11

THEDIVISION OF WORKERS’

COMPENSATIONMEDICAL 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 providers• Events that trigger required medical EDI reportsEvents that trigger required medical EDI reports• Required medical data elementsRequired medical data elementsData editsData editsSystem specificationsSystem specificationsIAIABC 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 M

Data edits

Page 81

Pages 82-87Pages 82-87 66

IAIABC Detailed Data EditsIAIABC Detailed Data Edits Mandatory field not present Mandatory field not present Must be numeric (0-9)Must be numeric (0-9)Must be a valid date (CCYYMMDD)Must be a valid date (CCYYMMDD)Must be A-Z, 0-9, or spacesMust be A-Z, 0-9, or spacesMust be a valid time (HHMMSS)Must be a valid time (HHMMSS)Must be <= date of injuryMust be <= date of injuryMust be >= date of injuryMust be >= date of injuryNo match on databaseNo match on databaseAll digits cannot be the sameAll digits cannot be the sameMust be <= current dateMust be <= current dateDuplicate transmission/transactionDuplicate transmission/transactionCode/ID invalidCode/ID invalidEvent table criteria not metEvent table criteria not metInvalid event sequence/relationshipInvalid event sequence/relationshipInvalid data relationshipInvalid data relationshipMust be>= date payer received billMust be>= date payer received billMust be >= from date of serviceMust be >= from date of serviceMust be <= thru service dateMust be <= thru service date

Page 42Page 42 77

824 TR = Transaction Rejected824 TR = Transaction Rejected Error Code Message Example

001 Mandatory field not present Claims Administrator Claim Number

028 Must be numeric (0-9) Zip Code

029 Must be a valid date (CCYYMMDD) Date of Injury

030 Must be A-Z, 0-9, or spaces City of Oakland

031 Must be a valid time (HHMMSS) Header (Time Transmission sent)

033 Must be <= date of injury Never occurs

034 Must be >= date of injury Every Date reported

039 No match on databaseNo FROI received; (DOI <= Jan 1,

2002)

040 All digits cannot be the same FEIN

041 Must be <= current date Date of injury

057 Duplicate transmission/transaction Batch Control Number

058 Code/ID invalid Jurisdictional paid procedure code

061 Event table criteria not met Report date > 90 after bill was paid

063 Invalid event sequence/relationship Receive a “01” before receiving “00”

064 Invalid data relationship Conditional relationships

073 Must be>= date payer received bill Date payer paid bill

074 Must be >= from date of service Date payer paid bill

075 Must be <= thru service date Procedure date

88

824 with an ErrorISA*00* *00**ZZ*943160882*ZZ*450483908 *051122*1202*U*00401**00* *00**ZZ*943160882*ZZ*450483908 *051122*1202*U*00401*000000045000000045*0*P*~*0*P*~GSGS*01*943160882*450483908*20051122*1202**01*943160882*450483908*20051122*1202*6868*X*004010~*X*004010~STST*824*0015~*824*0015~

BGN*11*MED01*20051122*1202~BGN*11*MED01*20051122*1202~N1*10**FI*943160882~N1*10**FI*943160882~N4***946121413~N4***946121413~N1*40**FI*450483908~N1*40**FI*450483908~N4***239640040~N4***239640040~OTI*OTI*TRTR*55**55*0000100001***20051109*1627***837~***20051109*1627***837~DTM*009*20051121*153124~DTM*009*20051121*153124~LM*IB~LM*IB~

LQ*FZ*LQ*FZ*040040~~RED~RED~....RED~RED~SESE**1111*0015~*0015~GEGE*1**1*6868~~IEAIEA*1**1*000000045000000045~~

Page 88Page 88 99

California Specific Data EditsCalifornia 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 (Bill Submission Reason Code (0000 or or 0101 or or 0505))• Billing Format Code ( Billing Format Code ( AA or or BB))• Billing Type Code ( Billing Type Code ( DMDM or or MOMO or or RXRX))• Diagnosis Pointer (Diagnosis Pointer (11 or or 2 2 or or 33 or or 44))• Service Adjustment Group Code ( Service Adjustment Group Code ( COCO or or MAMA or or OAOA or or PIPI or or PRPR))

1010

Section N

System Specifications

Page 69

Page 90Page 90 1111

Bill Submission SequencingBill Submission Sequencing

• Bill submission reason codes (BSRC)Bill submission reason codes (BSRC)

• 00 Original00 Original

• 01 Cancellation01 Cancellation

• 05 Replace05 Replace

• 00 00 must be used with the initial medical bill payment report sent.must be used with the initial medical bill payment report sent.

• 0101 must be preceded by the initial (00) medical bill payment report. must be preceded by the initial (00) medical bill payment report.

• 0505 must be preceded by the initial (00) medical bill payment report.must be preceded by the initial (00) medical bill payment report.

Page 91Page 91 1212

Application Acknowledgment CodesApplication 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

– TATA • Transaction acceptedTransaction accepted

– No ErrorsNo Errors

– TRTR

• Transaction rejectedTransaction rejected

– At least one errorAt least one error

– TE TE • Transaction accepted with errorsTransaction accepted with errors

– No Claim Administrator Claim Number in the WCIS DatabaseNo Claim Administrator Claim Number in the WCIS Database

1313

DWC Automated ProcessesDWC 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 Replacement of a claims administrator claim numberclaim number • (BSRC=05)(ACC=TA)(BSRC=05)(ACC=TA)

Page 91Page 91 1414

Corrected data element process Corrected data element process (BSRC=00)(ACC=TR)(BSRC=00)(ACC=TR)

1.1. Sender transmits original bill, including all Sender transmits original bill, including all lines, utilizing a BSRC "00".lines, utilizing a BSRC "00".

2.2. DWC sends a “TR” 824 acknowledgement DWC sends a “TR” 824 acknowledgement with errors to sender.with errors to sender.

3.3. Sender corrects errors in the original bill.Sender corrects errors in the original bill.

4.4. Sender transmits the corrected bill, Sender transmits the corrected bill, including all lines, as an original BSRC including all lines, as an original BSRC "00"."00".

5.5. DWC sends a 997 and a “TA” 824 DWC sends a 997 and a “TA” 824 acknowledgement to sender.acknowledgement to sender.

Page 91Page 91 1515

Corrected medical bill process Corrected medical bill process (BSRC=01)(ACC=TA)(BSRC=01)(ACC=TA)

1.1. Sender transmits original bill, including all lines, utilizing a BSRC Sender transmits original bill, including all lines, utilizing a BSRC "00"00". ".

2.2. DWC sends a 997 and a “TA” 824 acknowledgement to sender. DWC sends a 997 and a “TA” 824 acknowledgement to sender.

3.3. Sender changes the value of data elements on the original bill.Sender changes the value of data elements on the original bill.

4.4. Sender cancels incorrect original bill by transmitting a BSRC Sender cancels incorrect original bill by transmitting a BSRC "01"."01".

5.5. DWC sends a 997 and a “TA” 824 acknowledgement to sender.DWC sends a 997 and a “TA” 824 acknowledgement to sender.

6.6. Sender transmits the updated bill, including all lines, as a BSRC Sender transmits the updated bill, including all lines, as a BSRC "00"."00".

7.7. DWC sends a 997 and “TA” 824 acknowledgement to sender.DWC sends a 997 and “TA” 824 acknowledgement to sender.

Page 92Page 92 1616

Replacement of a claims administrator claim Replacement of a claims administrator claim number processnumber process

(BSRC=05)(ACC=TA)(BSRC=05)(ACC=TA)

1.1. Sender transmits original bill, including all lines, Sender transmits original bill, including all lines, utilizing a BSRC "00". utilizing a BSRC "00".

2.2. DWC sends a 997 and a “TA” 824 acknowledgement to DWC sends a 997 and a “TA” 824 acknowledgement to sender.sender.

3.3. Sender changes the claims administrator claim Sender changes the claims administrator claim number on the original bill.number on the original bill.

4.4. Sender notifies the DWC\WCIS of the new claims Sender notifies the DWC\WCIS of the new claims administrator claim number by transmitting a BSRC administrator claim number by transmitting a BSRC "05" with the old and new claims administrator claim "05" with the old and new claims administrator claim number. number.

Page 92Page 92 1717

Duplicate transmissions, transactions, Duplicate transmissions, transactions, and medical billsand 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 ST-SE transaction sets from the same sender, contain the same information on the claim administrator FEIN, claim administrator claim number, and unique bill the claim administrator FEIN, claim administrator claim number, and unique bill identification numberidentification number. .

Page 93Page 93 1818

Detailed

Segment

Detailed

Segment

Detailed

Segment

DWC 837 formatDWC 837 format

ISA-IEA (Interchange)ISA-IEA (Interchange)

contains control information and identifies the sender contains control information and identifies the sender

and receiver.and receiver.

GS-GE (Functional Group)GS-GE (Functional Group) identifies the business purpose of identifies the business purpose of

multi-functional transaction sets.multi-functional transaction sets.

ST-SE (Transaction Set)ST-SE (Transaction Set) provides the business document contents.provides the business document contents.

Page 93Page 93 1919

WCIS matching rulesPrimary:Primary:

1.1. Jurisdiction claim numberJurisdiction claim number

Secondary match for medical bill payment reports to the FROI:Secondary match for medical bill payment reports to the FROI:

2a.2a. Claim administrator claim numberClaim administrator claim numberInsurer FEIN (match on insurer FEIN if provided, Insurer FEIN (match on insurer FEIN if provided, otherwise otherwise

match on claim administrator FEIN)match on claim administrator FEIN)

2b.2b. Employee social security number Employee social security number

2c.2c. Date of injury Date of injury Employee last nameEmployee last name

Employee middle nameEmployee middle nameEmployee first name Employee first name

Page 93 - 94Page 93 - 94 2020

Unmatched TransactionsUnmatched Transactions(BSRC=00)(ACC=TE)(BSRC=00)(ACC=TE)

1.1. The DWC retains the transmission and The DWC retains the transmission and continuously searches for a match (FROI).continuously searches for a match (FROI).

2.2. If no match (FROI) or BSRC = 01 the DWC If no match (FROI) or BSRC = 01 the DWC sends an 824 acknowledgment indicating sends an 824 acknowledgment indicating transaction accepted with errors (TE). The transaction accepted with errors (TE). The error code will be 039_nomatch on database.error code will be 039_nomatch on database.

3.3. The DWC continues to retain the transmission The DWC continues to retain the transmission and searches for a match (FROI).and searches for a match (FROI).

4.4. The DWC plans to produce data quality The DWC plans to produce data quality reports within 30 days to send to all trading reports within 30 days to send to all trading partners.partners.

2121

Section O

IAIABCInformation

Page 95

Pages 95 - 99Pages 95 - 99 2222

• Introduction

• History of the IAIABC and EDI

• What is EDI?

• Standards

• Software

• Communications

IAIABC Information

2323

Section P

Code listsand

State license numbers

Page 99

2424

Standard Code SetsStandard 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 (11.25 -11.43)Claim Adjustment Reason Codes (11.25 -11.43)• 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

2525

Standard Code SetsStandard 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

2626

Chapter 4.5 Division of Workers' Compensation

Subchapter 1 Administrative Director-Administrative Rules

Article 5.3__Official Medical Fee Schedule§§9789.10 through §9789.111§9789.111

Article 5.5__Application of Official Medical Fee Schedule§§9790. through §9792.15§9792.15

Article 5.6__Medical-legal Expenses and Comprehensive Medical-Legal Evaluations

§§9793. through §9795§9795 Article 5.7__Fees for Interpreter Services

§§9795.1 through §9795.4§9795.4

California DWC Code Sets

2727

California DWC Code SetsCalifornia DWC Code Sets• Official Medical Fee ScheduleOfficial Medical Fee Schedule

– Evaluation and ManagementEvaluation and Management 99201 -- 9949999201 -- 99499

– AnesthesiologyAnesthesiology 00100 --00100 -- 0199901999

99100 – 9914099100 – 99140

– SurgerySurgery 10040 – 6997910040 – 69979

– RadiologyRadiology 70010 – 7999970010 – 79999

– Pathology and LaboratoryPathology and Laboratory 80002 – 8939980002 – 89399

– MedicineMedicine 90701 -- 99199 90701 -- 99199

• Official Hospital Fee ScheduleOfficial Hospital Fee Schedule– §§9789.24

• PharmacyPharmacy– §§9789.40

• Durable Medical EquipmentDurable Medical Equipment– §§9789.60

2828

DWC/WCIS Medical Code Contact

David HendersonWCIS Research UnitResearch Program Specialist II (Medical Data)Division of Workers' Compensation1515 Clay Street, 18th floorOakland, CA 94612 Tel:   916-263-0942Fax: 916-263-0971 

e-mail:dhenderson@dir.ca.gov 

2929

Form HCFA-1500 or CMS-1500

3030

Form HCFA-1450 or UB-92

3131

American Dental Association Claim Form

3232

NCDPD Universal Claim Form