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3 Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1.0 December 2005
Citation preview
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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
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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
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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
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• UB92/HCFA1450 /CMS 1500
• CMS-1500 Form (formerly HCFA1500)
• Insurers
• Payers
• Health Care Provider
• Jurisdictional Licensing Boards
• Senders
Sources of Medical Data Elements
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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
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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.
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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
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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
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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
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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)
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Example of a Scenario 1
Bill