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

2. 2 Division of Workers’ Compensation Workers’ Compensation Information System

3. 3 Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1.0 December 2005 www.dir.ca.gov

4. 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. 5 Section L Required medical data elements Page 69

6. 6 BHT*0080*00*0123*19960618*0932~ NM1*10*2******FI*123456789~ N4***751230064~ NM1*40*2******FI*987654321~ N4***751230064~ DTP*582*RD8*19970201-19970228~ NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~ H DTP*558*D8*19920101~ NM1*CC*1*DOE*SALLY*J***34*012345678~ REF*Y1*528779999~ CLM*A37YH556*500**MO*11:B*Y**********P***00~ DTP*050*D8*19970115~ DTP*666*D8*19970115~ REF*DD*13579~ REF*2I*TJ98UU321~ NM1*82*1*WELBY*MARCUS*C**SR*FI*123456789~ PRV*PE*S3*203BP0400Y~ N4***751230064~ REF*OB*PSY00001574~ LX*1~ Step 1 Mandatory Segments (BSRC = 00)

7. 7 BHT*0080*00*0123*19960618*0932~ NM1*10*2******FI*123456789~ N4***751230064~ NM1*40*2******FI*987654321~ N4***751230064~ HL*1**20*1~ DTP*582*RD8*19970201-19970228~ NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~ HL*2*1*EM*1~ MN1*36*2~ HL*3*2*CL~ DTP*558*D8*19920101~ NM1*CC*1*DOE*SALLY*J***34*012345678~ REF*Y1*528779999~ CLM*A37YH556*500**MO*11:B*Y**********P***00~ DTP*050*D8*19970115~ DTP*666*D8*19970115~ REF*DD*13579~ REF*2I*TJ98UU321~ NM1*82*1*WELBY*MARCUS*C**SR*FI*123456789~ PRV*PE*S3*203BP0400Y~ N4***751230064~ REF*OB*PSY00001574~ LX*1~ Step 2 Hierarchical Segments (BSRC = 00)

8. 8 Step 3 (continued) Conditional Data Elements/Segments (BSRC = 00) Professional 837 Office visit with drugs dispensed Institutional 837 Hospital/Surgical Scenario   Other Bill Types   Pharmaceutical utilizing a Professional 837   Pharmaceutical utilizing a NCPDP   Durable Medical Equipment   Dental utilizing a Professional 837   Various Generic Bill Adjustment Scenarios   Capitated treatment   Previous Provider Over payment   Provider Refund