* *0932~ NM1*10*2******FI* ~ N4*** ~ NM1*40*2******FI* ~ N4*** ~ DTP*582*RD8* ~ NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI* ~ DTP*558*D8* ~ NM1*CC*1*DOE*SALLY*J***34* ~ REF*Y1* ~ CLM*A37YH556*500**MO*11:B*Y**********P***00~ DTP*050*D8* ~ DTP*666*D8* ~ REF*DD*13579~ REF*2I*TJ98UU321~ NM1*82*1*WELBY*MARCUS*C**SR*FI* ~ PRV*PE*S3*203BP0400Y~ N4*** ~ REF*OB*PSY ~ LX*1~ California Mandatory Segments (BSRC = 00)

20 Mandatory Data Elements (BSRC = 01) Loop ID Loop DescriptionSegment Number and descriptionData ElementsPage BHT Beginning of Hierarchical Transaction532 Batch control Number 74 BHT Beginning of Hierarchical Transaction100 Date Transmission Sent 74 BHT Beginning of Hierarchical Transaction101 Time Transmission Sent ASender InformationNM1 Identification Code98 Sender FEIN ASender InformationN4 Identification Code98 Sender Postal Code BReceiver InformationNM1 Identification Code99 Receiver FEIN BReceiver InformationN4 Identification Code99 Receiver Postal Code ASource of Hierarchical LevelDTP Date/Time Period615 Reporting Period Code AAInsurer/SI/CA InfoNM1 Name6 Insurer FEIN CAClaimant Info DescriptionREF Claimant Claim Number 15 Claim Administrator Claim Number Billing InformationCLM Billing information 503 Billing Format Code Billing InformationCLM Billing information 508 Bill Submission Reason Code Billing InformationREF Unique Bill Identification Number 500 Unique Bill ID 78

21 BHT*0080*00*0123* *0932~ NM1*10*2******FI* ~ N4*** ~ NM1*40*2******FI* ~ N4*** ~ DTP*582*RD8* ~ NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI* ~ REF*Y1* ~ CLM*A37YH556*500**MO*11:B*Y**********P***01~ REF*DD*13579~ California Mandatory Segments (BSRC = 01)

22 Mandatory Data Elements (BSRC = 05) Loop ID Loop DescriptionSegment Number and descriptionData ElementsPage BHT Beginning of Hierarchical Transaction532 Batch control Number 74 BHT Beginning of Hierarchical Transaction100 Date Transmission Sent 74 BHT Beginning of Hierarchical Transaction101 Time Transmission Sent ASender InformationNM1 Identification Code98 Sender FEIN ASender InformationN4 Identification Code98 Sender Postal Code BReceiver InformationNM1 Identification Code99 Receiver FEIN BReceiver InformationN4 Identification Code99 Receiver Postal Code ASource of Hierarchical LevelDTP Date/Time Period615 Reporting Period Code AAInsurer/SI/CA InfoNM1 Name6 Insurer FEIN CAClaimant Info DescriptionREF Claimant Claim Number 15 Claim Administrator Claim Number Billing InformationCLM Billing information 508 Bill Submission Reason Code 78

23 BHT*0080*00*0123* *0932~ NM1*10*2******FI* ~ N4*** ~ NM1*40*2******FI* ~ N4*** ~ DTP*582*RD8* ~ NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI* ~ REF*Y1* ~ REF*Y1* ~ CLM*A37YH556*500**MO*11:B*Y**********P***05~ California Mandatory Segments (BSRC = 05)

24 Example of a Scenario 1 Bill