11

CALIFORNIA DIVISION OF WORKERS’ COMPENSATION

MEDICAL DATA TRAINING

WCIS Medical Data Collection

22

Division of Workers’ Compensation

Workers’ Compensation Information System

33

Workers’ Compensation Information Workers’ Compensation Information System (WCIS)System (WCIS)

California EDI Implementation GuideCalifornia EDI Implementation Guidefor for

Medical Bill Payment RecordsMedical Bill Payment RecordsVersion 1.0Version 1.0

December 2005December 2005

www.dir.ca.gov

Page 3Page 3 44

California Implementation GuideCalifornia Implementation GuideTable of ContentsTable of Contents

EDI service providersEDI service providersEvents that trigger required medical EDI reportsEvents that trigger required medical EDI reportsRequired medical data elementsRequired medical data elements• Data editsData edits• System specificationsSystem specifications• IAIABC informationIAIABC information• Code lists and state license numbersCode lists and state license numbers• Medical EDI glossary and acronymsMedical EDI glossary and acronyms• Standard medical formsStandard medical forms

55

Section J

EDI service providersEDI service providers

Page 60

66

EDI service providersEDI service providers

• Providers of consultationProviders of consultation

• Technical support Technical support

• VAN service VAN service

• Software productsSoftware products

• Organizations providing data collection Organizations providing data collection servicesservices

77

Section KEvents that trigger required medical

EDI reports

Page 66

88

California Event TableCalifornia 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, Quarterly Daily, Weekly, Monthly, Quarterly 

O1 is a Cancellation O1 is a Cancellation (Reversal(Reversal of an '00' transaction 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 Replacement of a claim administrator claim number previously

submittedsubmitted.  .  • immediatelyimmediately

99

California Event TableEVENT

PRODUCTION LEVEL IND.

IMPLEMENTATION DATE

REPORT TRIGGER CRITERIA

REPORT TRIGGER

VALUE

EFFECTIVE DATE REPORT DUE

BILL SUBMISSION

REASON

REPORT TYPE

SUBMISSION DESCRIPTION

REASON FROM TO FROMTO CRITERIA VALUE

OO Original

 

T = Test

P=Production  Periodic

TBD by Trading Partners

   Within 90 days of

date paid

DailyWeeklyMonthly

Quarterly

O1 Cancellation

 

     

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'

O5 Replace

 

     

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'

1010

Section L

Required medical data elements

Page 69

1111

Data Dictionarieswww.dir.ca.gov/dwc/WCIS

• 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

1212

• UB92/HCFA1450 /CMS 1500

• CMS-1500 Form (formerly HCFA1500)

• Insurers

• Payers

• Health Care Provider

• Jurisdictional Licensing Boards

• Senders

Sources of Medical Data Elements

1313

Sources of Data for 837 Sources of Data for 837

Sender

Professional Bills

837 Medical Bill Payment Records File

Legacy Files

Jurisdiction Licensing Boards

PharmaceuticalBills

UB92 Medical Bills

InsurerDental BillsPayer/Accounts payable

DME Bills

Look-up Tables

Claims

1414

Section LSection L70 – 7370 – 73

Source TableSource Table

California EDI Implementation GuideFor

Medical Bill Payment RecordsDecember, 2005

1515

Medical data element requirement table

M = MandatoryM = Mandatory The data element must be sent and all edits applied to it must The data element must be sent and all edits applied to it must be passed successfully or the entire transaction will be be passed successfully or the entire transaction will be rejected. rejected.

C = ConditionalC = Conditional The data element becomes mandatory under conditions The data element becomes mandatory under conditions established by the Mandatory Trigger.established by the Mandatory Trigger.

O = OptionalO = Optional

The data element is sent if available. If the data element is The data element is sent if available. If the data element is sent the data edits are applied to the data element.sent the data edits are applied to the data element.

Mandatory TriggerMandatory Trigger:: The trigger which makes a conditional data element The trigger which makes a conditional data element mandatory.mandatory.

1616

Section LSection L74 – 8074 – 80

Element Requirement TableElement Requirement Table

California EDI Implementation GuideFor

Medical Bill Payment RecordsDecember, 2005

1717

Mandatory Data Elements (BSRC = 00)

Loop ID Loop Description Segment Number and description Data Elements Page

    BHT Beginning of Hierarchical Transaction 532 Batch control Number 74

    BHT Beginning of Hierarchical Transaction 100 Date Transmission Sent 74

    BHT Beginning of Hierarchical Transaction 101 Time Transmission Sent 74

1000A Sender Information NM1 Identification Code 98 Sender FEIN 74

1000A Sender Information N4 Identification Code 98 Sender Postal Code 74

1000B Receiver Information NM1 Identification Code 99 Receiver FEIN 74

1000B Receiver Information N4 Identification Code 99 Receiver Postal Code 74

2000A Source of Hierarchical Level DTP Date/Time Period 615 Reporting Period Code 74

2010AA Insurer/SI/CA Info NM1 Name 7 Insurer Name 75

2010AA Insurer/SI/CA Info NM1 Name 6 Insurer FEIN 75

2000C Claimant Hierarchical Info DT Date of injury 31 Date of Injury 75

2010CA Claimant Info Description NM1 Claimant Information 43 Employee Last Name 75

2010CA Claimant Info Description NM1 Claimant Information 44 Employee First Name 75

2010CA Claimant Info Description NM1 Claimant Information 42 Employee SSN 75

2010CA Claimant Info Description REF Claimant Claim Number 15 Claim Administrator Claim Number 75

1818

Mandatory Data Elements (BSRC = 00)Loop ID Loop Description Segment Number and description Data Elements Page

2300 Billing Information CLM Billing information 501 Total Charge per Bill 78

2300 Billing Information CLM Billing information 503 Billing Format Code 78

2300 Billing Information CLM Billing information 507 Provider Agreement Code 78

2300 Billing Information CLM Billing information 508 Bill Submission Reason Code 78

2300 Billing Information DTP Date Insurer Received Bill 511 Date Insurer Received Bill 78

2300 Billing Information DTP Date Insurer Paid Bill 512 Date Insurer Paid Bill 78

2300 Billing Information REF Unique Bill Identification Number 500 Unique Bill ID 78

2300 Billing Information REF Transaction Tracking Number 266 Transaction Tracking Number 78

2310B Rendering Bill Provider NM1 Rendering Bill Provider Info 638 Rendering Bill Provider Group/Last Name 77

2310B Rendering Bill Provider NM1 Rendering Bill Provider Info 642 Rendering Bill Provider FEIN 77

2310B Rendering Bill Provider PRV Rendering Bill Provider Specialty 651 Rendering Bill Provider Specialty Code 77

2310B Rendering Bill Provider N4 Rendering Bill Provider City, State and Postal code 656 Rendering Bill Provider Postal Code 77

2310B Rendering Bill Provider REF Rendering Bill Provider Secondary Id Number

643 Rendering Bill Provider State License Number 77

2400 Service Line Information LX Service Line Information 547 Line Number                        79

1919

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~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~

California Mandatory Segments (BSRC = 00)

2020

Mandatory Data Elements (BSRC = 01)

Loop IDLoop Description Segment Number and description Data Elements Page

    BHT Beginning of Hierarchical Transaction 532 Batch control Number 74

    BHT Beginning of Hierarchical Transaction 100 Date Transmission Sent 74

    BHT Beginning of Hierarchical Transaction 101 Time Transmission Sent 74

1000A Sender Information NM1 Identification Code 98 Sender FEIN 74

1000A Sender Information N4 Identification Code 98 Sender Postal Code 74

1000B Receiver Information NM1 Identification Code 99 Receiver FEIN 74

1000B Receiver Information N4 Identification Code 99 Receiver Postal Code 74

2000A Source of Hierarchical Level DTP Date/Time Period 615 Reporting Period Code 74

2010AA Insurer/SI/CA Info NM1 Name 6 Insurer FEIN 75

2010CA Claimant Info Description REF Claimant Claim Number 15 Claim Administrator Claim Number 75

2300 Billing Information CLM Billing information 503 Billing Format Code 78

2300 Billing Information CLM Billing information 508 Bill Submission Reason Code 78

2300 Billing Information REF Unique Bill Identification Number 500 Unique Bill ID 78

2121

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~REF*Y1*528779999~CLM*A37YH556*500**MO*11:B*Y**********P***01~REF*DD*13579~

California Mandatory Segments (BSRC = 01)

2222

Mandatory Data Elements (BSRC = 05)

Loop IDLoop Description Segment Number and description Data Elements Page

    BHT Beginning of Hierarchical Transaction 532 Batch control Number 74

    BHT Beginning of Hierarchical Transaction 100 Date Transmission Sent 74

    BHT Beginning of Hierarchical Transaction 101 Time Transmission Sent 74

1000A Sender Information NM1 Identification Code 98 Sender FEIN 74

1000A Sender Information N4 Identification Code 98 Sender Postal Code 74

1000B Receiver Information NM1 Identification Code 99 Receiver FEIN 74

1000B Receiver Information N4 Identification Code 99 Receiver Postal Code 74

2000A Source of Hierarchical Level DTP Date/Time Period 615 Reporting Period Code 74

2010AA Insurer/SI/CA Info NM1 Name 6 Insurer FEIN 75

2010CA Claimant Info Description REF Claimant Claim Number 15 Claim Administrator Claim Number 75

2300 Billing Information CLM Billing information 508 Bill Submission Reason Code 78

2323

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~REF*Y1*528779999~REF*Y1*999988746~CLM*A37YH556*500**MO*11:B*Y**********P***05~

California Mandatory Segments (BSRC = 05)

2424

Example of a Scenario 1

Bill