Workers compensation information system

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Workers’ Compensation Information System (WCIS)

California EDI Implementation Guide

for

Medical Bill Payment Records

Version 1.01

December 2005January 2010

CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS

John ReaDuncan, actingDirector

DIVISION OF WORKERS’ COMPENSATION

Carrie Nevans, Chief Deputy Administrative Director

September 1, 2005 January 1, 2010

Dear Claims Administrators:

Welcome to the California Division of Workers’ Compensation electronic data interchange (EDI) for medical bill payment records. The California Division of Workers’ Compensation (DWC) is pleased to introduce a newly developed system for receiving workers’ compensation medical bill payment records data via EDI. The detailed medical data will be integrated with other data in the workers’ compensation information system (WCIS) to provide a rich resource of information for analyzing the performance of California’s workers’ compensation system.

Theis manual, California EDI Implementation Guide for Medical Bill Payment Records, is intended to be a primary resource for the DWC’s “trading partners” – administrators of California workers’ compensation medical bill payment records. Some organizations already have substantial experience transmitting EDI data to the DWC with first and subsequent reports of injury. For existing and new trading partners, the medical implementation guide can serve as a reference for California-specific medical record protocols. Although, the California DWC adheres to national EDI standards, the California medical record implementation guide does have minor differences from other states.

The California EDI Implementation Guide for Medical Bill Payment Records will be posted on our Web site at dir.dwc. I hope the start-up of current revision of medical record EDI reporting in California is smooth and painless, both for the Division and its EDI trading partners.

The California DWC is dedicated to open communication as a cornerstone of a successful start-up medical EDI process, and this guide is a key element of that communication.

Sincerely,

Carrie Nevans

Acting DWC Chief Deputy aAdministrative dDirector

Workers’ Compensation Information System (WCIS)

CALIFORNIA EDI IMPLEMENTATION GUIDE

for Medical Bill Payment Records

Version 1.1

January 2010

Table of Contents

Section A: Electronic data interchange in California – an overview 1

Electronic data interchange – EDI 2

Benefits of EDI within workers’ compensation 2

Workers' compensation information system history 3

California EDI requirements 4

Sending Data to the WCIS 4

Five steps of EDI - from testing to production 6

Step one: Sender submits Trading Partner Profile 6

Step two: Sender tests FTP connectivity 7

Step three: Sender transmits numerous ANSI 837 bill types 7

Step four: Structural Testing - Sender receives and processes a 997 from DWC 7

Step five: Detailed Testing - Sender receives and processes an 824 from DWC 7

Section B: Where to get help – contacting WCIS and other information resources 9

California Division of Workers’ Compensation 10

WCIS web site 10

WCIS contact person 10

WCIS e-news 11

EDI service providers 11

IAIABC…. 12

Section C: Implementing medical EDI – a managers’ guide 13

Get to know the basic requirements 14

Assign responsibilities for implementing medical EDI 14

Decide whether to contract with an EDI service provider 14

The FTP transmission mode for medical data 15

Make sure your computer system contains all the required data 15

Developing a comprehensive EDI system 15

Handling error messages sent by WCIS 1617

Benefits of adding “data edits” 1617

Updating software and communications services 1617

Test your system internally 1718

Testing and production stages of medical EDI transmission 1718

Evaluate your EDI system and consider future refinements 1819

Section D: Authorizing statutes 1920

Labor Code section 138.6. Development of workers' compensation information system 2021

Labor Code section 138.7. “Individually identifiable information”; restricted access 2021

Section E: WCIS regulations – Title 8 CCR sections 9700-9704 2324

Section F: Trading partner profile 2425

Who should complete the trading partner profile? 2526

ELECTRONIC DATA INTERCHANGE TRADING PARTNER PROFILE 2627

INSTRUCTIONS FOR COMPLETING TRADING PARTNER PROFILE 3031

Section G: Testing and production phases of medical EDI 3637

Overview of the five step process 3839

Step one: Complete a medical EDI trading partner profile 3940

Step two: Sender tests FTP connectivity 3940

Step three: Sender transmits numerous ANSI 837 bill types 3940

Step four: Structural testing - Sender receives and processes a 997 from DWC 4142

Process the 997 functional acknowledgment and correct any errors 4142

Re-transmit corrected file to WCIS 4142

Structural testing communication loop 4243

Transmission 997 acknowledgment error messages 4243

Step five: Detailed testing - Sender receives and processes an 824 from DWC 4546

Data quality criteria 4647

Prepare detailed test file(s) 4647

Detailed testing communication loop 4748

Electronic acknowledgment from WCIS 4748

Detailed 824 acknowledgment error messages…….………………………..…...49

Process the detailed 824 acknowledgment 4849

Production Status 50

Section H: Supported transactions and ANSI file structure 5253

Supported transactions 5354

Health care claim transaction sets (837 & 824) 5354

ANSI definitions 5354

California ANSI 837 loop, segment and data element summary 5556

California ANSI 824 loop, segment and data element summary 6061

Section I: The FTP transmission mode 6263

Data transmission with file transfer protocol (FTP) 6364

FTP server account user name and password 6364

FTP communication ports 6364

FTP over SSL 6465

FTP Server name and IP address 6465

Section J: Events that trigger required medical EDI reports 7576

Event table definitions 7677

Section K: Required medical data elements 7879

Medical data elements by name and source 7980

Medical data element requirement table 8384

Section L: Data edits 9697

California-adopted IAIABC data edits and error messages 9798

Section M: System specifications 105106

Jurisdiction claim number………………………………………………………………….107

Transaction processing and sequencing 106107

Correcting data elements (BSRC=00)(AAC=TR) 107108

Updating data elements (BSRC=01)(AAC=TA) 107108

Replacing a claim administrator claim number (BSRC=05)(AAC=TA) 108109

Duplicate medical bills 108109

WCIS medical matching rules and processes for a claim 109110

Unmatched Transactions (AAC=TE) 110111

Section N: Code lists and state license numbers 115116

Code Sources……………………………………………………………………………….117

Postal code 116117

Healthcare financing administration common procedural coding system (HCPCS) 116117

International classification of diseases clinical modification (ICD-9 CM) procedure 116117

Current procedural terminology (CPT) codes 117118

National drug code (NDC) 117118

Diagnosis related groups (DRG) 117118

Provider taxonomy codes 118119

Facility/Place of service codes 118119

Revenue billed /paid code 121122

Claim adjustment group codes 132133

Claim adjustment reason codes 133134

California state medical license numbers 133134

National plan and provider enumeration system 133134

Section O: California-adopted IAIABC data elements 134135

Numerically-sorted list of California-adopted IAIABC data elements 134135

Section P: Lump sum bundled lien bill payment…………………………139

Appendix A: Major changes in the medical implementation guide 141

List of changes from version 1.0 to version 1.1 by section 140141

Workers’ Compensation Information System (WCIS)

CALIFORNIA EDI IMPLEMENTATION GUIDE

for Medical Bill Payment Records

Version 1.0

December 2005

Table of Contents

Page

A Electronic data interchange in California – an overview 4

B Where to get help – contacting WCIS and other information sources .10

C Implementing medical EDI – a manager’s guide 13

D Authorizing statutes – Labor Code 19

E WCIS regulations 23

F Trading partner profile 24

G Testing and production phases of medical EDI 34

H Supported transactions and ANSI file structure 46

I Transmission modes 56

J EDI service providers 60

K Events that trigger required medical EDI reports 66

L Required medical data elements 69

M Data edits 81

N System specifications 89

O IAIABC information 95

P Code lists and state license numbers 99

Q Medical EDI glossary and acronyms 117

R Standard medical forms 123

Section A: Electronic data interfacchange in California – an overview

Electronic data interchange – EDI 5

Benefits of EDI within workers’ compensation 5

Workers' compensation information system history 6

Components of the WCIS 6

California EDI requirements 7

Sending data to the WCIS 8

Four stages of EDI - from testing to production 9

Stage one: EDI trading partner profile 9

Stage two: structural testing 9

Stage three: detailed testing 9

Stage four: production 9

Electronic data interchange – EDI

Electronic data interchange (EDI) is the computer-to-computer exchange of data or information in a standardized format. In California workers’ compensation, medical EDI refers to the electronic transmission of detailed medical bill payment records information from trading partners, i.e. senders, to the California Division of wWorkers’ cCompensation agency.

Data are transmitted in a format standardized by the International Association of Industrial Accident Boards and Commissions (IAIABC) American National Standards Institute (ANSI). The International Association of Industrial Accident Boards and Commissions (IAIABC) adapted the ANSI file standard to workers’ compensation. The IAIABC is a professional association of workers’ compensation specialists from the public and private sectors and has spearheaded the introduction of EDI in workers’ compensation. (For further details, See Section O – IAIABC Information.) All data elements to be collected have been reviewed for a valid business need, and definitions and formats are standardized.

EDI Electronic data interchange is in use in workers’ compensation nationwide. Currently, over twenty states and more than 200 insurance companies and claims administrators are routinely transmitting data by EDI. Several states have established legal mandates to report data by EDI, including Indiana, Iowa, Kentucky, Montana, Nebraska, New Mexico, Oregon, South Carolina, Texas, and California.

Benefits of EDI within workers’ compensation

• Allows state agencies to respond to policy makers’ questions regarding their state programs

EDI Electronic data interchange allows states to evaluate the effectiveness and efficiency of the workers’ compensation system by providing comprehensive and readily accessible information on all claims. The information can then be made available to state policy makers considering any changes to the system.

• Avoids costs in paper handling

EDI Electronic data interchange reduces costs in the processing of paper documents for the claims administrator and the jurisdiction: mail processing costs, duplicated data entry costs, shipping costs, filing costs, and storage costs.

• Increases data quality

EDI Electronic data interchange has built-in automated data quality checking procedures that are triggered when data are received by the state agency. Many claims administrators adopt the national standard data-checking procedures for in-house systems to reduce the costly data-correction efforts that result when erroneous data are passed among the parties to a claim.

• Simplifies reporting requirements for multi-state insurers

EDI Electronic data interchange helps claims administrators cut costs by having a single system for internal data management and reporting across multiple state jurisdictions.

Workers' compensation information system history

The California legislature enacted sweeping reforms to California’s workers’ compensation system in 1993. The reform legislation was preceded by a vigorous debate among representatives of injured workers, their employers, insurance companies, and medical providers. All parties agreed that changes were due, but they could not reach agreement on the nature of the problems to be corrected nor on the likely impact of alternative reform proposals. One barrier to well-informed debate was the absence of comprehensive, impartial information about the performance of California’s workers’ compensation system.

Foreseeing that debate about the strengths and weaknesses of the system would continue, the legislature directed the Division of Workers’ Compensation (DWC) to put together comprehensive information about workers’ compensation in California (see Section D). The result is the WCIS – the Workers’ Compensation Information System. The WCIS has been in development since 1995, and its design has been shaped by a broad-based advisory committee.

The WCIS has four main objectives:

• help DWC manage the workers’ compensation system efficiently and effectively,

• facilitate the evaluation of the benefit delivery system,

• assist in measuring benefit adequacy, and

• provide statistical data for further research.

Components of the WCIS

The WCIS encompasses three major components. The core of the system is standard data on every California workers’ compensation claim. Historically the data was ere collected in paper form: employer and physician First Reports of Injury (FROI) benefit notices, and similar data. Beginning in 2000, the DWC began to collect standardized electronic data on the FROI via the WCIS EDI system. Beginning in 2006, the WCIS EDI system was expanded to include Medical EDI transmissions (see sSection E).

The WCIS will also use information from the DWC’s existing case tracking system. The DWC has extensive computerized files on adjudicated cases and on claims that have been submitted for disability evaluation. The existing DWC information will be linked with EDI data to help examine and explain any differences between adjudicated and non-adjudicated casesutilizing EAMS (Electronic Adjudication Management System).

Finally, the WCIS will conduct periodic surveys of a sample of injured workers, employers, and medical providers. The surveys will supplement the standard data, and allow the WCIS to address a wide variety of policy questions.

California EDI requirements

California’s WCIS regulations define EDI reporting requirements for claims administrators. A claims administrator is an insurer, a self-insured self-administered employer, or a third-party administrator. In A brief, summary of what Cclaims Aadministrators are required to submit the followsing:

• First reports: First Reports of Injury (FROI) have been transmitted by EDI to the DWC since March 1, 2000.

• Subsequent reports: Subsequent Reports of Injury (SROI) have been transmitted by EDI to the DWC since July 1, 2000. Subsequent reports must be submitted within 10 business days of whenever benefit payments to an employee are started, changed, suspended, restarted, stopped, delayed, denied, closed, reopened, or upon notification of employee representation.

• Medical bill/payment records reports: Medical bill payment reports began to be transmitted to the DWC six months from the effective date of the regulations were adopted on March 22, 2006 and require medical services with a date of service on or after September 22, 2006 and a date of injury on or after March 1, 2000 to be transmitted to the DWC within 90 calendar days of the medical bill payment or the date of the final determination that payment for billed medical services would be denied. These medical services need to be reported to the WCIS by all claims administrators handling 150 or more total claims per year. The required data elements are listed in Section KL-Required data elements of this guide and in the California Medical Data Dictionary (). See also Section E – WCIS Rregulations, which references the complete DWC/WCIS regulations.

• Annual summary of benefits: An annual summary of benefits must be submitted for every claim with any benefit activity (including medical) during the preceding year, beginning January 31, 2001.

Sending Data to the WCIS

California workers’ compensation medical bill payment records are processed by diverse organizations: large multi-state insurance companies, smaller specialty insurance carriers, self-insured employers or insurers, third-party administrators handling claims on behalf of self-insured employers, as well as bill review companies. The organizations have widely differing technological capabilities, so the WCIS is designed to be as flexible as possible in supporting EDI medical transmissions. The electronic communications options are described more fully in Secion I-Transmission modes.

Following the IAIABC standards the WCIS supports the American National Standards Institute (ANSI) file format. The California-adopted ANSI file format is summarized in Section H – Supported transactions and ANSI file structure and completely specified in Section 5 of the IAIABC EDI Implementation Guides for Medical Bill Payment Records, Release 1.1, Reporting July 1, 20049. ().

Claims administrators that who wish to avoid the technical details of IAIABC EDI guidelines can choose among several firms that sell EDI related software products, consulting, and related services. See Section J – EDI Service Providers.

Currently, after a worker is injured, medical bill payment records are either mailed or electronically transmitted from medical providers to the insurers or their representatives and then via the medical EDI transmissions to the California Workers’ Compensation Information System (WCIS).

Flow of Medical Data in the California Workers Compensation System

[pic]

Injured

Worker

Medical Industry Insurers Electronic DWC/

Providers Billing Data WCIS

Standards Interface

Four stages of EDI - from testing to production

Attaining full production EDI reporting with the DWC is a four stage process. Each stage of the process is described in more detail in Section G – Testing and production phases of medical EDI.

Stage one: EDI trading partner profile

The trading partner first provides an EDI trading partner profile to the DWC at least 30 (thirty) days before the first submission of electronic data. The trading partner profile form is in Section F. The trading partner profile is used to establish communications protocols between the WCIS and each trading partner with respect to: what file format to expect, where to send an acknowledgement, when to transmit reports, and similar information.

Stage two: structural testing

The trading partner next runs a preliminary test by transmitting an ANSI 837 test file to ensure the WCIS system can read and interpret the data. The trading partner passes the structural test when the minimum technical requirements are met: WCIS recognizes the sender, the ANSI 837 file format is correct, and the trading partner can receive electronic 997 functional acknowledgements from the WCIS.

Stage three: detailed testing

After a structural test file is successfully transmitted, the trading partner transmits real detailed medical bill payment data, in test status. During the detailed test phase, the trading partner’s submissions are analyzed for data completeness, validity, and accuracy. The trading partner can submit detailed medical bill payment records both by EDI and in hard copy during the pilot. If paper bills are submitted, the DWC uses the parallel reports to conduct a comparison study. The trading partner must meet minimum data quality requirements in order to complete the detailed testing stage.

Stage four: production

During production, data transmissions will be monitored for completeness, validity, and accuracy. Each trading partner will be routinely sent reports describing their data quality. The data edits are more fully described in Section M – Data edits and in the IAIABC EDI Implementation Guides for Medical Bill Payment Records, Reporting July 2004. ( ).

Five steps of EDI - from testing to production

Attaining full production medical EDI reporting with the DWC is a four stage five step process. Each stage step of the process is described in more detail in Section G – Testing and production phases of medical EDI.

Step one: Sender submits Trading Partner Profile

The trading partner first provides a completed EDI trading partner profile form to the DWC at least 30 (thirty) days before the first submission of electronic data. The form is contained in Section F. The trading partner profile is used to establish communications protocols between the WCIS and each trading partner with respect to: what file format to expect, where to send an acknowledgment, when to transmit medical bills and similar information. Send the completed trading partner profile by email to WCIS@dir. or fax to 510-286-6862

Step two: Sender tests FTP connectivity

Within 5 days of receiving the completed profile, WCIS will email or fax a FTP information form with an IP Address to the technical contact named in trading partner profile form, Part B, Trading Partner Contact Information (See Section F). Within 7 days of receiving completed FTP Information form, WCIS will open a port and ask the trading partner to send a sample test file to ensure the WCIS system can accept and return an electronic file to the trading partner.

Step three: Sender transmits numerous ANSI 837 bill types

The trading partner compiles small ANSI 837 files with the required loops, segments, and data elements which represent different types of medical bills (See Section H). The trading partner passes the structural test when the minimum technical requirements of the ANSI 837 file format are correct.

Step four: Structural Testing - Sender receives and processes a 997 from DWC

The trading partner can receive and process electronic 997 functional acknowledgments from the WCIS. The trading partner tests the internal capability to process the 997 from the DWC and correct any structural errors detected by the WCIS.

Step five: Detailed Testing - Sender receives and processes an 824 from DWC

After an 837 structural test file is successfully transmitted, the trading partner transmits real detailed medical bill payment data, in test status. During detailed testing, the trading partner’s submissions are analyzed for data completeness, validity, and accuracy. The trading partner must meet minimum data quality requirements in order to complete detailed testing.

After the structural and detailed testing is successfully completed, the trading partner transmits a cancellation of at least one the medical bills sent in step three but not all. The cancelled bills are matched to the original bills sent in step three and deleted from the WCIS database. The trading partner receives a 997 and 824 ANSI file from the WCIS.

Once the structural and detailed testing is successfully completed, the trading partner transmits a replacement of a claim number sent in step three. The original claim number is matched to the original claim number sent in step three in the WCIS database. The trading partner receives a 997 and 824 ANSI file from the WCIS.

Upon successful completion of the five testing steps, the trading partner may begin to send production data.

During production, data transmissions will be monitored for completeness, validity, and accuracy. The data edits are more fully described in Section L and in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009. ().

Section B: Where to get help – contacting WCIS and other information resources

California Division of Workers’ Compensation 11

WCIS web site 11

WCIS contact person 11

WCIS e-news 12

EDI service providers 12

User groups 12

IAIABC 12

California Division of Workers’ Compensation

Starting up a new medical EDI system is not simple. It requires detailed technical information as well as close cooperation between the organizations that send data, the trading partner, and the organization that receives data, the California Division of Workers’ Compensation (DWC). The following is a list of resources available to trading partners for information and assistance.

WCIS web site

Visit the WCIS web site – – to:

□ download the latest version of the California EDI Implementation Guide for Medical Bill Payment Records,

□ get answers to frequently asked questions, and

□ review archived WCIS e-news letters, and

□ download power point training materials.

WCIS contact person

Each WCIS trading partner will be assigned an individual contact person at the DWC. The assigned person will help answer trading partner questions about medical EDI in the California WCIS, work with the trading partner during the testing process, and be an ongoing source of support during production.

The WCIS contact person can be reached by phone, e-mail, or mail. When initially contacting the WCIS, be sure to provide your company name so that you will be assigned to the appropriate WCIS contact person.

By phone:

510-286-6753 Trading Partner Letters C, G-H, M, P-R

510-286-6763 Trading Partner Letters B, D-F, N-O, W-Y

6772. Trading Partner Letters A, I-L, S-V, Z

By fax: (415) 703-5911 (510) 286-6862

By e-mail: wcis@dir.

By Mail: WCIS EDI Unit

Attn: Name of WCIS contact (if known)

Department of Industrial Relations

IS Department

1515 Clay Street, 198th Floor

Oakland, CA 94612

WCIS e-news

WCIS e-news is an email newsletter sent out periodically to inform WCIS trading partners of announcements and technical implementations. The WCIS e-news is archived on the WCIS web site. Interested parties who are not already receiving WCIS e-news can register at the WCIS website to be added to the WCIS e-news mailing list.

EDI service providers

Several companies can assist in reporting medical data via EDI. A wide range of products and services are available, including:

( software that works with existing computer systems to transmit medical data automatically,

( systems consulting, to help get your computer systems EDI-ready, and

( data transcription services, which accept paper forms, create electronic files, keypunch the data, and transmit the medical data via EDI.

See Section J – EDI service providers for a list of companies known to the DWC to provide EDI services.

A list of companies known to DWC that provide these services can be found at .

Claims administrators seeking assistance in implementing EDI may wish to consult one or more of the EDI service providers listed on the DWC website. Many of these firms offer a full range of EDI-related services: consultation, technical support, value added network (VAN) services, and/or software products. These products and services can make it possible for claims administrators to successfully transmit claims data via EDI and avoid the technical details of EDI.

Another alternative to developing a complete EDI system is to contract for the services of a data collection agent. For a fee, a data collection agent will receive paper forms by fax or mail, enter the data, and transmit it by EDI to state agencies or other electronic commerce trading partners.

The California Division of Workers’ Compensation does not have a process for granting “approvals” to any EDI service providers. Listings of providers, which are found on the Division’s website, are simply of providers known to the Division. The lists will be updated as additional resources become known.

Appearance on the EDI service provider lists does not in any way constitute an endorsement of the companies listed or a guarantee of the services they provide. Other companies not listed may be equally capable of providing EDI-related services.

Note to suppliers of EDI-related services: Please contact wcis@dir. if you wish to have your organization added or removed from DWC’s list, or to update your contact information.

User groups

Some organizations may find it useful to communicate with others who are transmitting medical data via EDI to the California Workers’ Compensation Information System. Information about users’ groups will be posted to the WCIS web site.

IAIABC

The International Association of Industrial Accident Boards and Commissions (IAIABC) is the organization that sets the national standards for the transmission of workers’ compensation medical data via EDI. The IAIABC published the standards in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, Reporting July 20049.

For more information about the IAIABC and how to access the IAIABC EDI Implementation Guides, See Section O – IAIABC Information, and/or visit the IAIABC web site at: .

Section C: Implementing medical EDI – a managers’ guide

Get to know the basic requirements…………………………………………………………14

Assign responsibilities for implementing medical EDI……………………………….…….14

Decide whether to, or not to, contract with an EDI service provider……………..………14

Choose a transmission mode for medical data …………………………………………...15

Make sure your computer system contains all the required data………………………...15

Developing a comprehensive EDI system…………………………………………………..15

Handling error messages sent by WCIS…………………………………………………….16

Benefit of adding “data edits.”…………………………………………………………...…...16

Updating software and communications services………………………………………….16

Test your system internally …………………………………………………………………...17

Testing and production stages of medical EDI transmission……………………………..17

Evaluate the efficiency of your EDI system, and consider future refinements………….18

Get to know the basic requirements

Starting up a new EDI system can be a complex endeavor. Make sure you understand all that is required before investing resources. Otherwise you may end up with a partial rather than a comprehensive solution.

The California EDI Implementation Guide for Medical Bill Payment Records has much of the information needed to implement medical EDI in California. As more information becomes available it will be posted on our to the WCIS Wweb site:

dir.dwc/wcis.htm

Assign responsibilities for implementing medical EDI

Implementing medical EDI will affect your information systems, claims processing practices and other business procedures. Some organizations appoint the information systems manager, while others designate the claims manager as medical EDI implementation team leader. Regardless of who is assigned primary responsibility, make sure that all eaffected systems, procedures, and maintenance activities are included as you designed and implemented your EDI procedures.

Many organizations find that implementing EDI highlights the importance of data quality. Addressing data quality problems may require adjustments in your overall business procedures. Your medical EDI implementation team will probably need access to someone with authority to make the adjustments if needed.

Decide whether to, or not to, contract with an EDI service provider

Formatting and transmitting electronic medical records by EDI generally requires some specialized automated routines. Programming a complete EDI system also requires in-depth knowledge of EDI standards and protocols.

Some organizations may choose to develop the routines internally, especially if they are familiar with EDI or are efficient in bringing new technology on-line. Make a realistic assessment of your organization’s capabilities when deciding whether or not to internally develop the needed EDI capacity.

Other organizations may choose to out source with vendors for dedicated EDI software or services. Typically, EDI vendor products interface with your organization’s data to produce medical EDI transactions in the required ANSI format. The benefit is that no one in your organization has to learn all the intricacies of EDI – the service provider takes care of file formats and many other details that may seem foreign to your organization. Some EDI vendors can also provide full-service consulting – helping you update your entire data management process to prepare it for electronic commerce. Some EDI vendors are listed in Section J – EDI service providers.

Contracting with an EDI service provider would relieve your organization of the detailed mechanics of EDI – such as file formats and transmission modes – but if you decide to develop your own system you will have some important decisions to make. The decisions will determine the scope and difficulty of the programming work.

Choose a The FTP transmission mode for medical data

Choose a transmission mode from Tthe two that WCIS supports: Value Added Networks (VAN) and or File Transfer Protocol (FTP) files transmissions using Secure Sockets Layer (SSL) and Pretty Good Privacy (PGP) encryption (See Section I). – Transmission modes- for further information.

Summary information about the required ANSI format can is contained in Section H – Supported transactions and ANSI file structure and detailed information about ANSI formats is included in Section 5 of the IAIABC EDI Implementation Guide for Medical Billing Payment Reports Records, Release 1.1, July 1, 20029, published by the IAIABC at:

The This IAIABC EDI Implementation Guide for Medical Billing Payment Reports is essential if you are programming your own EDI system.

Make sure your computer system contains all the required data

Submitting medical data by EDI requires the data to be readily accessible on your electronic systems. Review Section LK – Required medical data elements and determine which data elements are readily accessible, which are available but accessible with difficulty, and which are not captured at this time. An example of a required data element not internally captured required date element may be medical provider state facility license numbers, which are issued, maintained, and distributed by the California Department of Consumer Affairs Public Health (see Section P).

If all the medical data are electronically available and readily accessible, then you are in great shape. If not, you will need to develop and implement a plan for capturing, storing, and accessing the necessary medical data electronically.

Developing a comprehensive EDI system

The California DWC EDI requirements have gone into effect in multiple phases. The first phase consisted of EDI transmissions of FROI’s information beginning in March, 2000. The second phase added the SROI’s information in July, 2000. A third requirement, an annual summary of payments on each active claim, went into effect January, 2001. The latest initial requirement ofor reporting all medical payments goes into effect six months from effective date of the WCIS regulations became effective March 22, 2006 for medical services provided on or after September 22, 2006, to employees injured on or after March 1, 2000. As of February, 2005 the DWC was receiving FROI data from 205 trading partners and SROI dara from 80 trading partners. Implementing the requirements of the EDI transmission of the FROI’s and SROI’s information may have provided your organization a basic framework in which to implement the requirements of the medical bill payment reports records.

Handling error messages sent by WCIS

The DWC will transmit “error messages” from the WCIS back to you if the medical data transmitted to the DWC does not meet the regulatory requirements to provide complete, valid, and accurate data.

You will need a system for responding to error messages received from the WCIS. Establish a procedure for responding to error messages before you begin transmitting medical data by EDI. Typically errors related to technical problems are common when a system is new, but quickly become rare. Error messages related to data quality and completeness are harder to correct (See Section G - Testing and production phases of medical EDI).

Benefits of adding “data edits”

Medical bill payment record data transmitted to the WCIS will be subjected to “edit rules” to assure that the medical data are valid. The edit rules are detailed in Section ML – Data edits. Data that violate the edit rules will cause medical data transmissions to be rejected with error messages.

Correcting erroneous data may require going to the original source. In some organizations the data passes through many hands before being it is transmitted to WCIS. For example, the medical data may first be processed in a claim reporting center, then to by a data entry clerk, to followed by a claims adjuster, before finally being transmitted to the WCIS and then through an information systems department. Any error messages would typically be passed through the same channel in the opposite direction.

An alternative is to install in your system, as close as possible to the original source of data (medical provider, claims department), data edits that match the WCIS edit rules. As an example, consider a claims reporting center in which claims data are entered directly into a computer system with data edits in place. Most data errors could be caught and corrected between the medical provider and the claims reporting center. Clearly, early detection eliminates the expense of passing bad data through the system and back again.

Updating software and communications services

After the EDI system is designed, begin to purchase or develop system software and/or contract for services as needed.

Most systems will need at least the following:

□ software/services to identify events that trigger required medical reports,

□ software/services to gather required medical data elements from your databases,

□ software/services to format the data into an approved medical EDI file format,

□ an electronic platform to transmit the medical data to the DWC and receive acknowledgements, with possible error messages, back from WCIS.

Test your system internally

Most new systems do not work perfectly the first time. Make sure the “data edit” and “error response” parts of the system are thoroughly tested before beginning the testing and production stages of EDI with the WCIS. Internally debugging the “data edit” and “error response” systems in advance will decrease the number of error messages associated with transmitting invalid or inaccurate data to the WCIS. More detail is included in Section G - Testing and production phases of medical EDI.

Include in the internal tests some complex test cases as well as simple ones. For example, test the system with medical bill payment records containing multiple components, like medical treatments, durable medical equipment, and pharmaceuticals. Fix any identified problems before entering into the testing and production phases of medical EDI with the WCIS. The WCIS has procedures in place to help detect errors in your systems so that you can transmit complete, valid, and accurate medical data by the time you achieve production status.

Testing and production stages of medical EDI transmission

The first step is to complete a trading partner profile (See Section F). The profile is used to establish an electronic link between the WCIS and each trading partner: it identifies who the trading partner is; where to send the WCIS acknowledgements, when the trading partner plans to transmit medical bills, and other pertinent information necessary for EDI.

Step two of the process is to test a structural file. A sSuccessful testing includes the tests for basic EDI connectivity between the trading partners system and the WCIS system, the WCIS verifying the medical transmissions match the WCIS technical specifications, and that the trading partner has the capability to you can receive and process a 997 acknowledgments in return from the WCIS. (See Section G for more detail).

During the third step of the process real data is transmitted and validated. Testing may include optional, matching medical data on paper reports (CMS 1500, UB92, ADA, Pharmaceutical UCF) to the electronic reports transmitted to the DWC. The DWC will send an 824 acknowledgment containing “error codes” which are generated by the “data edits”. To successfully complete stage three the trading partner will need to be able to process the ANSI 824 detailed acknowledgment and respond to any “error messages” it contains (See Section G for more detail).

Upon the successful completion of step three, the five-step testing process and after a period of routinely transmitting your medical data via EDI to the WCIS for at least 30 days, the DWC will issue confirm by e-mail that each trading partner you a written determination that you have demonstrated the capability to transmit complete, valid, and accurate medical data in production status. You will then be authorized to move into the production stage – routinely transmitting your medical data via EDI to the WCIS.

The IAIABC maintains the EDI standards for adopted by the California Division of Workers’ Compensation. For further information, contact the IAIABC (see contact information in Section O).

Evaluate your EDI system, and consider future refinements

Many organizations find that implementing EDI brings unexpected benefits. For example, EDI may provide an opportunity to address long-standing data quality, processing, and storage problems.

Arrange a review session after your system has been running for a few months. Users will be able to suggest opportunities for future refinements. Managers from departments not directly affected may also be interested in participating, because EDI will eventually affect many business procedures in the workers’ compensation industry.

Please let us know if you have any comments on this manager’s guide.

Send us an e-mail, addressed to:

wcis@dir..

Section D: Authorizing statutes – Labor Code §138.6, 138.7

L.C. §138.6 Workers’ compensation information system 20

L.C. §138.7 Individually identifiable information 20

L.C. §Labor Code section 138.6. Development of workers' compensation information system

   (a) The administrative director, in consultation with the Insurance Commissioner and the Workers' Compensation Insurance Rating Bureau, shall develop a cost-efficient workers' compensation information system, which shall be administered by the division. The administrative director shall adopt regulations specifying the data elements to be collected by electronic data interchange.

 

   (b) The information system shall do the following:

 

    (1) Assist the department to manage the workers' compensation system in an

effective and efficient manner.

 

    (2) Facilitate the evaluation of the efficiency and effectiveness of the benefit

delivery system.

 

    (3) Assist in measuring how adequately the system indemnifies injured workers

and their dependents.

 

   (4) Provide statistical data for research into specific aspects of the workers'

compensation program.

 

   (c) The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions. The administrative director may adopt regulations authorizing the use of other nationally recognized data transmission formats in addition to those set forth in the Electronic Data Interchange System for the transmission of data required pursuant to this section. The administrative director shall accept data transmissions in any authorized format. If the administrative director determines that any authorized data transmission format is not in general use by claims administrators, conflicts with the requirements of state or federal law, or is obsolete, the administrative director may adopt regulations eliminating that data transmission format from those authorized pursuant to this subdivision

L.C. §Labor Code section 138.7. “Individually identifiable information”; restricted access

   (a) Except as expressly permitted in subdivision (b), a person or public or private entity not a party to a claim for workers' compensation benefits may not obtain individually identifiable information obtained or maintained by the division on that claim. For purposes of this section, "individually identifiable information" means any data concerning an injury or claim that is linked to a uniquely identifiable employee, employer, claims administrator, or any other person or entity.

 

   (b)(1) The administrative director, or a statistical agent designated by the administrative director, may use individually identifiable information for purposes of creating and maintaining the workers' compensation information system as specified in Section 138.6.

 

(2) The State Department of Health Services may use individually identifiable information for purposes of establishing and maintaining a program on occupational health and occupational disease prevention as specified in Section 105175 of the Health and Safety Code.

 

(3)(A) Individually identifiable information may be used by the Division of Workers' Compensation, the Division of Occupational Safety and Health, and the Division of Labor Statistics and Research as necessary to carry out their duties. The administrative director shall adopt regulations governing the access to the information described in this subdivision by these divisions. Any regulations adopted pursuant to this subdivision shall set forth the specific uses for which this information may be obtained.

 

   (B) Individually identifiable information maintained in the workers' compensation information system and the Division of Workers' Compensation may be used by researchers employed by or under contract to the Commission on Health and Safety and Workers' Compensation as necessary to carry out the commission's research. The administrative director shall adopt regulations governing the access to the information described in this subdivision by commission researchers. These regulations shall set forth the specific uses for which this information may be obtained and include provisions guaranteeing the confidentiality of individually identifiable information. Individually identifiable information obtained under this subdivision shall not be disclosed to commission members. No individually identifiable information obtained by researchers under contract to the commission pursuant to this subparagraph may be disclosed to any other person or entity, public or private, for a use other than that research project for which the information was obtained. Within a reasonable period of time after the research for which the information was obtained has been completed, the data collected shall be modified in a manner so that the subjects cannot be identified, directly or through identifiers linked to the subjects.

 

   (4) The administrative director shall adopt regulations allowing reasonable access to individually identifiable information by other persons or public or private entities for the purpose of bona fide statistical research. This research shall not divulge individually identifiable information concerning a particular employee, employer, claims administrator, or any other person or entity. The regulations adopted pursuant to this paragraph shall include provisions guaranteeing the confidentiality of individually identifiable information. Within a reasonable period of time after the research for which the information was obtained has been completed, the data collected shall be modified in a manner so that the subjects cannot be identified, directly or through identifiers linked to the subjects.

 

   (5) This section shall not operate to exempt from disclosure any information that is considered to be a public record pursuant to the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code) contained in an individual's file once an application for adjudication has been filed pursuant to Section 5501.5.

 

   However, individually identifiable information shall not be provided to any person or public or private entity who is not a party to the claim unless that person identifies himself or herself or that public or private entity identifies itself and states the reason for making the request. The administrative director may require the person or public or private entity making the request to produce information to verify that the name and address of the requester is valid and correct. If the purpose of the request is related to preemployment screening, the administrative director shall notify the person about whom the information is requested that the information was provided and shall include the following in 12-point type:

 

   "IT MAY BE A VIOLATION OF FEDERAL AND STATE LAW TO DISCRIMINATE AGAINST A JOB APPLICANT BECAUSE THE APPLICANT HAS FILED A CLAIM FOR WORKERS' COMPENSATION BENEFITS."

 

   Any residence address is confidential and shall not be disclosed to any person or public or private entity except to a party to the claim, a law enforcement agency, an office of a district attorney, any person for a journalistic purpose, or other governmental agency.

 

   Nothing in this paragraph shall be construed to prohibit the use of individually identifiable information for purposes of identifying bona fide lien claimants.

 

   (c) Except as provided in subdivision (b), individually identifiable information obtained by the division is privileged and is not subject to subpoena in a civil proceeding unless, after reasonable notice to the division and a hearing, a court determines that the public interest and the intent of this section will not be jeopardized by disclosure of the information. This section shall not operate to restrict access to information by any law enforcement agency or district attorney's office or to limit admissibility of that information in a criminal proceeding.

 

   (d) It shall be unlawful for any person who has received individually identifiable information from the division pursuant to this section to provide that information to any person who is not entitled to it under this section.

Section E: WCIS regulations – Title 8 CCR § sections 97010-97034

Pertinent WCIS Regulations

The regulations pertinent to WCIS are stated in Title 8, California Code of Regulations, Ssections 9700-9704. They are available at dir.t8/ch4_5sb1a1_1.html

Section F: Trading partner profile

Who should complete the trading partner profile? 25

EDI trading partner profile form 26

Instructions for completing trading partner profile 29

Who should complete the trading partner profile?

A separate trading partner profile form must be completed for each trading partner transmitting EDI medical records to WCIS (see page 9, 11, and 35). Each trading partner has a unique identification composed of the trading partner's federal tax identification number (“Master FEIN”) and postal code. The identification information must be reported in the header record of every transmission. The trading partner identification, in conjunction with the sender information, transmission date, time of transmission, batch control number, and reporting period are used to identify communication parameters for the return of acknowledgments to the trading partners.

For some senders, the insurer FEIN (federal tax identification number) provided in each ST-SE transaction set will always be the same as the sender identification master FEIN. Other senders may have multiple FEIN’s for insurers or claims administrators. If The transactions for a sender with multiple insurer FEIN’s or claims administrator FEIN’s share the same transmission specifications, the data can be sent under the same sender identification master FEIN.

For example, a single parent insurance organization might wish to send transactions for two subsidiary insurers together in one 837 transmission. In such a case, the parent insurance organization could complete one trading partner profile, providing the master FEIN for the parent insurance company in the sender ID, and could then transmit ST-SE transaction sets from both subsidiary insurers, identified by the appropriate insurer FEIN in each ST-SE transaction set within the 837 transmission.

Another example is, a single organization that might wish to send transactions for multiple insurers or claims administrators together in one 837 transmission. In such a case, the sending organization could complete one trading partner profile, providing the master FEIN for the sending company in the sender ID, and could then transmit ST-SE transaction sets for the multiple insurers or claims administrators, identified by the appropriate insurer FEIN or Claims Administrator FEIN in each ST-SE transaction set within the 837 transmission.

The WCIS uses either an insurer FEIN, a claims administrator FEIN, or a bill review company FEIN to process individual 837 transmissions. Transmissions for unknown senders will be rejected by WCIS. For this reason, it is vital for each WCIS trading partner profile to be accompanied by a list of all sender FEIN’s who will be sending 837 transmissions under a given Trading Partners Master FEIN. The trading partner profile form contains only one FEIN: multiple FEIN’s for all other senders must be submitted on a separate sheet of paper with the trading partner profile. If the list of multiple FEIN’s is not provided, WCIS will assume the sender FEIN reported by that trading partner will be the master FEIN and the only trading partner sender identification

[pic] DIVISION OF WORKERS’ COMPENSATION

MEDICAL

ELECTRONIC DATA INTERCHANGE TRADING PARTNER PROFILE

PART A. Trading Partner Background Information:

Date:

Sender Name:_______________________________________________

Sender Master FEIN: _________________________________________

Physical Address: _____________________________________________

City: ________________________________________ State: ______

Postal ZipCode: _____________________

Mailing Address: ______________________________________________

City: ________________________________________ State: ______

Postal ZipCode: _____________________

Trading partner type (check all that apply):

__ Self Administered Insurer

__ Service Bureau

__ Self Administered, Self-Insurer (employer) __ Other:

__ Third Party Administrator of insurer

__ Third Party Administrator of self-insurer

PART B. Trading Partner Contact Information:

Business Contact: Technical Contact:

Name: _________________________ Name: __________________________

Title: __________________________ Title: ___________________________

Phone: _________________________ Phone: __________________________

FAX: ___________________________ FAX: ___________________________

E-mail Address: __________________ E-mail Address: __________________

PART C. Trading Partner Transmission Specifications:

Part C1 - Please complete the following:

If submitting more than one profile, please specify:

PROFILE NUMBER (1, 2, etc.): __________

DESCRIPTION: ______________________________________

Select Transmission Mode to be used for sending data to DWC (check one):

___ Value Added Network (VAN) -- Complete sections C1 and C2 below.

___ File Transfer Protocol (FTP) -- Complete sections C1 and C3 below.

C1 Van and FTP users, please complete the following:

|Transaction Type |Mode of Transmission |Expected Days of Transmission |Production Response |

| | |(circle any that apply) |Period |

|Medical Bill Payment |ANSI 837 | Daily | |

|RecordsReports | |Monday Tuesday Wednesday | |

| | |Thursday Friday Saturday Sunday | |

| | |Weekly | |

C2 Van users, please complete the following:

Network:

| |Test |Production |

|Mail Box Account Identification | | |

|User Identification | | |

C3 FTP users, please complete the following:

|User Name | |

|Password | |

|Network IP Address (optional) | |

|E-mail Address | |

Part C2 - FTP ACCOUNT INFORMATION FOR MEDICAL BILL

Sender/Trading Partner Name: _________________________

Sender/Trading Partner E-mail: _________________________

| | |

| |DWC Use Only |

|User Name: (A-Z, a-z, 0-9) | |

| | |

|__________________________ | |

| | |

|For PGP user only: suffix of @wcismed_pgp will be required after your user name. | |

|Password: (8 characters min.) | |

| | |

|__________________________ | |

|Transmission Modes: (choose one) | |

|_____ PGP+SSL | |

|_____ SSL | |

|Source Public Network IP Address: (limit to 6 max.) | |

| | |

|__________________________ | |

|File Naming Convention: | |

| | |

|Prefix: (max. 4 characters) _____________ | |

| | |

|Unique Identifier: (choose one) | |

|___ Sequence | |

|___ Date/Time | |

|___ Date/Sequence | |

|___ Other __________ | |

PART D. Receiver Information (to be completed by DWC):

Name: California Division of Workers’ Compensation

FEIN: 943160882

Physical Address: 1515 Clay Street, 19th Floor Suite 1800

City: Oakland State: CA PostalZip Code: 94612-149189

Mailing Address: 1515 Clay Street, 19th Floor P.O. Box 420603

City: Oakland San Francisco State: CA Zip PostalCode: 94612142-0603

Business Contact: Technical Contact:

Name: (Varies by trading partner) Name: (Varies by trading partner)

Title: (Varies by trading partner) Title: (Varies by trading partner)

Phone: (Varies by trading partner) Phone: (Varies by trading partner)

FAX: 510-286-6862 FAX: 510-286-6862

E-mail Address: wcis@dir. E-mail Address: wcis@dir.

RECEIVER’S FTP ELECTRONIC MAILBOX(s):

Network: A.T. & T Network: IBM Global (Advantis)

| |TEST |PROD | | |TEST |PROD |

|Mailbox Acct ID |(N/A) |(N/A) | |Mailbox Acct ID |DIRW |DIRW |

|User ID |(N/A) |(N/A) | |User ID |DIRWCIS |DIRWCIS |

RECEIVER’S ANSI X12 TRANSMISSION SPECIFICATIONS:

Segment Terminator: ~ ISA Information: TEST PROD

Data Elements Separator: * Sender/Receiver Qualifier: ZZ ZZ

Sub-Element Separator: : Sender/Receiver ID: (Use Master FEINs)

STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS

DIVISION OF WORKERS’ COMPENSATION

Electronic Data Interchange Trading Partner Profile

INSTRUCTIONS FOR COMPLETING TRADING PARTNER PROFILE

Each trading partner will complete parts A, B and C, providing information as it pertains to them. Part D contains receiver information, and will be completed by the DWC.

PART A. TRADING PARTNER BACKGROUND INFORMATION:

NAME : The name of your business entity corresponding with the Master FEIN.

Master

FEIN: The Federal Employer’s Identification Number of your business entity. The FEIN, along with the 9-position zip postal code (Zippostal+4) in the trading partner address field, will be used to identify a unique trading partner.

Physical

Address: The street address of the physical location of your business entity. It will represent where materials may be received regarding “this” Trading Partner Profile if using a delivery service other than the U.S. Postal Service.

City: The city portion of the street address of your business entity.

State: The 2-character standard state abbreviation of the state portion of the street address of your business entity.

PostalZip

Code: The 9-position zip postal code of the street address of your business entity. This field, along with the Trading Partner FEIN, will be used to uniquely identify a trading partner.

Mailing

Address: The mailing address used to receive deliveries via the U. S. Postal Service for your business entity. This should be the mailing address that would be used to receive materials pertaining to “this” Trading Partner Profile. If this address is the same as the physical address, indicate “Same as above”.

Trading

Partner

Type: Indicate any functions that describe the T trading partner. If “other”, please specify.

PART B. TRADING PARTNER CONTACT INFORMATION:

This section provides the ability to identify individuals within your business entity who can be used as contacts. Room has been provided for two contacts: business and technical.

BUSINESS

CONTACT: The individual most familiar with the overall data extraction and transmission process within your business entity. He/she may be the project manager, business systems analyst, etc. This individual should be able to track down the answers to any issues that may arise from your trading partner that the technical contact cannot address.

TECHNICAL

CONTACT: The individual that should be contacted if issues regarding the actual transmission process arise. This individual may be a telecommunications specialist, computer operator, etc.

BUSINESS/TECHNICAL The name of the contact.

CONTACT (Name)

BUSINESS/TECHNICAL The title of the contact.

CONTACT (Title)

BUSINESS/TECHNICAL The telephone number of the contact.

CONTACT (Phone)

BUSINESS/TECHNICAL The telephone number of the FAX machine

CONTACT (FAX) for the contact.

BUSINESS/TECHNICAL The e-mail address of the contact.

CONTACT (E-mail)

PART C. TRANSMISSION SPECIFICATIONS:

This section is used to communicate all allowable options for EDI transmissions between the trading partner and the DWC.

One profile should be completed for each set of transactions with common transmission requirements. Although one profile will satisfy most needs, it should be noted that if transmission parameters vary by transaction set IDs, a trading partner could specify those differences by providing more than one profile.

PROFILE ID: A number assigned to uniquely identify a given profile.

PROFILE ID

DESCRIPTION: A free-form field used to uniquely identify a given profile between trading partners. This field becomes critical when more than one profile exists between a given pair of trading partners. It is used for reference purposes.

TRANSMISSION

MODE: The trading partner must select one of the following two transmission modes through which the WCIS can accept transactions: EDI transactions are sent through a File Transfer Protocol (FTP). When selecting complete section C1 and either C2 or C3.

Van and FTP TRANSFERS:

Section Part C1:

TRANSACTION SETS FOR THIS PROFILE:

This section identifies all the transaction sets described within the profile along with any options the DWC provides to the trading partner for each transaction set.

TRANSACTION

TYPE: Indicates the types of EDI transmissions accepted by Division of Workers’ Compensation.

MODE OF

TRANSMISSION: DWC will accept the ANSI X12 VERSION 4010 contained in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 41, 20029. The WCIS will transmit detailed acknowledgements utilizing the acknowledgement format that corresponds to the format of the original transaction.

EXPECTED

TRANSMISSION

DAYS OF WEEK: Indicate expected transmission timing for each transaction type by circling the applicable day or days. Transmission days of week information will help DWC to forecast WCIS usage during the week. Note that DWC reserves the right to impose restrictions on a trading partner’s transmission timing in order to control system utilization.

PRODUCTION

RESPONSE

PERIOD: DWC will indicate here the maximum period of elapsed time within which a sending trading partner may expect to receive an acknowledgment for a given transaction type.

SECTION C2: VAN users:

ELECTRONIC

MAILBOX

FOR THIS

PROFILE: The trading partner will specify the electronic mailbox to which data can be transmitted. Separate mailbox information may be provided for transmitting production versus test data.

NETWORK: The name of the value added on which the mailbox can be accessed.

NETWORK

MAILBOX

ACCOUNT ID: The name of the trading partner’s mailbox on the specified VAN.

NETWORK:

USER ID: This is the identifier of the trading partner’s entity to the VAN.

SECTION C3: FTP users:

Part C2 - FTP ACCOUNT INFORMATION FOR MEDICAL BILL

Sender/Trading Partner Name and E-MAIL ADDRESS: Specify name and e-mail address

USER NAME: Specify a user name (A-Z, a-z, 0-9).

PASSWORD: Specify a password.

TRANSMISSION MODES: Choose one: PGP+SSL or SSL

SOURCE PUBLIC NETWORK IP ADDRESS: Optional

E-MAIL ADDRESS: Specify an e-mail address.

File Naming Convention: Specify Prefix and Unique Identifier

PART D. RECEIVER INFORMATION (to be completed by DWC):

This section contains DWC’s trading partner information.

Name: The business name of California Division of Workers’ Compensation.

FEIN: The Federal Employer’s Identification Number of DWC. This FEIN, combined with the 9-position zip postal code (Zippostal+4), uniquely identifies DWC as a trading partner.

Physical

Address: The street address of DWC. The 9-position zip postal code of this street

address, combined with the FEIN, uniquely identifies DWC as a trading partner.

Mailing

Address: The address DWC uses to receive deliveries via the U.S. Postal Service.

Contact

Information: This section identifies individuals at DWC who can be contacted with issues pertaining to this trading partner. The TECHNICAL CONTACT is the individual that should be contacted for issues regarding the actual transmission process. The BUSINESS CONTACT can address non-technical issues regarding the WCIS.

RECEIVER

ELECTRONIC

MAILBOXES: This section specifies DWC’s mailboxes, which trading partners can use to transmit EDI transactions to DWC. Separate mailbox information may be provided for receiving production versus test data.

NETWORK: FTP service on which the DWC’s mailbox can be accessed.

NETWORK

MAILBOX

ACCT ID: The name of the DWC mailbox on the specified FTP.

NETWORK:

USER ID: This is the identifier of the DWC’s entity to the FTP.

RECEIVER’S ANSI X12 TRANSMISSION SPECIFICATIONS:

SEGMENT The character to be used as a segment terminator is

TERMINATOR: specified here.

DATA ELEMENT The character to be used as a data element separator

SEPARATOR: is specified here.

SUB-ELEMENT The character to be used as a sub-element separator

SEPARATOR: is specified here.

SENDER/RECEIVER This will be the trading partner’s ANSI ID Code

QUALIFIER: Qualifier as specified in an ISA segment. Separate Qualifiers are provided to exchange Production and Test data, if different identifiers are needed.

SENDER/RECEIVER

ID: The ID Code that corresponds with the ANSI Sender/Receiver Qualifier (ANSI ID Code Qualifier). Separate Sender/Receiver IDs are provided to exchange Production and Test data, if different identifiers are needed.

Section G: Testing and production phases of medical EDI

Overview of the four step process 35

Step 1. Complete medical EDI trading partner profile 35

Step 2. Complete the structural test phase 35

Purpose 35

Test criteria 35

Test procedure 36

Step 3. Complete the detailed test phase 39

Overview 39

Purpose 39

Data quality criteria 39

Bill submission reason codes 40

Medical EDI detailed testing procedure 40

Parallel pilot paper procedure 43

Moving from test to production status 43

Step 4. Production 43

Data quality requirements 43

Data quality reports 44

Trading partner profile 44

WCIS paper pilot identification form 45

Overview of the four step process

The four step process is a step-by-step guide on how to become a successful EDI trading partner in the California workers’ compensation system. Attaining DWC\WCIS EDI capability is a four step process, beginning with completing a trading partner profile, followed by a structural test phase, a detailed testing phase, and finally production capability. The steps outlined below are meant to help each trading partner through the process by providing information on what to expect, what could go wrong, and how to fix problems. The DWC is offering the four step process to help facilitate each individual trading partner’s adoption of EDI capabilities. A WCIS contact person is available to work with each trading partner during this process to ensure the transition to production is successful.

Step 1. Complete a medical EDI trading partner profile

Completing a trading partner profile form is the first step in reporting medical record EDI data to the WCIS. The WCIS regulations (section 9702(j)) require the profile form be submitted to the division at least 30 days before the first transmission of EDI data, i.e., at least 30 days before the trading partner sends the first “test” transmission (see step 2). See section F – Trading partner profile details on how to complete a trading partner profile form.

Step 2. Complete the structural test phase

Purpose

The purpose of the structural test is to ensure the electronic transmissions meet the required technical specifications. The WCIS needs to recognize and process your ANSI 837 transmissions and your system needs to recognize and process 997 acknowledgment transmissions from the WCIS. The following are checked during the test:

( Transmission mode (value added network (VAN) or file transfer protocol (FTP) are functional and acceptable for both receiver and sender.

( Sender/receiver identifications are valid and recognized by the receiver and sender.

( File format (ANSI X12 837) matches the specified file structural format

Test criteria

In order for your system and the WCIS system to communicate successfully, a number of conditions need to be met.

( Establish Van or FTP connectivity

( No errors in header or trailer records

( Trading partners can send a structurally correct ANSI 837 transmission

( Trading partners can receive and process a 997 functional acknowledgment.

Test procedure

Trading partners using an FTP server should follow the steps given in section I – Transmission modes before sending a test file.

Prepare a test file

Trading partners using the VAN or FTP transmission modes will be sending medical data to the WCIS in ANSI 837 transmission consisting of three parts:

( An ISA-IEA interchange control header/trailer which identifies the sender, the receiver, test / production status, the time and date sent, etc.

( GS-GE functional group header(s)/trailer(s), which among other things, identifies the number of ST-SE transactions in each GS-GE functional group.

( ST-SE transactions which contain the medical data elements (see section L)

Send the test file

Send the test file to WCIS. The structural test data sent will not be posted to the WCIS production database. Any live California medical bill payment records sent as structural test data will have to be re-sent to WCIS during production to be posted to the WCIS production database.

Wait for an electronic 997 acknowledgment from WCIS

Trading partners must be able to both receive and process structural electronic acknowledgments from WCIS. When a structural test file has been received and processed by the DWC\WCIS, an electronic 997 acknowledgment will be transmitted to the trading partner by WCIS. The acknowledgment will report whether the transmission was successful (no errors) or unsuccessful (errors occurred). Please note that if the test file is missing the header, or if the sender identification in the interchange control header is not recognized by WCIS, no acknowledgment will be sent. The 997 functional acknowledgment sent during the structural test phase contains information relating to the structure of the ANSI 837 . Information about errors in the individual medical records will be included in the 824 detailed acknowledgment which follows in the detailed testing phase.

Overview of the five step process

The five step process is a step-by-step guide on how to become a successful EDI trading partner for medical bill reporting in the California workers’ compensation system. The five step process begins with completing a trading partner profile, followed by FTP connectivity, structural testing, detailed testing, medical bill cancellation, claim identifier replacement, and finally production capability. The steps outlined below are intended to help each trading partner through the process by providing information on what to expect, what could go wrong, and how to fix problems. The DWC is offering the five step process to help facilitate each individual trading partner’s adoption of EDI capabilities. A WCIS contact person is available to work with each trading partner during this process to ensure the transition to production is successful.

Step one: Complete a medical EDI trading partner profile

Completing a trading partner profile form is the first step in reporting medical record EDI data to the WCIS. The WCIS regulations (Title 8 CCR, section 9702(k)) require the profile form be submitted to the Division at least 30 days before the first transmission of EDI data, i.e., at least 30 days before the trading partner sends the first “test” transmission (see step two). See Section F for complete instructions on how to complete a trading partner profile form.

Step two: Sender tests FTP connectivity

Within 5 days of receiving the completed profile, WCIS will email or fax a File Transfer Protocol (FTP) information form with an IP Address to the technical contact named in the trading partner profile form, Part B, Trading Partner Contact Information (See Section F). Within 7 days of receiving the completed FTP information form, WCIS will open a port and ask the trading partner to send a sample of test files to ensure the WCIS system can accept and return an electronic file to the trading partner.

( Transmission mode is File Transfer Protocol (FTP).

( Establish FTP connectivity.

Step three: Sender transmits numerous ANSI 837 bill types

The trading partner compiles small ANSI 837 files with the required loops, segments, and data elements which represent different types of medical bills (See Section H). The trading partner passes the structural test when the minimum technical requirements of the California-adopted IAIABC 837 file format are correct.

Trading partners will be sending medical data to the WCIS in a California-adopted IAIABC 837 transmission consisting of three parts:

( An ISA-IEA interchange control header/trailer which identifies the sender, the receiver, test /production status, the time and date sent, etc.

( GS-GE functional group header(s)/trailer(s), which among other things, identifies the number of ST-SE transactions in each GS-GE functional group.

( ST-SE transactions which contain the medical data elements (See Section KJ)

[pic]

The DWC/WCIS suggests the test file consist of one ISA-IEA electronic envelope. The DWC/WCIS has developed several medical bill payment scenarios for California including professional bills, institutional bills, dental bills, pharmaceutical bills, and others to be included in the ST-SE transaction sets. The trading partner will also be required to send three bill submission reason codes (00, 01, and 05) while testing. The WCIS contact person assigned to the trading partner has additional information and is available to answer questions during the testing phase.

Step four: Structural testing - Sender receives and processes a 997 from DWC

The trading partner can receive and process electronic 997 functional acknowledgments from the WCIS. The trading partner tests the internal capability to process the 997 from the DWC/WCIS and correct any structural errors detected by the WCIS.

The purpose of the structural test is to ensure the electronic transmissions meet the required technical specifications. The WCIS needs to recognize and process your ANSI 837 transmissions and your system needs to recognize and process 997 acknowledgment transmissions from the WCIS. In order for your system and the WCIS system to communicate successfully, a number of conditions need to be met.

( Sender/receiver identifications are valid and recognized by the receiver and sender

( File format (ANSI X12 837) matches the specified file structural format

( Trading partners can send a structurally correct ANSI 837 transmission

( No errors in ISA-IEA, GS-GE, and ST-SE header/trailer records

( Trading partners can receive and process a 997 functional acknowledgment

Send the test file to WCIS. The structural test data sent will not be posted to the WCIS production database. Any live California medical bill payment records sent as structural test data will have to be re-sent to WCIS during production to be posted to the WCIS production database.

Trading partners must be able to both receive and process structural electronic acknowledgments from WCIS. When a structural test file has been received and processed by the DWC/WCIS, an electronic 997 acknowledgment will be transmitted to the trading partner by WCIS. The acknowledgment will report whether the transmission was successful (no errors) or unsuccessful (errors occurred). Please note that if the test file is missing the header, or if the sender identification in the interchange control header is not recognized by WCIS, no acknowledgment will be sent. The 997 functional acknowledgment sent during the structural test phase contains information relating to the structure of the ANSI 837. Information about errors in the individual medical records will be included in the 824 detailed acknowledgment which follows in the detailed testing phase.

Process the 997 functional acknowledgment and correct any errors

If you receive an error acknowledgment (application acknowledgment code = R or E, “837 transmission rejected”), you will need to check the ANSI 837 file format and make corrections before re-transmitting the file to WCIS. If the acknowledgment code = A (“837 transmission accepted”), skip to step five.

Re-transmit corrected file to WCIS

Send the corrected ANSI 837 file to the DWC. If the test fails again, repeat steps three and four until your test file is accepted by WCIS. You may send as many test files as you need to. The WCIS contact person assigned to you is available if you have any questions or problems during the process.

Structural level testing communication loop

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Transmission 997 acknowledgment error messages

Trading partners should receive an electronic 997 acknowledgment within 48 hours of sending the test transmission. If you do not receive an acknowledgment within 48 hours, contact the person identified in your WCIS Trading Partner Profile. The DWC/WCIS utilizes the 997 functional acknowledgment transaction set within the context of an Electronic Data Interchange (EDI) environment. The 997 functional acknowledgment indicates the results of the syntactical analysis of the 837 Transaction Set.

|997 Segment |Error Code |Error Message |

|AK3_Data Segment Note |2 |Unexpected segment |

|AK3_Data Segment Note |3 |Mandatory segment missing |

|AK3_Data Segment Note |8 |Segment has data element errors |

|997 Segment |Error Code |Error Message |

|AK4_Data Element Note |1 |Mandatory data element missing |

|AK4_Data Element Note |3 |Too many data elements |

|AK4_Data Element Note |4 |Data element too short |

|AK4_Data Element Note |5 |Data element too long |

|AK4_Data Element Note |6 |Invalid character in data element |

|AK4_Data Element Note |8 |Invalid date |

|AK4_Data Element Note |9 |Invalid time |

The general structure of a 997 functional acknowledgment transaction set is as follows:

010 ST Transaction Set Header

020 AK1 Functional Group Response Header

030 AK2 Transaction Set Response Header

040 AK3 Data Segment Note

050 AK4 Data Element Note

060 AK5 Transaction Set Response Trailer

070 AK9 Functional Group Response Trailer

080 SE Transaction Set Trailer

Process the 997 functional acknowledgment and correct any errors

If you receive an error acknowledgment (application acknowledgement code = R or E (837 transmission rejected)), you will need to check the ANSI 837 file format and make corrections before re-transmitting the file to WCIS. If the acknowledgment code = A (“837 transmission accepted”), skip to step six.

Re-transmit corrected file to WCIS

Send the corrected ANSI 837 file to the DWC. If the test fails again, repeat steps two through five until your test file is accepted by WCIS. You may send as many test files as you need to. The WCIS contact person assigned to you is available if you have any questions or problems during the process.

Notify the division when you are ready to proceed to the pilot phase

After the DWC system is able to successfully communicate with your system and all the transmitted files are structurally correct, then contact the person identified in your WCIS trading partner agreement and notify the person of your readiness to proceed to step 3. The WCIS contact person will notify you by phone or e-mail when the DWC system is ready to accept your detailed test data to begin the detailed testing phase of the process.

Step 3. Complete the detailed test phase

Overview

During the detailed test phase, trading partners may optionally submit copies of paper medical reports, CMS 1500, UB92, UCF pharmaceutical or dental forms, from the corresponding EDI medical transmissions, which are compared to the electronic data for accuracy, validity and completeness (see section R - Standard medical forms).

Purpose

Testing for data quality, both during the detailed testing phase and during production, will help trading partners comply with section 9702, electronic data reporting of the WCIS regulations (8 CCR §9702(a)):

“Each claim administrator shall, at a minimum, provide complete, valid, accurate data for the data elements set forth in this section.”

( Complete data – In order to evaluate the effectiveness and efficiency of the California workers’ compensation system (one of the purposes of WCIS set forth in the 1993 authorizing statute), trading partners must submit all required medical bill payment data elements for the required reporting periods

( Valid data – Valid means the data are what they are purported to be. For example, data in the date of injury field must be date of injury and not some other date. Data must consist of allowable values, e.g., date of injury cannot be Sep. 31, 1999, a non-existent date. At a more subtle level, each trading partner must have the same understanding of the meaning of each data element and submit data with that meaning only. Review the definitions for each required data element in the data dictionary of the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1 () and the California medical data dictionary () to be sure your use of the data element matches that assigned by the IAIABC and the California DWC. If your meaning or use of a data element differs, you will need to make changes to conform to the California adopted IAIABC standards.

( Accurate data – Accurate means free from errors. There is little value in collecting and utilizing data unless there are assurances the data are accurate (see section M - Data edits).

The detailed testing phase ensures the above requirements are met before a trading partner is allowed to routinely submit electronic medical data to the WCIS in production status.

Data quality criteria

The DWC allows the detailed testing phase to be conducted in two steps, which may be conducted concurrently if desired. Reports are first transmitted to WCIS via EDI, and are tested for completeness and validity using automatic built-in data edits on the WCIS system. See section M – Data edits for more detail.

The DWC\WCIS requires the transmission of medical bill payment records in accordance with various billing scenarios. The medical bill payment record transmissions should contain zero errors before the detailed testing phase is successfully completed. The medical data reporting requirements for each data element are listed in section L – Required medical data elements of this guide.

If the criteria of zero errors during the detailed testing phase cannot be attained. The DWC suggests a random subset of the EDI bill payment records be manually crosschecked against the corresponding paper reports for accuracy. The sender may be asked to justify any mismatches between the paper and EDI reports to help clarify errors in the 837 transmissions.

A cross-walk of data elements contained on the CMS 1500 and the UB92 are provided in section L – Required medical data elements and in the IAIABC EDI Implementation Guides for Medical Bill Payment Records, Reporting July 2004. ()..

Bill submission reason codes

Following are the bill submission reason codes (BSRC) are utilized in California (see section K _ Events that trigger required medical EDI reports):

Original 00

Cancel 01

Replace 05

Medical EDI detailed test procedure

Prepare detailed test file(s)

Begin transmitting detailed data as soon as the WCIS contact person has notified you the WCIS is ready to receive detailed medical bill payment records. The WCIS suggest the detailed test file consist of one ISA-IEA electronic envelop with several (number to be determined) ST-SE transaction sets. The DWC\WCIS has developed several medical bill payment scenarios for California including Medical Provider Networks (MPN), reevaluations, matching to FROI, and others to be included in the ST-SE transaction sets. The trading partner will also be required to send three bill submission reason codes (00, 01, and 05) while testing, your WCIS contact person will have the additional information

After the DWC system is able to successfully communicate with your system and all the transmitted files are structurally correct, then contact the person identified in your WCIS Trading Partner Profile and notify the person of your readiness to proceed to step five. The WCIS contact person will notify you by phone or e-mail when the DWC system is ready to accept your detailed test data to begin the detailed testing phase of the process.

Step five: Detailed testing - Sender receives and processes an 824 from DWC

After an 837 structural test file is successfully transmitted, the trading partner transmits real detailed medical bill payment data, in test status. During detailed testing, the trading partner’s submissions are analyzed for data completeness, validity and accuracy. The trading partner must meet minimum data quality requirements in order to complete the detailed testing stage. The trading partner will receive an 824 detailed acknowledgment containing information about each 837 transmission.

Testing for data quality, both during the detailed testing phase and during production, will help trading partners comply with section 9702, electronic data reporting of the WCIS regulations (Title 8 CCR section 9702(a)):

“Each claims administrator shall, at a minimum, provide complete, valid, accurate data for the data elements set forth in this section.”

( Complete data – In order to evaluate the effectiveness and efficiency of the California workers’ compensation system (one of the purposes of WCIS set forth in the 1993 authorizing statute), trading partners must submit all required medical bill payment data elements for the required reporting periods

( Valid data – Valid means the data are what they are purported to be. For example, data in the date of injury field must be date of injury and not some other date. Data must consist of allowable values, e.g., date of injury cannot be Sep. 31, 1999, a non-existent date. At a more subtle level, each trading partner must have the same understanding of the meaning of each data element and submit data with that meaning only. Review the definitions for each required data element in the data dictionary of the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009 () and the California medical data dictionary () to be sure your use of the data element matches that assigned by the IAIABC and the California DWC. If your meaning or use of a data element differs, you will need to make changes to conform to the California-adopted IAIABC standards.

( Accurate data – Accurate means free from errors. There is little value in collecting and utilizing data unless there are assurances the data are accurate (See Section K).

The detailed testing phase ensures the above requirements are met before a trading partner is allowed to routinely submit electronic medical data to the WCIS in production status.

Data quality criteria

The DWC procedure sequentially tests for structural errors and then tests for detailed errors. Records transmitted to WCIS via EDI are tested for completeness, accuracy and validity using both structural and detailed data edits that are built into the WCIS data processing system (See Section K).

If the criteria of zero errors during the detailed testing phase cannot be attained, the DWC suggests a random subset of the EDI bill payment records be manually crosschecked against the corresponding paper bills for accuracy. The sender may be asked to justify any mismatches between the paper and EDI reports to help clarify errors in the 837 transmissions. A cross-walk of data elements contained on the CMS 1500 and the UB92 are provided in Section K and in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009. ().

Prepare detailed test file(s)

Begin transmitting detailed data as soon as the WCIS contact person has notified you the WCIS is ready to receive detailed medical bill payment records.

Detailed-level testing communication loop

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Wait for eElectronic acknowledgment from WCIS

The data sent you send to WCIS will automatically be subjected to EDI data quality edits. The edits consist of the IAIABC standard edits, (see edit matrices in IAIABC EDI Implementation Guides for Medical Bill Payment Records, Release 1), and the California-specific edits, which are listed in Section L. M – Data edits of this guide. Each field in a transaction is validated using the edit rules. The DWC/WCIS medical bill payment specific scenarios will be tested for validity and accuracy. If a data element fails to pass any data validation edit, an error message will be generated for that data element. The WCIS will process all medical bills included in the transmission until 20 errors per medical bill have been detected. The 824 detailed acknowledgements will contain information about all detected errors for each 837 transmission.

You should receive a detail acknowledgment (824) from the WCIS within five business days 48 hours of your data transmission. The only exception is when the transaction does not have a match on the database (See Section ML). The acknowledgment will identify each data elements in which an error was detected (See Section H).

Detailed 824 acknowledgment error messages

|Error Code |Message |

|001 |Mandatory field not present |

|028 |Must be numeric (0-9) |

|029 |Must be a valid date (CCYYMMDD) |

|030 |Must be A-Z, 0-9, or spaces |

|031 |Must be a valid time (HHMMSS) |

|033 |Must be <= date of injury |

|034 |Must be >= date of injury |

|039 |No match on database |

|040 |All digits cannot be the same |

|041 |Must be <= current date |

|057 |Duplicate transmission/transaction |

|058 |Code/ID invalid |

|061 |Event table criteria not met |

|063 |Invalid event sequence/relationship |

|064 |Invalid data relationship |

|073 |Must be>= date payer received bill |

|074 |Must be >= from date of service |

|075 |Must be <= thru service date |

Process the detailed 824 acknowledgment

If the acknowledgment indicates correctable any errors, transaction rejected (TR), the sender will need to make corrections and send the corrections to the WCIS in order to meet the data quality requirements for validity and completeness. When making corrections, all data elements in the affected ST-SE transaction originally submitted need to be submitted again (See Section LJ and Section NL).

Repeat steps three two through five four until completeness, and validity and accuracy criteria are met.

After the structural and detailed testing is successfully completed, the trading partner transmits a cancellation of the medical bills sent in step three. The cancelled bills are matched to the original bills sent in step three and deleted from the WCIS database. The trading partner receives a 997 and 824 ANSI file from the WCIS.

After the structural and detailed testing is successfully completed, the trading partner transmits a replacement of a claim number sent in step three. The original claim number is matched to the original claim number sent in step three in the WCIS database. The trading partner receives a 997 and 824 ANSI file from the WCIS.

Parallel pilot procedure

Optional parallel standard paper form analysis

An optional step is to submit the paper bills of the corresponding EDI reports to be crosschecked for accuracy. This step may be required by the DWC if the criterion of zero errors is not fulfilled during the detailed test phase.

Prepare paper copies of bills

Make one of a completed original medical report submitted in the EDI portion of the pilot. Fill out a WCIS pilot paper identification form. The form allows the DWC to link your EDI medical reports to your paper medical bills.

Send paper reports to DWC

Send the paper medical forms and the completed WCIS pilot paper identification form to the WCIS contact person assigned to you. Mail the entire packet to:

WCIS Pilot-Parallel Phase

Attn: WCIS Contact

Department of Industrial Relations

EDI Unit, Information Systems

1515 Clay Street, 19th Floor

Oakland, CA 94612

Wait for parallel pilot analysis report

Your WCIS contact will compare the standard paper forms and EDI medical reports for consistency and prepare a “Parallel Pilot Analysis Report.” The report describes any discrepancies noted between data sent on the standard paper forms and data sent electronically. A WCIS contact person will phone or schedule a meeting to discuss any discrepancies.

Step 4. Production

Data quality requirements

Data sent to WCIS will continue to be monitored for completeness and validity. The following are guidelines for data quality trading partners should strive to meet or exceed:

• All data quality errors will result in a Transaction Rejected (TR) 824 acknowledgment. The DWC will process all medical bills in each ST-SE transaction set until 20 errors are detected and then send the 824 acknowledgment.

Data quality reports

The WCIS automatically monitors the quality of data received during production from individual trading partners. The system tracks all outstanding errors and produces automated data quality reports. The division plans to provide these reports to each trading partner on a regular basis. The frequency of providing the reports has not yet been determined.

Trading partner profile

Trading partner profiles must be kept up-to-date. The division must be notified of any changes to the trading partner profile, since changes will affect the ability of the WCIS to recognize transmissions. Note: Changing the transmission mode (FTP or VAN) may require re-testing some or all transaction types.

Production Status

After successful completion of the five testing steps, the trading partner may begin to send production data. During production, data transmissions will be monitored for completeness, validity and accuracy. The data edits are more fully described in Section L and in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009. ().

• All data quality errors will result in a Transaction Rejected (TR) 824 acknowledgment. The DWC will process all medical bills in each ST-SE transaction set until 20 errors per bill are detected and then send the 824 acknowledgment.

WCIS PAPER PILOT IDENTIFICATION FORM

TO: ___________________________

WCIS Contact

FROM: TRADING PARTNER (the following information must be as it appears on your

trading partner profile)

NAME

ADDRESS

FEIN

ZIP CODE

DATE(S) ELECTRONIC TRANSMISSION(S) WERE SENT

TOTAL NUMBER OF EDI MEDICAL TRANSACTIONS SENT

DATE PAPER MEDICAL BILLS MAILED

NUMBER OF PAPER MEDICAL BILLS MAILED

PREPARED BY

PHONE

COMPLETE THIS FORM AND RETURN WITH PAPER COPIES OF MEDICAL BILL / PAYMENT FORMS TO:

WCIS PARALLEL PILOT PHASE

ATTN: WCIS Contact Person

EDI Unit, Information Systems

1515 Clay Street, 189th Floor

Oakland, CA 94612

Section H: Supported transactions and ANSI file structure

Supported transactions 47

Health care claim transaction sets (837 and 824) 47

ANSI definitions 47

California ANSI 837 loop, segment, data element summary 49

California ANSI 824 loop, segment, data element summary 54

Supported transactions

The IAIABC has approved the ANSI X12 formats – based on the American National Standards Institute (ANSI) X12 EDI standard. The ANSI X12 is the primary EDI standard for electronic commerce in a wide variety of applications. Data elements are strung together continuously, with special data element identifiers and separator characters delineating individual data elements and records. The ANSI X12 is extremely flexible but also somewhat complex, so most X12 users purchase translation software to handle the X12 formatting. Because X12 protocols are used for many types of business communications, X12 translation software is commercially available. Some claims administrators may already be using X12 translation software for purchasing, financial transactions or other business purposes.

Health care claim transaction sets (837 & 824)

The X12 transaction set contains the format and establishes the data contents of the health care claim transaction set (837) and the bill payment acknowledgment set (824) for use within the context of an EDI environment. The 837 transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediaries and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing and/or payment of health care services within a specific health care/insurance industry segment.

The 824 acknowledgment set is to inform the sender of the status of the health care claim transaction set (837). Each health care claim transaction set (837) is edited for required data elements and against the edit matrix, element requirement table and the event table. Out of those edit processes, each transaction will be determined to be either accepted or rejected. A bill payment acknowledgment set (824) will be sent to each trading partner after each health care claim transaction set (837) is evaluated for errors.

For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, pharmacies, and other entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. This is the same standard that is used to report institutional claim adjudication information for payment to private and public payers.

ANSI definitions

Loop:

A group of segments that may be repeated. The hierarchy of the looping structure is insuredr, employer, patient, bill provider level and bill service line level.

Segment ID:

Groups of logically-related data elements. The record layouts show divisions between segments. Each segment begins with a segment identifier. Each data element within a segment is indicated by the segment identifier plus ascending sequence number. Data segments are defined in the ANSI loop and segment summary.

Segment name/data element name:

Included are loop names, segment names and data element names.

Format:

Type of data element as described below:

AN String: Any characters from the basic or extended character sets. The basic character set defined as: Uppercase letters: "A" through "Z". Digits: "0" through "9". Special characters: ! " & ' ( ) * + , - . / : ; ? = Space character: " " The extended character sSet defined as: Lowercase letters: “a” through “z” Special characters: % ~ @ [ ] _ { } \ | < > # $. At least one non-space character is required. The significant characters should be left-justified. Trailing spaces should be suppressed.

Example: Claim administrator claim number AN1709MPN05

ID Identification code: Specific code taken from a pre-defined list of codes maintained by the Accredited Standards Committee (ASC) X12 or some other body recognized by the DWC/WCIS.

Example: Place of service code 11

R Decimal number: Numeric value containing explicit decimal point. The decimal point must appear as part of the data stream if at any place other than the rightmost end of the number. Leading zeros should be suppressed. Trailing zeros following the decimal point should be suppressed. If a decimal point is not included in the number, none will be assumed. Do not use commas in the decimal number.

Example: Principal diagnosis code 519.2

Note: ANSI 837 v.4010 transaction including the X12 recommended delimiters of asterisk, colon, and tilde. Delimiters used in the transaction must be identified in the appropriate position of the ISA segment and must be consistent throughout the transaction. Be aware that the delimiters chosen cannot be used as part of any data value or string. ). More detailed information can be found in IAIABC EDI Implementation Guides for Medical Bill Payment Records, Release 1.1, July 1, 2009.

Delimiters:

* Data element delimiter

: Sub data element delimiter

~ End of string delimiter

California ANSI 837 loop, segment, and data element summary

ST Transaction Set Header

Segment ST Transaction Set Control Number

Segment BHT Beginning of Hierarchy Transaction

Data Element 532 Batch Control Number

Data Element 100 Date Transmission Sent

Data Element 101 Time Transmission Sent

LOOP ID 1000A Sender Information

Segment NM1 Identification code

Data Element 98 Sender Identification (FEIN only)

Segment N4 Identification code

Data Element 98 Sender Identification (Postal Code only)

LOOP ID 1000B Receiver Information

Segment NM1 Identification code

Data Element 99 Receiver Identification (FEIN only)

Segment N4 Identification code

Data Element 99 Receiver Identification (Postal Code only)

LOOP ID 2000A Source of Hierarchical Information

Segment DTP Date/Time Period

Data Element 615 Reporting Period

LOOP ID 2010AA Insurer/Self Insured/Claim Admin. Info.

Segment NM1 Insurer/Self Insured/Claim Admin. Info.

Data Element 7 Insurers Name

Data Element 6 Insurers FEIN

Data Element 188 Claim Administrators Name

Data Element 187 Claim Administrators FEIN

LOOP ID 2000B Employer Hierarchical Information

LOOP ID 2010BA Employer Named Insurer Information

Segment NM1 Employer Name

Loop ID 2000C Claimant Hierarchical Information

Segment DTP Date/Time Period

Data Element 31 Date of Injury

Loop ID 2010CA Claimant Information

Segment NM1 Claimant Information

Data Element 43 Employee Last Name

Data Element 44 Employee First Name

Data Element 45 Employee Middle Name/Initial

Data Element 42 Employee Social Security Number

Data Element 153 Employee Green Card

Data Element 156 Employee Passport Number

Data Element 152 Employee Employment Visa

Loop ID 2010CA Claimant Information (Continued)

Segment REF Claimant Claim Number

Data Element 15 Claim Administrators Claim Number

Data Element 5 Jurisdiction Claim Number

Loop ID 2300 Billing Information (Repeat > 1)

Segment CLM Billing Information

Data Element 523 Billing Provider Unique Bill ID Number

Data Element 501 Total Charge per Bill

Data Element 502 Billing Type Code

Data Element 504 Facility Code

Data Element 555 Place of Service Bill Code

Data Element 503 Billing Format Code

Data Element 526 Release of Information Code

Data Element 507 Provider Agreement Code

Data Element 508 Bill Submission Reason Code

Segment DTP Date/Time Period

Data Element 511 Date Insurer Received Bill

Data Element 513 Admission Date

Data Element 514 Discharge Date

Data Element 509 Service Bill Date(s) Ranges

Data Element 527 Prescription Bill Date

Data Element 510 Date of Bill

Data Element 512 Date the Insurer Paid Bill

Segment CN1 Contract Information

Data Element 515 Contract Type Code

Data Element 518 DRG Code

Segment AMT Total Amount Paid

Data Element 516 Total Amount Paid Per Bill

Segment REF Unique Bill ID

Data Element 500 Unique Bill Identification Number

Segment REF Transaction Tracking Number

Data Element 266 Transaction Tracking Number

Segment HI Diagnosis

Data Element 521 Principal Diagnosis Code

Data Element 535 Admitting Diagnosis Code

Data Element 522 ICD_9 Diagnosis Code

Segment HI Institutional Procedure Codes

Data Element 626 HCPCS Principal Procedure Billed Code

Data Element 525 ICD_9 CM Principal Procedure Billed Code

Data Element 550 Principal Procedure Date

Data Element 737 HCPCS Billed Procedure Code

Data Element 736 ICD_9 CM Billed Procedure Code

Data Element 524 Procedure Date

Loop ID 2310A Billing Provider Information

Segment NM1 Billing Provider Information

Data Element 528 Billing Provider Last/Group Name

Data Element 629 Billing Provider FEIN

Segment PRV Billing Provider Specialty Information

Data Element 537 Billing Provider Primary Specialty Code

Segment N4 Billing Provider City, State, and Postal Code

Data Element 542 Billing Provider Postal Code

Segment REF Billing Provider Secondary ID Number

Data Element 630 Billing Provider State License Number

Data Element 634 Billing Provider National Provider ID

Loop ID 2310B Rendering Bill Provider Information

Segment NM1 Rendering Bill Provider Information

Data Element 638 Rendering Bill Provider Last/Group Name

Data Element 642 Rendering Bill Provider FEIN

Segment PRV Rendering Bill Provider Specialty Info

Data Element 651 Rendering Bill Provider Primary Specialty Code

Segment N4 Rendering Bill Provider City, State, Postal Code

Data Element 656 Rendering Bill Provider Postal Code

Segment REF Rendering Bill Provider Secondary ID Number

Data Element 649 Rendering Bill Provider Specialty License Number

Data Element 643 Rendering Bill Provider State License Number

Data Element 647 Rendering Bill Provider National Provider ID

Loop ID 2310C Supervising Provider Information

Segment REF Supervising Provider National Provider ID

Data Element 667 Supervising Provider National Provider ID

Loop ID 2310D Facility Information

Segment NM1 Facility Information

Data Element 678 Facility Last/Group Name

Data Element 679 Facility FEIN

Segment N4 Facility City, State, and Postal Code

Data Element 688 Facility Postal Code

Segment REF Facility Secondary ID Number

Data Element 680 Facility State License Number

Data Element 681 Facility Medicare Number

Data Element 682 Facility National Provider ID

Loop ID 2310E Referring Provider Information

Segment REF Referring Provider National Provider ID

Data Element 699 Referring Provider National Provider ID

Loop ID 2310F Managed Care Organization Information

Segment NM1 Managed Care Organization Information

Data Element 209 Managed Care Organization Last/Group Name

Data Element 704 Managed Care Organization FEIN

Segment N4 Managed Care Organization City, State, and Postal Code

Data Element 712 Managed Care Organization Postal Code

Segment REF Managed Care Organization Identification Number

Data Element 208 Managed Care Organization Identification Number

Loop ID 2320 Subscriber Insurance

Segment CAS Bill Level Adjustment Reasons Amount

Data Element 543 Bill Adjustment Group Code

Data Element 544 Bill Adjustment Reason Code

Data Element 545 Bill Adjustment Amount

Data Element 546 Bill Adjustment Units

Loop ID: 2400 Service Line Information

Segment LX Service Line Information

Data Element 547 Line Number

Segment SV1 Procedure Code Billed

Data Element 721 NDC Billed Code

Data Element 714 HCPCS Line Procedure Billed Code

Data Element 717 HCPCS Modifier Billed Code

Data Element 715 Jurisdictional Procedure Billed Code

Data Element 718 Jurisdictional Modifier Billed Code

Data Element 552 Total Charge per Line

Data Element 553 Days/Units Code

Data Element 554 Days/Units Billed

Data Element 600 Place of Service Line Code

Data Element 557 Diagnosis Pointer

Segment SV2 Institutional Service Revenue Procedure Code

Data Element 559 Revenue Billed Code

Data Element 714 HCPCS Line Procedure Billed Code

Data Element 717 HCPCS Modifier Billed Code

Data Element 715 Jurisdictional Procedure Billed Code

Data Element 718 Jurisdictional Modifier Billed Code

Data Element 552 Total Charge per Line

Segment SV3 Dental Service

Data Element 714 HCPCS Line Procedure Billed Code

Data Element 717 HCPCS Modifier Billed Code

Data Element 552 Total Charge per Line

Data Element 600 Place of Service Line Code

Segment SV4 Prescription Drug Information

Data Element 561 Prescription Line Number

Data Element 721 NDC Billed Code

Data Element 563 Drug Name

Data Element 562 Dispense as Written Code

Data Element 564 Basis of Cost Determination

Segment SV5 Durable Medical Equipment

Data Element 714 HCPCS Line Procedure Billed Code

Data Element 717 HCPCS Modifier Billed Code

Data Element 553 Days/Units Code

Data Element 554 Days/Units Billed

Data Element 565 Total Charge per Line Rental

Data Element 566 Total Charge per Line Purchase

Data Element 567 DME Billing Frequency Code

Segment DTP Service Date(s)

Data Element 605 Service Line Date(s) Range

Segment DTP Prescription Date

Data Element 604 Prescription Line Date

Segment QTY Quantity

Data Element 570 Drugs/Supplies Quantity Dispensed

Data Element 571 Drugs/Supplies Number of Days

Segment AMT Dispensing Fee Amount

Data Element 579 Drugs/Suppliesd Dispensing Fee

Segment AMT Drug/Suppliesy Billed Amount

Data Element 572 Drug/Suppliesy Billed Amount

Loop ID 2420 Rendering Line Provider Name

Segment NM1 Rendering Line Provider Information

Data Element 589 Rendering Line Provider Last/Group Name

Data Element 586 Rendering Line Provider FEIN

Segment PRV Rendering Line Provider Specialty Information

Data Element 595 Rendering Line Provider Primary Specialty Code

Segment N4 Rendering Provider City, State, and Postal Code

Data Element 593 Rendering Line Provider Postal Code

Segment REF Rendering Line Provider Secondary ID Identification Number

Data Element 592 Rendering Line Provider National Provider ID Number

Data Element 599 Rendering Line Provider State License Number

Loop ID 2430 Service Line Adjustment

Segment SVD Service Line Adjudication

Data Element 574 Total Amount Paid per Line

Data Element 726 HCPCS Line Procedure Paid Code

Data Element 727 HCPCS Modifier Paid Code

Data Element 728 NDC Paid Code

Data Element 729 Jurisdiction Procedure Paid Code

Data Element 730 Jurisdiction Modifier Paid Code

Data Element 576 Revenue Paid Code

Data Element 547 Line Number

Segment CAS Service Line Adjustment

Data Element 731 Service Adjustment Group Code

Data Element 732 Service Adjustment Reason Code

Data Element 733 Service Adjustment Amount

SE Transaction Set Trailer

Segment Transaction Set Trailer

California ANSI 824 loop, segment and data element summary

The medical bill payment detailed acknowledgment (824) reports back to the trading partner either an acceptance (TA), rejection (TR), or accepted with errors (TE) of the health care claim transaction set (837).   The following outline summarizes the loop, segment, and data element structure of the medical bill payment detailed acknowledgment (824). More detailed information can be found in IAIABC EDI Implementation Guides for Medical Bill Payment Records, Release 1.1, July 1, 2009.

ST Transaction Set Header

Segment ST Transaction Set Control Number

Segment BGN Beginning Segment

Data Element 105 Interchange Version Identification

Data Element 100 Date Transmission Sent

Data Element 101 Time Transmission Sent

Loop ID: N1A Sender Information

Segment N1 Sender Identification

Data Element 98 Sender Identification (FEIN)

Segment N4 Geographic Location

Data Element 98 Sender Identification (Postal Code)

Loop ID: N1B Receiver Information

Segment N1 Receiver Identification

Data Element 99 Receiver Identification (FEIN)

Segment N4 Geographic Location

Data Element 99 Receiver Identification (Postal Code)

Loop ID: OTI Original Identification Transaction

Segment OTI Original Transaction Identifier

Data Element 111 Application Acknowledgment Code

Data Element 500 Unique Bill Identification Number

Data Element 532 Batch Control Number

Data Element 102 Original Transmission Date

Data Element 103 Original Transmission Time

Data Element 110 Acknowledgment Transaction Set Identifier

Segment DTM Processing Date

Data Element 108 Date Processed

Data Element 109 Time Processed

Segment LM Code Source Information

Loop ID: LQ Industry Code

Segment LQ Industry Code

Data Element 116 Element Error Number

Segment RED Related Data

Data Element 6 Insurer FEIN

Data Element 187 Claim Administrator FEIN

Data Element 15 Claim Administrator Claim Number

Data Element 500 Unique Bill Identification Number

Data Element 266 Transaction Tracking Number

Data Element 115 Element Number

Data Element 547 Line Number

SE Transaction Set Trailer

Segment Transaction Set Trailer

Section I: The FTP Ttransmission modes

Value added networks (VAN) 57

File transfer protocol 57

Data transmission with FTP 57

Trading partner profile ...57

FTP server account and password 57

FTP Communication ports 57

FTP server root certificate 57

FTP server name and Internet address 58

Trading partner source IP address 58

Testing FTP connectivity 58

Sending data through FTP 58

Receiving acknowledgment files through FTP 58

Naming conventions 58

Pathway transmissions 59

Value added networks (VAN)

A value added network (VAN) is a commercially-owned network providing specific services restricted to users. Businesses that provide VAN services act as intermediaries during electronic message exchange. VAN users typically purchase leased lines to connect to the network or use a dial-up number to gain access to the network.

The advantages of using a VAN include security, auditing, tracking capabilities and formatting services. Several EDI service providers provide VAN services. Be aware that billing can be complex, and it typically consists of per byte charge and per “envelope” charge, which vary depending on how the user sends the information. It is important to note that the Division of Workers’ Compensation does not pay VAN charges for either incoming or outgoing EDI transmissions. VAN messages will not be transmitted if the trading partner does not specify that it will accept charges for both incoming and outgoing transmissions. See section J – EDI service modes for VAN contact information.

Data transmission with Ffile transfer protocol (FTP)

The Internet file transfer protocol is defined in RFC 959 by the Internet Engineering Task Force and the Internet Engineering Steering Group. Data files are confidential through authentication and encryption, using secure socket layer (SSL).

Trading partners will send all data files to an FTPS (FTP over SSL, RFC4217) server hosted by the WCIS.  Acknowledgments will be retrieved from the same server.  Use of FTPS to encrypt the network connection is required.  In addition, trading partners may optionally use PGP (Pretty Good Privacy, RFC4880) to encrypt the files before transmission. A history of the PGP program and frequently asked questions is available at .

Data transmission with FTP

Certain processes and procedures must be coordinated to ensure the efficient and secure transmission of data and acknowledgement files via FTP.

Trading partner profile

Complete the trading partner profile form in Section F-Trading Partner Profile. Be sure to indicate the transmission mode is FTP. Acknowledgments will be returned by FTP. After the trading partner profile form is completed (see Section F), follow the steps below.

FTP server account user name and password

The WCIS FTP server requires an account user name and password to access it. The account user name and password is are entered in C2 on the trading partner profile form (Part C2). After establishing connectivity, the trading partner may change the password. Password changes and resets can be coordinated with the trading partner contact.

FTP communication ports

The WCIS FTP server requires the following communications ports to be opened for FTPS transmissions: 20, 21, 990 and 1024-122465535. FTPS uses TCP ports 1024 and above as data channels. The high-numbered ports are assigned sequentially by the server per session.

FTP server root certificate

The WCIS server uses a private root certificate for SSL encryption. When a trading partner establishes connectivity with the WCIS FTP server, its private certificate is exchanged. Some FTP client software (e.g.; WS_FTP) acknowledge the private certificate while others do not. If the certificate is not recognized, the WCIS FTP server root certificate will need to be requested by the trading partner from their trading partner contact person and imported into their system. The trading partner software must be compatible with the WCIS FTP server software (i.e.; WS_FTP Server).

FTP over SSL

The WCIS FTP server requires “explicit” security for negotiating communication security for data transfer for SSL. Explicit security supports the “AUTH SLL” security command. The WCIS FTP server software (i.e. WS_FTP Server) only supports the “explicit” security.

The WCIS FTP server uses “passive” mode for transferring data. The server waits for the data connection from the trading partner’s FTP client software to initiate the data transfer process.

The WCIS server uses a private root certificate for SSL encryption. When a trading partner establishes connectivity with the WCIS FTP server, its private certificate is exchanged. Some FTP client software (e.g. ; WS_FTP, Cute FTP, Smart FTP, and Core FTP) acknowledge the private certificate while others do not. If the certificate is not recognized, the WCIS FTP server’s root certificate will need to be requested by the trading partner from their trading partner contact person and imported into their system.

FTP Server name and IP address

The WCIS FTP server name or IP address will be provided to trading partners by their trading partner contact person.

Trading partner source IP address

Access to the WCIS FTP server will be restricted to source IP addresses that are entered on the trading partner profile form. Trading partners may provide up to two source IP addresses. The source IP addresses must be public addresses. Although some network systems use private addresses for internal networks (e.g.; 10.0.0.0, 172.16.0.1 and 192.168.1.1), WCIS will require the public IP address that the private addresses translate to.

Testing FTP connectivity

The WCIS trading partner contact and the trading partner shall coordinate testing FTP connectivity. Trading partners shall be asked to send a plain text file for testing. The file should not contain data, but a simple test message. The file should be named test.txt and placed in the trading partner’s root directory of the WCIS FTP server.

Sending data through FTP

Trading partners will send data files to the WCIS FTP server by placing them in a directory named inbound. The contents of the directory are not visible by the trading partner.

File names must be unique and follow file naming conventions prescribed below. An error will result when a file of the same name is still in the inbound directory of the WCIS.

Receiving acknowledgment files through FTP

WCIS will place functional and detailed acknowledgement files (997 and 824) on the WCIS FTP server in the trading partner’s root directory 997 and 824 folders. Trading partners may delete acknowledgement files after they have retrieved the files. WCIS will periodically review contents of the trading partner’s directory and may delete unauthorized user folders and files older than 14 days old.

File naming conventions

The DWC/WCIS specific file naming conventions will be specified to each trading partner after the trading partner agreement profile is received by the DWC.

Pathway transmissions

Pathway transmissions

Section J: EDI service providers

Introduction to EDI service providers 61

Providers of consultation, technical support, VAN service, and software products 62

Organizations providing data collection agent services 65

Introduction to EDI service providers

Trading partners seeking assistance in implementing medical EDI may wish to consult one or more of the EDI service providers listed on the following pages. Many of these firms offer a full range of EDI-related services: consultation, technical support, value added network (VAN) services, and/or software products. These products and services can make it possible for trading partners to successfully transmit medical bill payment data via EDI, without themselves becoming knowledgeable about record layouts, file formats, event triggers, or other medical EDI details.

Another alternative to developing a complete EDI system is to contract for the services of a data collection agent. For a fee, a data collection agent will receive medical paper forms by fax or mail, enter the data, and transmit the medical bill payment data by EDI to the WCIS or other electronic commerce trading partners.

The California Division of Workers’ Compensation does not have a process for granting “approvals” to any EDI service providers. The listings below are simply providers known to the California Division of Workers’ Compensation. The lists will be updated as additional resources become known. The most up-to date version of these listings can be accessed through the WCIS home page ( ).

Appearance on the following lists does not in any way constitute an endorsement of the companies listed or a guarantee of the services they provide. Other companies not listed may be equally capable of providing medical EDI-related services.

Note to suppliers of EDI-related services: Please contact wcis@dir. if you wish to have your organization added or removed, or if you wish to update the contact information.

Providers of consultation, technical support, value added network (VAN) service, and software products:

| | |

|Claims Harbor |IBM Global Network / Advantis |

| |globalnetwork/ |

|1900 Emery Street |IBM Global Services |

|Atlanta, GA 30318 |P.O. Box 30021 |

|Telephone: (941) 739-7753 |Tampa, FL 33630 |

|Email: jcarpenter@ |Telephone: (800) 655-8865 |

| |E-mail: globalnetwork@info. |

| | |

|StellarNet, Inc |HealthTech, Inc. |

| |health- |

|John R. Stevens, CEO |Mark R. Hughes, President |

|124 Beale Street, Suite 400 |11730 W. 135th Street, Suite 31 |

|San Francisco, CA 94105-1811 |Overland Park, KS 66221 |

|Telephone: (415) 882-5700 |Telephone: (913) 764-9347 |

|Fax: (415) 882-5718 |Fax: (913) 764-0572 |

|E-mail: rtwfast@ |E-mail: mhughes@health- |

| | |

|MountainView Software Corp. |Alliance Consulting |

| | |

|Orson Whitmer, Sales Manager |One Commerce Square |

|1133 North Main St., Suite 103 |2005 Market Street |

|Layton, UT 84041 |32nd Floor |

|Telephone (888) 533-1122 |Philadelphia, PA 19103 |

|Fax (801) 544-3138 |Telephone 800 706 3339 |

|E-mail: Orson@ | |

| |E-Mail: Get-IT-solved-phi@alliance- |

continued:

| | |

|CompData |Red Oak E-Commerce Solutions, Inc. |

| | |

|Ron Diller |Patrick “Pat” Cannon |

|P.O. Box 729 |PO Box K-9 |

|Seal Beach, CA 90740-0729 |Carlisle, IA 50047 |

|Telephone: (800) 493-6652 |Telephone: (866)363-4297 |

|Fax: (562) 493-1550 |Fax: () (512) 363-4298 |

|E-mail: Customer@ |E-mail: prcannon@ |

| | |

|Valley Oak Systems |David Corp. |

| | |

|David Turner, Vice President |Chris Carpenter, President |

|3189 Danville Blvd., Suite # 255 |130 Battery St, Sixth floor |

|Alamo, CA 94507 |San Francisco, CA 94111 |

|Telephone: (925) 552-1650 |Telephone: (800) 553-2843 |

|Fax: (925) 552-1656 |Fax: (415) 362-5010 |

|E-mail: dturner@ |E-mail: support@ |

| | |

|Harbor Healthcare Ventures, LLC |W> , Inc. |

|11500 Olympic Blvd, Suite 400 |> |

|Los Angeles, CA 90049 |> > David J. DePaolo, CEO, President |

|Telephone: (310) 444-3001 |> 124 Mainsail Court |

|Fax: (310) 444-3002 |> Hueneme Beach, CA 93041 |

| |> Telephone: (805) 484-0333 |

| |> Fax: (805) 484-7272 |

| |> E-mail: david-depaolo@ |

| | |

|Insurance Services Office, Inc. | |

| | |

|545 Washington Blvd. | |

|Jersey City, NJ 07310-1686 | |

|Telephone: (609) 799-1800 | |

continued:

| | |

|Risk Management Technologies / STARS |Shelter Island Risk Services, LLC |

|Marsh Risk & Insurance Services |Chuck Wight, Regional Manager & VP |

| |174 Corte Alta |

|Chris Dempsey |Novato, CA 94949 |

|One California St. |Telephone: (415) 382-1424 |

|San Francisco, CA 94111 |Fax: (415) 382-2044 |

|Telephone: (415) 743-8293 |E-mail: Cwight@ |

|Fax: (415) 743-7789 | |

|E-mail: Christopher.k.dempsey@ | |

|PBM Corp. / MCO Advantage LTD. |Aimset Corporation |

| | |

|20600 Chagrin Boulevard |50 Woodside Plaza, Suite 511 |

|Suite 450 |Redwood City, California 94061 |

|Shaker Heights, Ohio 44122 |Telephone: 650-281-7997 |

|Local Contact |E-mail: info@ |

|Steve Goetz – Dir, Business Development | |

|Telephone: (415) 215-5874 | |

|Fax: (415) 651-8829 | |

|E-mail: stevegoetz@ | |

Organizations providing data collection agent services:

|Claims Harbor /Bridium, Inc. |Insurance Services Office, Inc. |

|(866) 448-1776 |(609) 799-1800 |

|Corporate Systems |HealthTech, Inc. |

|(800) 927-3343 |(913) 764-9347 |

|Concentra Managed Care, Inc. |Risk Management Technologies |

|(972) 364-8000 |(415) 743-8293 |

|Alliance Consulting |CompData |

|(800) 206-1078 |(800) 493-6652 |

| Red Oak E-Commerce Solutions, Inc. |Valley Oak Systems |

|(866) 363-4297 |(925) 552-1650 |

|W> , Inc. |David Corp. |

|(805) 484-0333 |(800) 553-2843 |

Section KJ: Events that trigger required medical EDI reports

Event table definitions 67

California event table 68

Event table definitions

The event table is designed to provide information integral for a sender to understand the DWC/WCIS EDI reporting requirements. It relates EDI information to events and under what circumstances they are initiated. This includes legislative mandates affecting different reporting requirements based on various criteria (i.e.g. dates of injury after a certain period).

It The event table is used and controlled by the receiver to convey the level of EDI reporting currently accepted.

Report type: The report type defines the specific transaction type being sent. (i.e. 837 = medical bill payment records)

BSRC: The bill submission reason code (BSRC) defines the specific purpose (event) for which the transaction is being sent (triggered).

00 = Original

This code is utilized the first time a medical bill is submitted to the jurisdiction including the re-submission of a medical bill rejected due to an correctable error.

01 = Cancellation

The original bill was sent in error. This transaction cancels the original (00).

05 = Replace

This is only utilized to replace DN15 Claim Administrator Claim Number.

Report trigger criteria:

This is a list of events that trigger a specific report and cause it to be submitted. If there are multiple events for a given bill submission reason, each event must be listed separately.

|California Event Table |

|EVENT |PRODUCTION LEVEL |IMPLEMENTATION DATE |REPORT TRIGGER |REPORT TRIGGER VALUE|EFFECTIVE DATE |REPORT DUE |

| |IND. | |CRITERIA | | | |

|BILL SUBMISSION REASON |

|00 |

|01 |

|05 |

|DN |DATA ELEMENT NAME |CMS 1500 |UB 9204 |IA |Payoer |HCP |JLB |SNDR |

|110 |ACKNOWLEDGMENT TRANSACTION SET ID |  |  |x |  |  |  |x |

|513 |ADMISSION DATE |  |1712 |  |  |  |  |  |

|535 |ADMITTING DIAGNOSIS CODE |  |7669 |  |  |  |  |  |

|111 |APPLICATION ACKNOWLEDGMENT CODE |  |  |x |  |  |  |x |

|564 |BASIS OF COST DETERMINATION CODE |  |  |  |x |  |  |  |

|532 |BATCH CONTROL NUMBER |  |  |  |  |  |  |x |

|545 |BILL ADJUSTMENT AMOUNT |  |  |  |x |  |  |  |

|543 |BILL ADJUSTMENT GROUP CODE |  |  |  |x |  |  |  |

|544 |BILL ADJUSTMENT REASON CODE |  |  |  |x |  |  |  |

|546 |BILL ADJUSTMENT UNITS |  |  |  |x |  |  |  |

|508 |BILL SUBMISSION REASON CODE |  |  |  |x |  |  |  |

|503 |BILLING FORMAT CODE |  |  |  |x |  |  |  |

|629 |BILLING PROVIDER FEIN |25 |5 |  |  |  |  |  |

|528 |BILLING PROVIDER LAST/GROUP NAME |33 |1 |  |  |  |  |  |

|634 |BILLING PROVIDER NATIONAL PROVIDER ID |33A |56 |  |x |x |  |  |

|542 |BILLING PROVIDER POSTAL CODE |33 |1 |  |  |  |  |  |

|537 |BILLING PROVIDER PRIMARY SPECIALTY CODE |33B | 81(B3) |  |x |x |  |  |

|630 |BILLING PROVIDER STATE LICENSE NUMBER |  |  |  |  |  |x |  |

|523 |BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER |  |  |  |  |  |x |  |

|502 |BILLING TYPE CODE |  |  |  |x |x |  |  |

|15 |CLAIM ADMINISTRATOR CLAIM NUMBER |  |  |  |x |x |  |  |

|187 |CLAIM ADMINISTRATOR FEIN |  |  |  |x |x |  |  |

|188 |CLAIM ADMINISTRATOR NAME |  |  |  |x |x |  |  |

|515 |CONTRACT TYPE CODE |  |  |  |x |x |  |  |

|512 |DATE INSURER PAID BILL |  |  |  |x |  |  |  |

|511 |DATE INSURER RECEIVED BILL |  |  |  |x |  |  |  |

|510 |DATE OF BILL |31 |8645(23) |  |  |  |  |  |

|31 |DATE OF INJURY |14 |231 |  |  |  |  |  |

|California Medical Data Elements by Source |

|DN |DATA ELEMENT NAME |CMS 1500 |UB 9204 |IA |Payoer |HCP |JLB |SNDR |

|108 |DATE PROCESSED |  |  |X |  |  |  |x |

|100 |DATE TRANSMISSION SENT |  |  |X |  |  |  |x |

|554 |DAYS/UNIT(S) BILLED |24G |46 |  |  |  |  |  |

|553 |DAYS/UNIT(S) CODE |  |  |  |  |x |  |  |

|557 |DIAGNOSIS POINTER |24 E |  |  |  |  |  |  |

|514 |DISCHARGE DATE |  |33-32-3436 |  |x |  |  |  |

|562 |DISPENSE AS WRITTEN CODE | | | | |x | | |

|567 |DME BILLING FREQUENCY CODE |  |  |  |  |x |  |  |

|518 |DRG CODE |  |  |  |  |x |  |  |

|563 |DRUG NAME |  |  |  |  |x |  |  |

|572 |DRUGS/SUPPLIES BILLED AMOUNT |  |  |  |  |x |  |  |

|579 |DRUGS/SUPPLIES DISPENSING FEE |  |  |  |  |x |  |  |

|571 |DRUGS/SUPPLIES NUMBER OF DAYS |  |  |  |  |x |  |  |

|570 |DRUGS/SUPPLIES QUANTITY DISPENSED |  |  |  |  |x |  |  |

|116 |ELEMENT ERROR NUMBER |  |  |x |  |  |  |x |

|115 |ELEMENT NUMBER |  |  |x |  |  |  |x |

|152 |EMPLOYEE EMPLOYMENT VISA | 1a | 60 |  | x |x |x |  |

|44 |EMPLOYEE FIRST NAME |2 |128 |  |  |  |  |  |

|153 |EMPLOYEE GREEN CARD | 1a | 60 |  | x |x |x |  |

|43 |EMPLOYEE LAST NAME |2 |128 |  |  |  |  |  |

|45 |EMPLOYEE MIDDLE NAME/INITIAL |2 |128 |  |  |  |  |  |

|156 |EMPLOYEE PASSPORT NUMBER | 1a | 60 |  | x |x |x |  |

|42 |EMPLOYEE SOCIAL SECURITY NUMBER | 1a | 60 |  | x |x |x |  |

|504 |FACILITY CODE |  |4(2-3) |  |  |  |  |  |

|679 |FACILITY FEIN | 32b |5 |  |  |x |  |  |

|681 |FACILITY MEDICARE NUMBER | 32 |51 |  |  |x |  |  |

|678 |FACILITY NAME |32 |1 |  |  |  |  |  |

|682 |FACILITY NATIONAL PROVIDER ID | 32a |51 |  |x |x |  |  |

|688 |FACILITY POSTAL CODE |32 |1 |  |  |  |  |  |

|680 |FACILITY STATE LICENSE NUMBER |  32b |  |  |  | x |x |  |

|737 |HCPCS BILL PROCEDURE CODE |24D |8174(a-e) |  |  |  |  |  |

|714 |HCPCS LINE PROCEDURE BILLED CODE |24D |44 |  |  |  |  |  |

|726 |HCPCS LINE PROCEDURE PAID CODE |  |  |  |x |  |  |  |

|717 |HCPCS MODIFIER BILLED CODE |24D |44 |  |  |  |  |  |

|727 |HCPCS MODIFIER PAID CODE |  |  |  |x |  |  |  |

|626 |HCPCS PRINCIPAL PROCEDURE BILLED CODE |  |8074 |  |  |  |  |  |

|522 |ICD-9 CM DIAGNOSIS CODE |21 |68-7567(A-Q) |  |  |  |  |  |

| | |1-4 | | | | | | |

|525 |ICD-9 CM PRINCIPAL PROCEDURE CODE | |8074 | | | | | |

|736 |ICD-9 CM PROCEDURE CODE | |8174(a-e) | | | | | |

|6 |INSURER FEIN |  | |  |x |  |  |  |

|California Medical Data Elements by Source |

|DN |DATA ELEMENT NAME |CMS 1500 |UB 9204 |IA |Payeor |HCP |JLB |SNDR |

|7 |INSURER NAME | 11c |50 |  |  |  |  |  |

|105 |INTERCHANGE VERSION ID |  |  |  |  |  |  |  |

|5 |JURISDICTION CLAIM NUMBER |  |  |  |x |  |  |  |

|718 |JURISDICTION MODIFIER BILLED CODE |24D | 44 |  |  |x |  |  |

|730 |JURISDICTION MODIFIER PAID CODE |  |  |  |x |  |  |  |

|715 |JURISDICTION PROCEDURE BILLED CODE | 24D | 44 |  | x |x |  |  |

|729 |JURISDICTION PROCEDURE PAID CODE |  |  |  |x |  |  |  |

|547 |LINE NUMBER |  |  |  |x |  |  |  |

|704 |MANAGED CARE ORGANIZATION FEIN |  |  |  |  |x |x |  |

|208 |MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER |  |  |  |  |  |x |  |

|209 |MANAGED CARE ORGANIZATION NAME |  |  |  |x |x |  |  |

|712 |MANAGED CARE ORGANIZATION POSTAL CODE |  |  |  |x |x |  |  |

|721 |NDC BILLED CODE |24 |  |  |  |x |  |  |

|728 |NDC PAID CODE |  |  |  |x |  |  |  |

|102 |ORIGINAL TRANSMISSION DATE |  |  |x |  |  |  |x |

|103 |ORIGINAL TRANSMISSION TIME |  |  |x |  |  |  |x |

|555 |PLACE OF SERVICE BILL CODE |  |  |  |  |x |  |  |

|600 |PLACE OF SERVICE LINE CODE |24 B |  |  |  |  |  |  |

|527 |PRESCRIPTION BILL DATE |  |  |  |  |x |  |  |

|604 |PRESCRIPTION LINE DATE |  |  |  |  |x |  |  |

|561 |PRESCRIPTION LINE NUMBER |  |  |  |  |x |  |  |

|521 |PRINCIPAL DIAGNOSIS CODE |  |67 |  |  |  |  |  |

|550 |PRINCIPAL PROCEDURE DATE |  |8074 |  |  |  |  |  |

|524 |PROCEDURE DATE |  |8174 |  |  |  |  |  |

|507 |PROVIDER AGREEMENT CODE |  |  |  |x |x |  |  |

|99 |RECEIVER ID |  |  |x |  |  |  |x |

|699 |REFERRING PROVIDER NATIONAL PROVIDER ID | 17b | |  |x |x |  |  |

|526 |RELEASE OF INFORMATION CODE |  |  |  |  |x |  |  |

|642 |RENDERING BILL PROVIDER FEIN |25 |  |  |  |  |  |  |

|638 |RENDERING BILL PROVIDER LAST/GROUP NAME |32 |76 |  |  |  |  |  |

|647 |RENDERING BILL PROVIDER NATIONAL PROVIDER ID | 32a |76a |  |x |x |  |  |

|656 |RENDERING BILL PROVIDER POSTAL CODE |32 |1 |  |  |  |  |  |

|651 |RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE |  |  |  |  |x |x |  |

|649 |RENDERING BILL PROVIDER SPECIALTY LICENSE NUMBER | 32b | 76 |  |  |  |x |  |

|643 |RENDERING BILL PROVIDER STATE LICENSE NUMBER | 32b |  |  |  |  |x |  |

|California Medical Data Elements by Source |

|DN |DATA ELEMENT NAME |CMS 1500 |UB 9204 |IA |Payoer |HCP |JLB |SNDR |

|586 |RENDERING LINE PROVIDER FEIN |  |  |  |  |x |  |  |

|589 |RENDERING LINE PROVIDER LAST/GROUP NAME |  |  |  |  |x |  |  |

|592 |RENDERING LINE PROVIDER NATIONAL PROVIDER ID |  |  |  |x |x |  |  |

|593 |RENDERING LINE PROVIDER POSTAL CODE |  |  |  |  |x |  |  |

|595 |RENDERING LINE PROVIDER PRIMARY SPECIALTY CODE |  |  |  |x |x |  |  |

|599 |RENDERING LINE PROVIDER STATE LICENSE NUMBER |  |  |  |  |  |x |  |

|615 |REPORTING PERIOD |  |  |  |x |  |  |  |

|559 |REVENUE BILLED CODE |  |42 |  |  |  |  |  |

|576 |REVENUE PAID CODE |  |  |  |x |  |  |  |

|98 |SENDER ID |  |  |x |  |  |  |x |

|733 |SERVICE ADJUSTMENT AMOUNT |  |  |  |x |  |  |  |

|731 |SERVICE ADJUSTMENT GROUP CODE |  |  |  |x |  |  |  |

|732 |SERVICE ADJUSTMENT REASON CODE |  |  |  |x |  |  |  |

|509 |SERVICE BILL DATE(S) RANGE |18 |6 |  |  |  |  |  |

|605 |SERVICE LINE DATE(S) RANGE |24A |45 |  |  |  |  |  |

|667 |SUPERVISING PROVIDER NATIONAL PROVIDER ID |  |  |  | |x |  |  |

|104 |TEST/PRODUCTION INDICATOR |  |  |x |  |  |  |  |

|109 |TIME PROCESSED |  |  |x |  |  |  |x |

|101 |TIME TRANSMISSION SENT |  |  |x |  |  |  |x |

|516 |TOTAL AMOUNT PAID PER BILL |  |  |  |x |  |  |  |

|574 |TOTAL AMOUNT PAID PER LINE |  |  |  |x |  |  |  |

|501 |TOTAL CHARGE PER BILL |28 |47 |  |  |  |  |  |

|552 |TOTAL CHARGE PER LINE |24F |47 |  |  |  |  |  |

|566 |TOTAL CHARGE PER LINE – PURCHASE |24F |  |  |  |  |  |  |

|565 |TOTAL CHARGE PER LINE – RENTAL |24F |  |  |  |  |  |  |

|266 |TRANSACTION TRACKING NUMBER |  |  |x |  |  |  |  |

Medical data element requirement table

Specific requirements depend upon the type of transaction reported; original (00), cancel (01), or replacement (05). The transaction type is identified by the Bill Submission Reason Code (BSRC) (See Section JK _ Events That Trigger Reporting). Each data element is designated as Mandatory (M), Conditional (C), or Optional (O).

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 that makes a conditional data element mandatory.

The alphabetically-sorted element requirement table provides a tool to communicate the business data element requirements of the DWC to each trading partner. The structure allows for requirement codes (M, C, or O) to be defined at the data element level (DN) for each bill submission reason code (00, 01, or 05). Further, it provides for data element requirements to differ based on report requirements criteria established on the Event Table. A requirement code is entered at each cell marked by the intersection of a bill submission reason code column and each data element row. (See Section J K –Events That Trigger Reporting).

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|532 |BATCH CONTROL NUMBER |M |M |M |  |

|100 |DATE TRANSMISSION SENT |M |M |M |  |

|101 |TIME TRANSMISSION SENT |M |M |M |  |

|98 |SENDER IDENTIFICATION |M |M |M |  |

|99 |RECEIVER IDENTIFICATION |M |M |M |  |

|615 |REPORTING PERIOD |M |M |M |  |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Reason Submission Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|5 |JURISDICTIONAL CLAIM NUMBER |C |O |O |If the first report of injury has been filed and a |

| | | | | |jurisdictional claim number is available  |

|715 |JURISDICTIONAL PROCEDURE BILLED CODE |C |O |O | If the special procedure is included in the California |

| | | | | |Official Medical Fee Schedule |

|718 |JURISDICTIONAL MODIFIER BILLED CODE |C |O |O | If DN715 is modified |

|729 |JURISDICTIONAL PROCEDURE PAID CODE |C |O |O |If different than DN715  |

|730 |JURISDICTIONAL MODIFIER PAID CODE |C |O |O | If different than DN718 |

|6 |INSURER FEIN |M |M |M | |

|7 |INSURER NAME |M |O |O |  |

|187 |CLAIM ADMINISTRATOR FEIN |C |O |O |If the Claim Administrator FEIN is different then Insurer|

| | | | | |FEIN, DN 6 |

|188 |CLAIM ADMINISTRATOR NAME |C |O |O |If the Claim Administrator name is different then Insurer|

| | | | | |name, DN 7 |

|15 |CLAIM ADMINISTRATOR CLAIM NUMBER |M |M |M |  |

|31 |DATE OF INJURY |M |O |O |  |

|43 |EMPLOYEE LAST NAME |M |O |O |  |

|44 |EMPLOYEE FIRST NAME |M |O |O |  |

|45 |EMPLOYEE MIDDLE NAME |O |O |O |  |

|153 |EMPLOYEE GREEN CARD |C |O |O |If Employee Social Security number is not available. (see|

| | | | | |DN42) |

|152 |EMPLOYEE EMPLOYMENT VISA |C |O |O |If Employee Social Security number or Employee Green Card|

| | | | | |number is not available. (see DN42) |

|156 |EMPLOYEE PASSPORT NUMBER |C |O |O |If Employee Social Security number, Employee Green Card |

| | | | | |Number, or Employee Employment Visa is not available. |

| | | | | |(see DN42) |

|42 |EMPLOYEE SOCIAL SECURITY NUMBER |M |O |O |Can use default values of all 9’s if injured worker is |

| | | | | |not a United States citizen and has no other |

| | | | | |identification (DN153, DN152, DN156) |

|704 |MANAGED CARE ORGANIZATION FEIN |C |O |O |For HCO claims use the FEIN of the |

| | | | | |sponsoring organization. |

|209 |MANAGED CARE ORGANIZATION NAME |O |O |O |  |

|712 |MANAGED CARE ORGANIZATION POSTAL CODE |O |O |O |  |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|208 |MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER |O |O |O |  |

|504 |FACILITY CODE |C |C |O |If DN 503 equals “A” |

|515 |CONTRACT TYPE CODE |C |O |O |If DN 518 is present, then use value 01 or 09 |

|518 |DRG CODE |C |O |O |If DN 503 equals “A” and if included in the California |

| | | | | |Inpatient Hospital Fee Schedule |

|521 |PRINCIPAL DIAGNOSIS CODE |C |O |O |If DN 503 equals “A” |

|550 |PRINCIPAL PROCEDURE DATE |C |O |O |If DN 503 equals “A” and if DN525 or DN626 is present |

|513 |ADMISSION DATE |C |O |O |If Billing Format Code, DN 503, is “A” and patient has |

| | | | | |been admitted |

|514 |DISCHARGE DATE |C |O |O |If Billing Format Code, DN 503, is “A” and patient has |

| | | | | |been discharged |

|535 |ADMITTING DIAGNOSIS CODE |C |O |O |If Billing Format Code, DN 503, is “A” and patient has |

| | | | | |been admitted |

|679 |FACILITY FEIN |C |O |O |If DN 503 equals “A” |

|678 |FACILITY NAME |C |O |O |If service performed in a licensed facility |

|688 |FACILITY POSTAL CODE |C |O |O |If service performed in a licensed facility |

|680 |FACILITY STATE LICENSE NUMBER |O |O |O | |

|681 |FACILITY MEDICARE NUMBER |O |O |O |  |

|559 |REVENUE BILLED CODE |C |O |O |If a value for DN 504 with 2nd digit equal to 1 |

|576 |REVENUE PAID CODE |C |O |O |If different than DN559 |

|629 |BILLING PROVIDER FEIN |C |O |O |If different from DN 642 |

|528 |BILLING PROVIDER LAST/GROUP NAME |C |O |O |If different from DN 638 |

|542 |BILLING PROVIDER POSTAL CODE |C |O |O |If different than DN656 |

|630 |BILLING PROVIDER STATE |C |O |O |If different than DN643(see WCIS regulations) |

| |LICENSE NUMBER | | | | |

|537 |BILLING PROVIDER PRIMARY SPECIALTY CODE |O |O |O |  |

|502 |BILLING TYPE CODE |C |O |O |If DN 503 equals "B" and prescriptions or durable medical|

| | | | | |equipment are billed |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|563 |DRUG NAME |C |O |O |If present |

|570 |DRUGS/SUPPLIES QUANTITY DISPENSED |C |O |O |If DN 502, value is "RX" or “MO”. |

|571 |DRUGS/SUPPLIES NUMBER OF DAYS |C |O |O |If DN 502, value is "RX" or “MO”. |

|572 |DRUGS/SUPPLIES BILLED AMOUNT |C |O |O |If DN 502, value is "RX" or “MO”. |

|579 |DRUGS/SUPPLIES DISPENSING FEE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|562 |DISPENSE AS WRITTEN CODE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|564 |BASIS OF COST DETERMINATION CODE |C |O |O | If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|721 |NDC BILLED CODE |C |O |O |If a pharmaceutical bill or a drug is dispensed by a |

| | | | | |physician during an office visit. |

|728 |NDC PAID CODE |C |O |O |If different then DN721 |

|527 |PRESCRIPTION BILL DATE |C |O |O |If different than DN604 |

|604 |PRESCRIPTION LINE DATE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|561 |PRESCRIPTION LINE NUMBER |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|638 |RENDERING BILL PROVIDER LAST/GROUP NAME |M |O |O |  |

|656 |RENDERING BILL PROVIDER POSTAL CODE |M |O |O |  |

|642 |RENDERING BILL PROVIDER FEIN |M |O |O |  |

|643 |RENDERING BILL PROVIDER STATE LICENSE NUMBER |M |O |O | |

|649 |RENDERING BILL PROVIDER SPECIALTY LICENSE NUMBER |C |O |O |If different then DN643 |

|651 |RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE |M |O |O |  |

|586 |RENDERING LINE PROVIDER FEIN |C |O |O |If different from DN 642 |

|589 |RENDERING LINE PROVIDER LAST/GROUP NAME |C |O |O |If different from DN 638 |

|593 |RENDERING LINE PROVIDER POSTAL CODE |C |O |O |If different from DN 656 |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|592 |RENDERING LINE PROVIDER NATIONAL ID |C |O |O | When available (see WCIS regulations) |

|595 |RENDERING LINE PROVIDER PRIMARY SPECIALTY |C |O |O |If different from DN 651 |

| |CODE | | | | |

|599 |RENDERING LINE PROVIDER STATE LICENSE NUMBER |C |O |O |If different from DN 643 |

|500 |UNIQUE BILL ID NUMBER |M |M |O |  |

|266 |TRANSACTION TRACKING NUMBER |M |O |O | |

|501 |TOTAL CHARGE PER BILL |M |O |O |  |

|523 |BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER|C |C |O |If DN501 is present |

|503 |BILLING FORMAT CODE |M |M |O |  |

|507 |PROVIDER AGREEMENT CODE |M |O |O |Enter the value "P" if the injured workers medical |

| | | | | |treatment is provided within a Medical Provider Network |

| | | | | |approved by the DWC. |

|508 |BILL SUBMISSION REASON CODE |M |M |M |  |

|509 |SERVICE BILL DATE(S) RANGE |C |O |O | If different than DN605 |

|510 |DATE OF BILL |O |O |O |  |

|511 |DATE INSURER RECEIVED BILL |M |O |O |  |

|512 |DATE INSURER PAID BILL |M |O |O |  |

|516 |TOTAL AMOUNT PAID PER BILL |C |O |O |If different than DN501  |

|522 |ICD-9 CM DIAGNOSIS CODE |C |O |O |If DN521 is present and more then one diagnosis occurs or|

| | | | | |if DN503 = B and DN714 or DN715 or a drug is dispensed by|

| | | | | |a physician during an office visit.  |

|544 |BILL ADJUSTMENT REASON CODE |C |O |O |If paid amount is not equal to billed amount |

|543 |BILL ADJUSTMENT GROUP CODE |C |O |O |If paid amount is not equal to billed amount |

|545 |BILL ADJUSTMENT AMOUNT |C |O |O |If paid amount is not equal to billed amount |

|546 |BILL ADJUSTMENT UNITS |C |O |O |If paid amount is not equal to billed amount |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|555 |PLACE OF SERVICE BILL CODE |C |C |O |If DN503 equals “B” |

|557 |DIAGNOSIS POINTER |C |O |O |If DN503 equals “B” and DN715 or DN714 is present or a |

| | | | | |drug is dispensed by a physician during an office visit. |

|567 |DME BILLING FREQUENCY CODE |C |O |O |If DN502 = DM and DN565 is present |

|526 |RELEASE OF INFORMATION CODE |O |O |O | |

|547 |LINE NUMBER |M |O |O |  |

|524 |PROCEDURE DATE |C |O |O |If DN 503 equals “A” and more than one surgical procedure|

| | | | | |was performed  |

|552 |TOTAL CHARGE PER LINE –OTHER |C |O |O |If DN502 not equal to RX or MO or DM |

|565 |TOTAL CHARGE PER LINE – RENTAL |C |O |O |If Durable Medical Equipment is rented |

|566 |TOTAL CHARGE PER LINE – PURCHASE |C |O |O |If Durable Medical Equipment is purchased |

|554 |DAYS/UNITS BILLED |C |O |O |If DN715 or DN714 are present or DN502 = DM, or a drug is|

| | | | | |dispensed by a physician during an office visit. |

|553 |DAYS/UNITS CODE |C |O |O |If DN715 or DN714 are present or DN502 = DM or a drug is |

| | | | | |dispensed by a physician during an office visit. |

|574 |TOTAL AMOUNT PAID PER LINE |C |O |O |If paid amount is not equal to billed amount |

|600 |PLACE OF SERVICE LINE CODE |C |O |O |If different from DN 555 and not a pharmacy bill |

|605 |SERVICE LINE DATE(S) RANGE |C |O |O | If not a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|525 |ICD-9 CM PRINCIPAL PROCEDURE CODE |C |O |O |If Billing Format Code, DN 503, is "A" and the code value|

| | | | | |is not a HCPCS code. For surgical bills only. |

|626 |HCPCS PRINCIPAL PROCEDURE BILLED CODE |C |O |O |If Billing Format Code, DN 503, is "A" and the code value|

| | | | | |is not an ICD-9 code. For surgical bills only. |

|736 |ICD_9 CM PROCEDURE CODE |C |O |O |If DN525 is present and more than one procedure is |

| | | | | |performed |

|737 |HCPCS BILL PROCEDURE CODE |C |O |O |If DN626 is present and more than one procedure is |

| | | | | |performed |

|714 |HCPCS LINE PROCEDURE BILLED CODE |C |O |O |If DN502 not equal RX or MO, and if DN715 or DN721 not |

| | | | | |present |

|717 |HCPCS MODIFIER BILLED CODE |C |O |O |If DN714 is modified |

|726 |HCPCS LINE PROCEDURE PAID CODE |C |O |O |If different than DN714 the line is adjusted |

|Bill Submission Reason Codes |

|  |  |Origina|Cancel|Replac|  |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|727 |HCPCS MODIFIER PAID CODE |C |O |O |If different than DN 717 |

|732 |SERVICE ADJUSTMENT REASON CODE |C |O |O |If paid amount is not equal to billed amount |

|731 |SERVICE ADJUSTMENT GROUP CODE |C |O |O |If paid amount is not equal to billed amount |

|733 |SERVICE ADJUSTMENT AMOUNT |C |O |O |If paid amount is not equal to billed amount |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|DN |Data Element Name |00 |01 |05 |Mandatory Trigger |

|513 |ADMISSION DATE |C |O |O |If Billing Format Code, (DN503), equals is “A” and |

| | | | | |patient has been admitted |

|535 |ADMITTING DIAGNOSIS CODE |C |O |O |If Billing Format Code, (DN503), equals is “A” and |

| | | | | |patient has been admitted |

|564 |BASIS OF COST DETERMINATION CODE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|532 |BATCH CONTROL NUMBER |M |M |M |  |

|545 |BILL ADJUSTMENT AMOUNT |C |O |O |If paid amount is not equal to billed amount |

|543 |BILL ADJUSTMENT GROUP CODE |C |O |O |If paid amount is not equal to billed amount |

|544 |BILL ADJUSTMENT REASON CODE |C |O |O |If paid amount is not equal to billed amount |

|546 |BILL ADJUSTMENT UNITS |C |O |O |If paid amount is not equal to billed amount |

|508 |BILL SUBMISSION REASON CODE |M |M |M |  |

|503 |BILLING FORMAT CODE |M |M |O |  |

|630 |BILLING PROVIDER STATE |CO |O |O |If different than DN643(see WCIS regulations) |

| |LICENSE NUMBER | | | | |

|528 |BILLING PROVIDER LAST/GROUP NAME |C |O |O |If different from Rendering Bill Provider Last/Group Name|

| | | | | |(DN638) |

|629 |BILLING PROVIDER FEIN |C |O |O |If different from Rendering Bill Provider FEIN (DN642) |

|634 |BILLING PROVIDER NATIONAL PROVIDER ID |C |O |O |If different from Rendering Bill Provider National |

| | | | | |Provider ID (DN647) |

|542 |BILLING PROVIDER POSTAL CODE |C |O |O |If different than from Rendering Bill Provider Postal |

| | | | | |Code (DN656) |

|537 |BILLING PROVIDER PRIMARY SPECIALTY CODE |O |O |O |  |

|523 |BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER|C |C |O |If Total Charge Per Bill (DN501) is present |

|502 |BILLING TYPE CODE |C |O |O |If Billing Format Code (DN503) equals "B" and |

| | | | | |prescriptions or durable medical equipment are billed |

|15 |CLAIM ADMINISTRATOR CLAIM NUMBER |M |M |M |  |

|187 |CLAIM ADMINISTRATOR FEIN |C |O |O |If the Claim Administrator FEIN is different then from |

| | | | | |Insurer FEIN (DN6) |

|188 |CLAIM ADMINISTRATOR NAME |C |O |O |If the Claim Administrator name is different then from |

| | | | | |Insurer Nname (DN7) |

|515 |CONTRACT TYPE CODE |C |O |O |If DRG Code (DN518) is present, then use value 01 or 09 |

|512 |DATE INSURER PAID BILL |M |O |O |  |

|511 |DATE INSURER RECEIVED BILL |M |O |O |  |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|510 |DATE OF BILL |O |O |O |  |

|31 |DATE OF INJURY |M |O |O |  |

|100 |DATE TRANSMISSION SENT |M |M |M |  |

|554 |DAYS/UNITS BILLED |C |O |O |If Jurisdiction Procedure Billed Code (DN715) or HCPCS |

| | | | | |Line Procedure Billed Code (DN714) are present or |

| | | | | |Billing Type Code (DN502) = equals “DM,” or a drug is |

| | | | | |dispensed by a physician during an office visit |

|553 |DAYS/UNITS CODE |C |O |O |If Jurisdiction Procedure Billed Code (DN715) or HCPCS |

| | | | | |Line Procedure Billed Code (DN714) are present or |

| | | | | |Billing Type Code (DN502) = equals “DM,” or a drug is |

| | | | | |dispensed by a physician during an office visit |

|557 |DIAGNOSIS POINTER |C |O |O |If Billing Format Code (DN503) equals “B” and HCPCS Line|

| | | | | |Procedure Billed Code (DN714) or Jurisdiction Procedure |

| | | | | |Billed Code (DN715) is present or a drug is dispensed by|

| | | | | |a physician during an office visit   |

|514 |DISCHARGE DATE |C |O |O |If Billing Format Code, (DN503), equals is “A” and |

| | | | | |patient has been discharged |

|562 |DISPENSE AS WRITTEN CODE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|567 |DME BILLING FREQUENCY CODE |C |O |O |If Billing Type Code (DN502) = equals “DM” and Total |

| | | | | |Charge per Line - Rental (DN565) is present |

|518 |DRG CODE |C |O |O |If Billing Format Code (DN503) equals “A” and if included|

| | | | | |in the California Inpatient Hospital Fee Schedule |

|563 |DRUG NAME |C |O |O |If present |

|572 |DRUGS/SUPPLIES BILLED AMOUNT |C |O |O |If Billing Type Code (DN502), value equals is "RX" or |

| | | | | |“MO” |

|579 |DRUGS/SUPPLIES DISPENSING FEE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|571 |DRUGS/SUPPLIES NUMBER OF DAYS |C |O |O |If Billing Type Code (DN502), value equals is "RX" or |

| | | | | |“MO” |

|570 |DRUGS/SUPPLIES QUANTITY DISPENSED |C |O |O |If Billing Type Code (DN502), value equals is "RX" or |

| | | | | |“MO” |

|152 |EMPLOYEE EMPLOYMENT VISA |C |O |O |If Employee Social Security Nnumber (DN42) or Employee |

| | | | | |Green Card Nnumber (DN153) is not available (see DN42) |

|44 |EMPLOYEE FIRST NAME |M |O |O |  |

|153 |EMPLOYEE GREEN CARD |C |O |O |If Employee Social Security Nnumber (DN42) is not |

| | | | | |available (see DN42) |

|43 |EMPLOYEE LAST NAME |M |O |O |  |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|45 |EMPLOYEE MIDDLE NAME |O |O |O |  |

|156 |EMPLOYEE PASSPORT NUMBER |C |O |O |If Employee Social Security Nnumber (DN42), Employee |

| | | | | |Green Card Nnumber (DN153), or Employee Employment Visa |

| | | | | |(DN152) is not available (see DN42) |

|42 |EMPLOYEE SOCIAL SECURITY NUMBER |M |O |O |Can use default values of all 9’s “999999999” or |

| | | | | |“000000006” if injured worker has no SSN, is not a United|

| | | | | |States citizen and has no other identification (DN153, |

| | | | | |DN152, DN156). If employee refuses to provide SSN, send |

| | | | | |“000000007”. |

|504 |FACILITY CODE |C |C |O |If Billing Format Code (DN503) equals “A” |

|679 |FACILITY FEIN |C |O |O |If Billing Format Code (DN503) equals “A” |

|681 |FACILITY MEDICARE NUMBER |O |O |O |  |

|678 |FACILITY NAME |C |O |O |If service performed in a licensed facility |

|682 |FACILITY NATIONAL PROVIDER ID |C |O |O |If facility services are billed on a UB04 format |

|688 |FACILITY POSTAL CODE |C |O |O |If service performed in a licensed facility |

|680 |FACILITY STATE LICENSE NUMBER |OC |O |O |If service preformed in a licensed facility |

|737 |HCPCS BILL PROCEDURE CODE |C |O |O |If HCPCS Principal Procedure Billed Code (DN626) is |

| | | | | |present and more than one procedure is performed |

|726 |HCPCS LINE PROCEDURE PAID CODE |C |O |O |If different than DN714 the line is adjusted |

|714 |HCPCS LINE PROCEDURE BILLED CODE |C |O |O |If Billing Type Code (DN502) not equal to “RX“ or “MO, “ |

| | | | | |and if Jurisdiction Procedure Billed Code (DN715) or NDC |

| | | | | |Billed Code (DN721) not present |

|717 |HCPCS MODIFIER BILLED CODE |C |O |O |If HCPCS Line Procedure Billed Code (DN714) is modified |

|727 |HCPCS MODIFIER PAID CODE |C |O |O |If different than from HCPCS Modifier Billed Code (DN717)|

|626 |HCPCS PRINCIPAL PROCEDURE BILLED CODE |C |O |O |If Billing Format Code, (DN503), is "A" and the code |

| | | | | |value is not an ICD-9 code For surgical bills only |

|736 |ICD_9 CM PROCEDURE CODE |C |O |O |If ICD-9 CM Principal Procedure Code (DN525) is present |

| | | | | |and more than one procedure is performed |

|522 |ICD-9 CM DIAGNOSIS CODE |C |O |O |If Principal Diagnosis Code (DN521) is present and more |

| | | | | |thaen one diagnosis occurs or if Billing Code Format |

| | | | | |(DN503) = equals “B” and HCPCS Line Procedure Billed Code|

| | | | | |(DN714) or Jurisdiction Procedure Billed Code (DN715) is |

| | | | | |present or a drug is dispensed by a physician during an |

| | | | | |office visit   |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|525 |ICD-9 CM PRINCIPAL PROCEDURE CODE |C |O |O |If Billing Format Code, (DN503), is "A" and the code |

| | | | | |value is not a HCPCS code. For surgical bills only |

|6 |INSURER FEIN |M |M |M | |

|7 |INSURER NAME |M |O |O |  |

|5 |JURISDICTIONAL CLAIM NUMBER |C |O |O |If the first report of injury has been filed and a |

| | | | | |jurisdictional claim number is available  |

|718 |JURISDICTIONAL MODIFIER BILLED CODE |C |O |O | If the Jurisdiction Procedure Billed Code (DN715) is |

| | | | | |modified |

|730 |JURISDICTIONAL MODIFIER PAID CODE |C |O |O | If different than from Jurisdiction Modifier Billed Code|

| | | | | |(DN718) |

|715 |JURISDICTIONAL PROCEDURE BILLED CODE |C |O |O | If the Jurisdiction Procedure Billed Code (DN715) is not|

| | | | | |a HCPCS procedure code included in the California |

| | | | | |Official Medical Fee Schedule |

|729 |JURISDICTIONAL PROCEDURE PAID CODE |C |O |O |If different than DN715 the line is adjusted |

|547 |LINE NUMBER |M |O |O |  |

|704 |MANAGED CARE ORGANIZATION FEIN |C |O |O |For HCO claims, use the FEIN of the |

| | | | | |sponsoring organization |

|208 |MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER |O |O |O |  |

|209 |MANAGED CARE ORGANIZATION NAME |O |O |O |  |

|712 |MANAGED CARE ORGANIZATION POSTAL CODE |O |O |O |  |

|721 |NDC BILLED CODE |C |O |O |If a pharmaceutical bill or a drug is dispensed by a |

| | | | | |physician during an office visit |

|728 |NDC PAID CODE |C |O |O |If different then DN721 the line is adjusted |

|555 |PLACE OF SERVICE BILL CODE |C |C |O |If Billing Format Code (DN503) equals “B” |

|600 |PLACE OF SERVICE LINE CODE |C |O |O |If different from Place of Service Bill Code (DN555) and |

| | | | | |not a pharmacy bill |

|527 |PRESCRIPTION BILL DATE |C |O |O |If different than from Prescription Line Date DN604 |

|604 |PRESCRIPTION LINE DATE |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|561 |PRESCRIPTION LINE NUMBER |C |O |O |If a pharmacy bill submitted on universal claim |

| | | | | |form/NCPDP format |

|521 |PRINCIPAL DIAGNOSIS CODE |C |O |O |If Billing Format Code (DN503) equals “A” |

|550 |PRINCIPAL PROCEDURE DATE |C |O |O |If Billing Format Code (DN503) equals “A” and if ICD-9 CM|

| | | | | |Principal Procedure Code (DN525) or HCPCS Principal |

| | | | | |Procedure Billed Code (DN626) is present |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|524 |PROCEDURE DATE |C |O |O |If Billing Format Code (DN503) equals “A” and more than |

| | | | | |one surgical procedure was performed  |

|507 |PROVIDER AGREEMENT CODE |M |O |O |Enter the value "P" if the injured workers medical |

| | | | | |treatment is provided within a Medical Provider Network |

| | | | | |approved by the DWC |

|99 |RECEIVER IDENTIFICATION |M |M |M |  |

|699 |REFERRING PROVIDER NATIONAL PROVIDER ID |C |O |O |When applicable on professional and institutional bills |

|526 |RELEASE OF INFORMATION CODE |O |O |O | |

|656 |RENDERING BILL PROVIDER POSTAL CODE |M |O |O |  |

|642 |RENDERING BILL PROVIDER FEIN |M |O |O |  |

|638 |RENDERING BILL PROVIDER LAST/GROUP NAME |M |O |O |  |

|647 |RENDERING BILL PROVIDER NATIONAL PROVIDER ID |M |O |O |Provide if available. If not, use string of consecutive |

| | | | | |nines. See WCIS regulation 9702(e) footnote 7 |

|651 |RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE |M |O |O |  |

|649 |RENDERING BILL PROVIDER SPECIALTY LICENSE NUMBER |CO |O |O |If different then DN643 |

|643 |RENDERING BILL PROVIDER STATE LICENSE NUMBER |M |O |O |Provide if available. If not, use string of consecutive |

| | | | | |nines. See WCIS regulation 9702(e) footnote 7 |

|595 |RENDERING LINE PROVIDER PRIMARY SPECIALTY |C |O |O |If different from Rendering Bill Provider Primary |

| |CODE | | | |Specialty Code (DN651) |

|592 |RENDERING LINE PROVIDER NATIONAL ID |C |O |O | If different from Rendering Bill Provider National ID |

| | | | | |(DN647) |

|593 |RENDERING LINE PROVIDER POSTAL CODE |C |O |O |If different than from Rendering Bill Provider Postal |

| | | | | |Code (DN656) |

|599 |RENDERING LINE PROVIDER STATE LICENSE NUMBER |C |O |O |If different from DN643 |

|586 |RENDERING LINE PROVIDER FEIN |C |O |O |If different from Rendering Bill Provider FEIN (DN642) |

|589 |RENDERING LINE PROVIDER LAST/GROUP NAME |C |O |O |If different from Rendering Bill Provider Last/Group Name|

| | | | | |(DN638) |

|615 |REPORTING PERIOD |M |M |M |  |

|559 |REVENUE BILLED CODE |C |O |O |If a value for Facility Code (DN504) is present with 2nd |

| | | | | |digit equal to 1 |

|576 |REVENUE PAID CODE |C |O |O |If different than from Revenue Billed Code (DN559) |

|98 |SENDER IDENTIFICATION |M |M |M |  |

|733 |SERVICE ADJUSTMENT AMOUNT |C |O |O |If paid amount is not equal to billed amount |

|731 |SERVICE ADJUSTMENT GROUP CODE |C |O |O |If paid amount is not equal to billed amount |

|MEDICAL DATA ELEMENT REQUIREMENT TABLE |

|Bill Submission Reason Codes |

| | |Origina|Cancel|Replac| |

| | |l |lation|e | |

|732 |SERVICE ADJUSTMENT REASON CODE |C |O |O |If paid amount is not equal to billed amount |

|509 |SERVICE BILL DATE(S) RANGE |C |O |O | If different than from Service Line Date(s) Range |

| | | | | |(DN605) |

|605 |SERVICE LINE DATE(S) RANGE |C |O |O | If nNot a pharmacy bill and submitted on universal claim|

| | | | | |form/NCPDP format |

|667 |SUPERVISING PROVIDER NATIONAL PROVIDER ID |C |0 |0 |When applicable on institutional bills |

|101 |TIME TRANSMISSION SENT |M |M |M |  |

|516 |TOTAL AMOUNT PAID PER BILL |C |O |O |If different than from Total Charge Per Bill (DN501)  |

|574 |TOTAL AMOUNT PAID PER LINE |C |O |O |If paid amount is not equal to billed amount |

|501 |TOTAL CHARGE PER BILL |M |O |O |  |

|566 |TOTAL CHARGE PER LINE – PURCHASE |C |O |O |If Durable Medical Equipment is purchased |

|565 |TOTAL CHARGE PER LINE – RENTAL |C |O |O |If Durable Medical Equipment is rented |

|552 |TOTAL CHARGE PER LINE –OTHER |C |O |O |If Billing Type Code (DN502) not equal to “RX“ or “MO“ |

| | | | | |or “DM“ |

|266 |TRANSACTION TRACKING NUMBER |M |O |O | |

|500 |UNIQUE BILL ID NUMBER |M |M |O |  |

Section ML: Data edits

California-adopted IAIABC data edits 82

California specific data edits 87

California-adopted IAIABC data edits and error messages

The California DWC adopted IAIABC data elements edit matrix provides the standard data edits and error codes the WCIS applies to the ANSI 837 EDI medical bill payment transmissions. The error codes will be transmitted back to each trading partner in the 824 acknowledgments. See the IAIABC EDI Implementation Guides for Medical Bill Payment Records, Release 1.1, July 20049 for more information on the standard IAIABC edits.

| |

|CALIFORNIA-ADOPTED IAIABC DATA EDITS AND ERROR MESSAGES |

|ERROR MESSAGES |

|ERROR MESSAGES |

|ERROR MESSAGES |

|ERROR MESSAGES |

|ERROR MESSAGES |Must |

| |be |

| |numeri|

| |c |

| |(0-9) |

|ERROR MESSAGES |

|DN |DATA ELEMENT NAME |EDIT |Error Code|

|110 |ACKNOWLEDGMENT TRANSACTION SET ID |Must be 3 digit numeric equal to 837 |058 |

|543 |BILL ADJUSTMENT GROUP CODE |Must be one of the following alpha values (CO or MA or OA or PI or PR) |058 |

|544 |BILL ADJUSTMENT REASON CODE |Must be numeric with 3 or less digits or 2 digit alpha-numeric |058 |

|California Specific Data Edits |

|DN |DATA ELEMENT NAME |EDIT |Error Code|

|508 |BILL SUBMISSION REASON CODE |Must be one of the following numeric values (00 or 01 or 05) |058 |

|503 |BILLING FORMAT CODE |Must be one of the following alpha values (A or B) |058 |

|542 |BILLING PROVIDER POSTAL CODE |Must be numeric with at least 5 digits and no more than 9 digits |028 |

|502 |BILLING TYPE CODE |Must be one of the following alpha values (DM or MO or RX) |058 |

|554 |DAYS/UNITS BILLED |Must be numeric |028 |

|553 |DAYS/UNITS CODE |Must be one of the following alpha values (DA or MJ or UN) |058 |

|557 |DIAGNOSIS POINTER |Must be one of the following numeric values (1 or 2 or 3 or 4) |058 |

|562 |DISPENSE AS WRITTEN CODE |Must be one of the following numerical values (0 or 1 or 2 or 3 or 4 or 5 or 6 |058 |

| | |or 7 or 8 or 9) | |

|567 |DME BILLING FREQUENCY CODE |Must be one of the following numeric values (1 or 4 or 6) |058 |

|518 |DRG CODE |Must be 3 digit numeric |058 |

|571 |DRUGS/SUPPLIED NUMBER OF DAYS |Must be 3 or less digits |028 |

|115 |ELEMENT NUMBER |Must be numeric with 1 digit or 2 digits or 3 digits |058 |

|42 |EMPLOYEE SOCIAL SECURITY NUMBER |Must be numeric with nine digits |028  |

|504 |FACILITY CODE |Must be numeric with 2 digits, not less than 11 or more than 99 |028 |

|688 |FACILITY POSTAL CODE |Must be numeric with at least 5 digits and no more than 9 digits |028 |

|105 |INTERCHANGE VERSION IDENTIFICATION |Alpha numeric of the following value (MED01) |058 |

|5 |JURISDICTIONAL CLAIM NUMBER |Must be numeric |028 |

| | |Must be either 12 digits or 22 digits | |

|712 |MANAGED CARE ORGANIZATION POSTAL CODE |Must be numeric with at least 5 digits and no more than 9 digits |028 |

|555 |PLACE OF SERVICE BILL CODE |Must be numeric with 2 digits, not less than 11 or more than 99 |028 |

|600 |PLACE OF SERVICE LINE CODE |Must be numeric with 2 digits, not less than 11 or more than 99 |028 |

|561 |PRESCRIPTION LINE NUMBER |Must be numeric, not less than 1 or more than 99 |028 |

|507 |PROVIDER AGREEMENT CODE |Must be one of the following alpha values (H or N or P or Y) |058 |

|99 |RECEIVER IDENTIFICATION |Two parts. First part must be 9 and the second part must be numeric with at |028 |

| | |least 5 digits and no more than 9 digits | |

|656 |RENDERING BILL PROVIDER POSTAL CODE |Must be numeric with at least 5 digits and no more than 9 digits |028 |

|593 |RENDERING LINE PROVIDER POSTAL CODE |Must be numeric with at least 5 digits and no more than 9 digits |028 |

|559 |REVENUE BILLED CODE |Must be numeric with three digits |058 |

|576 |REVENUE PAID CODE |Must be numeric with three digits |058 |

|98 |SENDER IDENTIFICATION |Two parts. First part must be 9 and the second part must be numeric with at |028 |

| | |least 5 digits and no more than 9 digits | |

|731 |SERVICE ADJUSTMENT GROUP CODE |Must be one of the following alpha values (CO or OA or PI or PR) |058 |

|732 |SERVICE ADJUSTMENT REASON CODE |Must be numeric with 3 or less digits or 2 digit alpha-numeric |058 |

Section NM: System specifications

Jurisdiction claim number (JCN) 90

Transaction processing and sequencing 90

824 detailed application acknowledgment codes (AAC) 91

Corrected data element (BSRC=00) (AAC=TR) 91

Corrected medical bill (BSRC=01) (AAC=TA) 91

Replacement of a claim administrator claim number (BSRC=05) (AAC=TA) 92

Duplicate transmissions, transactions, and medical bills 92

WCIS matching rules and processes for a claim 93

Unmatched transactions (AAC=TE) 93

More on how the WCIS matches incoming transactions to existing claim records 94

Jurisdiction claim number (JCN)

The IAIABC DN5, jurisdiction claim number (JCN), is either a 12 or 22 digit number created by WCIS to uniquely identify each claim. It is provided to the claims administrator in the acknowledgment of the first report of injury by the DWC. The revised WCIS system creates a 22-digit JCN and the old Before the WCIS system was revised in 2004, the original system created a 12-digit JCN. The revised system is backward compatible and will continue to accept the 12-digit JCN for claims originally reported to the old system., but a All new claims reported to the revised system will receive a 22-digit JCN.

The JCN is a conditional data element for the medical data requirements (See sSection K) and is used to match medical bills to the WCIS FROI database. – L required medical data elements). When a JCN is not available, Tthe data elements, claim administrator claim number (DN15) and insurer FEIN (DN6), will be utilized to match claims in the WCIS database in place of the JCN. under specific circumstances. For information on future changes to the JCN requirements, see the WCIS e·News #1.

Transaction processing and sequencing

Bill submission reason codes (BSRC) are used to define the specific purpose of a transmission. The DWC/WCIS only accepts three BSRC: 00, 01 and 05. The bill submission reason code (00) must be used with the initial medical bill payment report sent. The remaining bill submission reason codes (01, 05) must be preceded by the initial medical bill payment report. Medical bill payment report bill submission reason These codes are grouped in the following tables to clarify their purpose and to demonstrate a logical order for use.

The bill submission reason code used to report the initial medical bill payment report sent to WCIS is BSRC = 00.

|BSRC code |BSRC name |

|00 |Original |

After the initial medical bill payment report has been filed, the following medical bill payment report bill submission reason codes can be submitted to reflect cancellations or replacements. Resubmitted corrected medical bill payment report transmissions should be transmitted utilizing BSRC = 00. The originals of all corrected medical bill payment records are canceled utilizing BSRC = 01. Replacement medical bill payment report transmissions that inform the WCIS of a change in DN15 --- Claim Administrator Claim Number -- should be transmitted utilizing BSRC = 05.

|BSRC code |BSRC name |

|01 |Cancellation |

|05 |Replace (only used for changes in DN15) |

824 detailed application acknowledgment codes

The California DWC/\WCIS utilizes DN111, Aapplication Aacknowledgment Ccodes (AAC), in the ANSI 824 to inform the Ttrading partner of the accepted or rejected status of each 837 transmission to the DWC.

|AAC code |AAC meaning |

|TA |Transaction accepted |

|TR |Transaction rejected |

|TE |Transaction accepted with errors (only for unmatched transactions on the FROI database) |

Correctinged data elements (BSRC=00)(AAC=TR)

WCIS regulations require each claims administrator to submit to the WCIS any corrected data elements as defined by the California-adopted IAIABC (DN508) bill submission reason code Bill Submission Reason Code(BSRC) (See Section K). After correcting the data errors in a transmission previously submitted to the DWC\/WCIS, the sender transmits a BSRC=00 containing the corrected data. The re-submitted, corrected transmission (BSRC=00) are is sent in response to an 824 acknowledgement containing error messages (TR) from the DWC\/WCIS. When re-submitting a corrected transmission (BSRC=00) in response to a transaction rejected (TR), the sender must report all medical bill payment data elements, not just the data elements being corrected (See Section K L – Required medical data elements). The following five steps outline the procedure:

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

2. ReceiverDWC/WCIS sends a “TR” 824 acknowledgement with errors to sender.

3. Sender corrects errors in the original bill.

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

5. ReceiverDWC/WCIS sends a 997 and a “TA” 824 acknowledgement to sender.

Corrected medical bill Updating data elements (BSRC=01)(AAC=TA)

WCIS regulations require each claims administrator to submit to the WCIS any changed data elements to maintain complete, accurate, and valid data. To update the value of data elements contained in transmission already accepted by the DWC/\WCIS, the sender transmits a BSRC = 01 to cancel the original transmission (BSRC=00), and then transmits a different BSRC = 00 containing the updated data. The updated transmission (BSRC=00) is not sent in response to an 824 acknowledgment containing error messages (TR) from the DWC/WCIS. When submitting a transmission (BSRC=00) to update the value of a data element, the sender must report all medical bill payment data elements, not just the data elements being updated (See Section K L – Required medical data elements). The following seven steps outline the procedure:

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

2. ReceiverDWC/WCIS sends a 997 and a “TA” 824 acknowledgement to sender.

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

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

5. ReceiverDWC/WCIS sends a 997 and a “TA” 824 acknowledgement to sender.

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

7. ReceiverDWC/WCIS sends a 997 and “TA” 824 acknowledgement to sender.

* Note: The DWC/WCIS will accept a streamlined version where steps 4 and 6 are combined into one 837 transmission.

Replacingement of a claims administrator claim number (BSRC=05)(AAC=TA)

Replacement reports (BSRC=05) are sent to WCIS indicating a change in the claim administrator claim number (DN15) (See Ssection J K). The replacement transmission (BSRC=05) may or may not be sent in response to an 824 acknowledgment containing error messages (TR) from the DWC/WCIS (see “Unmatched transactions below). When submitting a replacement transmission (BSRC=05) to indicate a change in the claims administrators claim number, the sender must only resubmit a limited number of data elements (See Section K L– Required medical data elements). The following four steps outline the procedure:

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

2. ReceiverDWC/WCIS sends a 997 and a “TA” 824 acknowledgement to sender.

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

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

Duplicate transmissions, transactions and medical bills

Transmission duplicates occur when the ISA or GE functional groups in different 837 transmissions contain the same key header information (sender ID, date transmission sent, time transmission sent, and interchange version ID) that was previously accepted by the DWC.

Transaction duplicates occur when one or more ST-SE transaction sets contain the same header information; batch control number, date transmission sent, time transmission sent, sender identification, and reporting period.

Bill-level duplicates occur when one or more ST-SE transaction sets from the same sender, contain the same information on the claim administrator FEIN, claim administrator claim number, and unique bill identification number, line number and other data elements. The DWC will check for duplicate bills in all ST-SE transaction sets throughout all GS-GE functional groups included in each X12 interchange envelope (ISA-IEA interchange). The DWC will also check each bill for duplicates against the entire database. Duplicate medical bills that are not correctly coded with the appropriate claim adjustment reason code will be flagged with an 057 error code on the detailed 824 acknowledgment (see Section G).

[pic]

WCIS medical matching rules and processes for a claim

Primary:

1. Jurisdiction claim number (JCN)

Secondary match for medical bill payment reports to the FROI:

2a. Claim administrator claim number

Insurer FEIN (match on insurer FEIN if provided, otherwise match on claim administrator FEIN)

2b. Employee social security number

2c. Date of injury

Employee last name

Employee middle name

Employee first name

The WCIS uses the jurisdiction claim number as the primary means for matching medical bills in the 837 to claims previously received in the First Report of Injury (FROI) database. Secondary match criteria include the Claim Administrator Claim Number (DN15) and the Insurer FEIN (DN6). “No match on the database” for either DN15 or DN6 will cause an AAC of “TE” in the OTI segment and an error code of 039 in the LQ segment of the 824.

The claims administrator can only change DN15 (Claim Administrator Claim Number) in the medical database by submitting a BSRC = 05. Claims Administrators who submit a revised claim administrator claim number in the FROI database should submit an MTC “02.” Acquired claims in the FROI use the MTC “AU” and acquired payments in SROI use the MTC “AP.” (see the California FROI/SROI Implementation Guide).

Unmatched Transactions (AAC=TE)

The DWC/WCIS matches all medical bill payment record transmissions to the First Reports of Injury (FROI) in the WCIS relational database. If the DWC/WCIS receives an 837 medical bill payment record from a trading partner with no errors and no match in the DWC/WCIS FROI database, the DWC/WCIS procedure is as follows:

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

2. If no match (FROI) or BSRC = 01, the DWC sends an 824 acknowledgment indicating transaction accepted with errors (TE). The error code will be 039_nomatch on database when the DN15_Claim Administrator Claim Number or Insurer FEIN cannot be matched.

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

4. The DWC plans to produce data quality reports to each trading partner on an annual basis as part of the annual certification process.

More on how WCIS matches incoming transactions to existing claim records

The WCIS uses the jurisdiction claim number (JCN) as the primary means for matching transactions representing the same claim. Secondary match data will be used only if a JCN is not provided. For current JCN requirements see section L - Required medical data elements)

The claim administrator can only change the data elements in match data #2a by submitting a BSRC = 05. All Acquired Claims will be reported in the SROI utilizing the JCN (see the California FROI/SROI Implementation Guide).

Section O

IAIABC Information

Introduction 96

History of the IAIABC and EDI 96

What is EDI? 97

Standards 97

Software 97

Communications 98

Introduction

The following information about the International Association of Industrial Accident Boards and Commissions (IAIABC) was produced by the IAIABC. It is reproduced here by permission for users’ convenience.

History of the IAIABC and EDI

In April of 1914, just six years after the enactment of the first Workers’ Compensation Act in the United States, regulators from federal and state programs gathered in Lansing, Michigan and formed an association. The next year, a Canadian province joined and the International Association of Industrial Accident Boards and Commissions was formed (files/public/2006History of IAIABC.doc).

Concurrent with the activities of the IAIABC subcommittee reviewing BAIS, the National Association of Insurance Commissioners (NAIC) established a subcommittee to review the subject of data collection. The NAIC subcommittee was established at the same point in time that the IAIABC subcommittee was compiling the results of the second survey directed to the state agencies. Based upon the similarity of purpose in terms of expanded workers’ compensation data collection, a joint working group composed of members of the IAIABC subcommittee and the NAIC subcommittee was formed.

In March of 1991, several carriers and associations met with the IAIABC in an effort to truly standardize the electronic reporting process. The result was the formation of the EDI Steering Committee. This working group within the IAIABC proceeded with the concept of moving the data collection project into an implementation phase. At the same time, a technical working group was established—composed primarily of insurance representatives, state agency personnel, and consultants—who have focused on the detail of defining the data elements and developing the format in which the data can be electronically transferred. This group, after reviewing all the various forms presently filed with state agencies, identified distinct phases that the project would follow. These phases reflect the various generic categories into which the various state reporting forms fell and include:

First Report of Injury—the initial report designed to notify the parties of the occurrence of an injury or illness.

Subsequent Payment Record—consists of forms which gather information when benefit payments begin, case progress information, and paid amounts by benefit type when the claim is concluded.

Medical Data—consists of data pertinent to the dates of service, diagnostic and procedure codes, and costs associated with the providing of medical care.

Vocational Rehabilitation Data—monitors the incidence of vocational rehabilitation, the outcomes, and the costs associated with it.

Litigation Data—reflects the incidence of disputes, issues in dispute, outcome results at various adjudication levels, and system costs related to litigation.

Each of these categories represents a separate project phase for the technical working group. Focusing first on FROI, the working groups were able to create a standard reporting format that served the needs of virtually each one of the state agencies.

Efforts have also been directed at establishing the same standardized reporting formats for the Proof of Coverage (POC), the reporting of medical information, and the Subsequent Payment Report which contains all those claim derivatives—including the level and type of benefit payments—that occur following the initial reporting of the claim. Through the passage of time, the transaction standards for FROI and Subsequent Reports have evolved from a Release I to a Release III version.

What is EDI?

Electronic Data Interface (EDI) consists of standardized business practices that permit the flow of information between organizations without the need for human intervention. Imagine that an ambitious ant wanted to get from your left hand to your right hand. It would be a long journey for a little ant. Imagine next that you held a string between your fingers. The ant could cross that string and get there much faster in that situation. Finally, imagine that you took the two ends of the string and moved them together. That is EDI. It is moving the two points together, for instant travel. Using technology, when you communicate with yourself, you are also communicating with all of your necessary trading partners. Someone gathers the information, types it into the computer and the computer does the rest, routing the correct information to the correct systems, regardless of whether the system resides in the room next to you or somewhere across the globe.

The EDI is a member of a family of technologies for communicating business messages electronically. This family includes EDI, facsimile, electronic mail, telex, and computer conferencing systems. Technically speaking, EDI is the computer application to computer application exchange of business data in a structured format. In other words, the purpose of EDI is to take information from one company’s application and place it in the computer application of another company.(or in EDI vocabulary – a trading partner.)

Here are Three The key components of EDI: (1) are Standards, (2) Software, and (3) Communications.

Standards

Within the component of standards, there are three categories.

Transactions sets—a logical grouping of segments used to convey business data (also referred to as simply a document). These replace paper documents or verbal requests.

Data dictionary - defines the meaning of individual pieces of information (a.k.a. data elements) within a transaction set.

Systems-the electronic envelope that all of the information is contained in.

Software

Software solutions for managing the system will be dictated by communications technology and whether you will be reprogramming existing systems and purchasing a translator, purchasing an off-the-shelf solution, hiring an outside consultant, or using a third party to collect the data.

The EDI translation software component converts the application data to a standard EDI format. The telecommunication software initiates the communication session, establishes protocol, validates security, and transmits the EDI data. The telecommunication network provides the medium to connect two or more computer environments.

Communications

Communications is the technology that allows data to flow between one computer and another. The EDI telecommunications process involves a computer application to formulate the customized business partner’s data. Communications technology is divided into software and network choices. The number of choices depends on the “How” you choose to implement EDI. The two aspects of “How” are:

The communications software you choose will be dictated by your choice of communications network and whether you are communicating with the same structure or need a translator between systems. The primary objective of communications relative to EDI is to transport information between business partners in a cost effective and efficient manner. A second critical objective is to assure the privacy and confidentiality of the information while it is being electronically exchanged.

Section PN: Code lists and state license numbers

Code sources 100

Zip codes 100

Health care financing administration common procedural coding system 100

International classification of diseases clinical mod (ICD-9) CM procedure 100

Current procedural terminology (CPT) codes 101

National drug code 101

Diagnosis related groups (DRG) 101

Provider taxonomy codes 102

Facility/Place of service codes 102

Place of service bill\line codes 103

Revenue billed/paid codes 104

Claim adjustment reason codes 116

California state medical license numbers 116

Code sources

This section provides information on where to obtain source codes and current valid codes for several data elements. These valid code lists are provided as a convenience for our data providers, and are intended to be a simple repetition of code lists available elsewhere. All sources and codes are also available at

PostalZip code

Source: National Zip Code and Post Office Directory, Publication 65

The USPS Domestic Mail Manual

Available At:

U.S. Postal Service

Washington, DC 20260

New Orders

Superintendent of Documents

P.O. Box 371954

Pittsburgh, PA 15250-7954



Healthcare financing administration common procedural coding system (HCPCS)

Source: Centers for Medicare & Medicaid Services (CMS)

Available at:

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore MD 21244-1850



Abstract:

Healthcare Common Procedure Coding System (HCPCS) is the Centers for Medicare & Medicaid Services (CMS) coding scheme to group procedures performed for payment providers.

International classification of diseases clinical modification (ICD-9 CM) procedure

Source: International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9 CM)

Available at:

U.S. National Center of Health Statistics

Commission of Professional and Hospital Activities

1968 Green Road

Ann Arbor, MI 48105



Abstract:

The International Classification of Diseases, Ninth Revision, Clinical Modification, describes the classification of morbidity and mortality information for statistical purposes and the indexing of hospital records by disease and operations.

Current procedural terminology (CPT) codes

Source: Physicians’ Current Procedural Terminology (CPT) Manual

Available at:

Order Department

American Medical Association

515 North State Street

Chicago, IL 60610

?

childName=nochildcat&parentCategory=cat220008&productId=prod240142&categoryName=Data+Files&start=1&parentId=cat220008

Abstract:

Current Procedural Terminology (CPT) codes are the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.

National drug code (NDC)

Source: Blue book, Price Alert, National Drug Data File Master Drug Database v 2.5.

Available at:

First Databank

The Hearst Corporation

1111 Bayhill Drive

San Bruno, CA 94066

Wolters Kluwer Health – Medi-Span

8425 Woodfield Crossing Blvd., Ste 490

Indianapolis, IN 46240



Abstract:

The National Drug Code (NDC) is a coding convention established by the Food and Drug Administration (FDA) to identify the labeler, product number, and package sizes of FDA-approved prescription drugs. There are over 170,000 National Drug Codes on file.

Diagnosis related groups (DRG)

Source: Federal Register and Health Insurance Manual 15 (HIM 15)

Available at:

Superintendent of Documents

U.S. Government Printing Office

Washington, DC 20402



Abstract:

A DRG (Diagnosis Related Group) is a classification of a hospital stay in terms of what was wrong and what was done for a patient. The DRG classification (one of about 500) is determined by utilizing a an A grouper@ program based on diagnoses and procedures coded in ICD-9 CM and on patient age, sex, length of stay, and other factors. The DRG frequently determines the amount of money that will be reimbursed, independently of the charges that the hospital may have incurred. In the United States, the basic set of DRG codes are those defined by the Health Care Financing Administration (HCFA) for adult Medicare billing. For other patients types and payers -- CHAMPUS (Civilian Health and Medical Services of the Uniformed Services), Medicaid, commercial payers for neonate claims, Workers’ Compensation -- modifier grouper and additional DRG codes are used.

Provider taxonomy codes

Source: Washington Publishing Company

Available at:

Facility/Place of service codes

Source: Place of Service Codes for Professional Claims

Available at:

Centers for Medicare and Medicaid Services

CMSO, Mail Stop S2-01-16

7500 Security Blvd

Baltimore, MD 21244-1850



Abstract:

The Centers for Medicare and Medicaid Services develops place of service codes to identify the location where health care services are performed.

Type of Facility – 1st Digit

Hospital 1

Skilled Nursing 2

Home Health 3

Christian Science (Hospital) 4

Christian Science (Extended Care) 5

Intermediate Care 6

Clinic 7

Specialty Facility 8

Reserved for National Assignment 9

Bill Classification (Except Clinics/Special Facilities – 2nd Digit)

Inpatient (including Medicare Part A) 1

Inpatient (Medical Part B only) 2

Outpatient 3

Other 4

(Other category used for hospital referenced diagnostics services,

or home health not under a plan or treatment)

Intermediate Care Level I 5

Intermediate Care Level II 6

Sub acute Inpatient (Revenue Code 19x required) 7

Swing Beds 8

Reserved for National Assignment 9

Bill Classification (Clinics Only) – 3rd Digit

Rural Health Clinic (RHC) 1

Hospital Based or Independent Renal Dialysis Center 2

Free Standing 3

Outpatient Rehabilitation Facility 4

Comprehensive Outpatient Rehab Facilities (CORF) 5

Community Mental Health Center (CMHC) 6

Reserved for National Assignment 7-8

Other 9

Bill Classification (Special Facilities Only) – 4th Digit

Hospice (Non-hospital based) 1

Hospice (Hospital based) 2

Ambulatory Surgery Center 3

Free-Standing Birthing Center 4

Rural Primary Care (Critical Access Hospital) 5

Reserved for National Assignment 6-8

Other 9

Place of service line code

Values: 00 – 10 = Unassigned

11 = Office

12 = Home

13 – 20 = Unassigned

21 = Inpatient Hospital

22 = Outpatient Hospital

23 = Emergency Room – Hospital

24 = Ambulatory Surgical Center

25 = Birthing Center

26 = Military Treatment Facility

27 – 30 = Unassigned

31 = Skilled Nursing Facility

32 = Nursing Facility

33 = Custodial Care Facility

34 = Hospice

35 – 40 = Unassigned

41 = Ambulance – Land

42 = Ambulance – Air or Water

43 –49 = Unassigned

50 = Federally Qualified Health Center

51 = Inpatient Psychiatric Facility

52 = Psychiatric Facility Partial Hospitalization

53 = Community Mental Health Center

54 = Intermediate Care Facility/Mentally Retarded

55 = Residential Substance Abuse Treatment Center

56 = Psychiatric Residential Treatment Center

57 – 60 = Unassigned

61 = Comprehensive Inpatient Rehabilitation Facility

62 = Comprehensive Outpatient Rehabilitation Facility

63 – 64 Unassigned

65 = End Stage Renal Disease Treatment Facility

66 – 70 Unassigned

71 = State or Local Public Health Clinic

72 = Rural Health Clinic

73 – 80 Unassigned

81 = Independent Laboratory

82 – 98 = Unassigned

99 = Other Unlisted Facility

Revenue billed/paid code

Source: National Health Care Claim Payment/Advice Committee Bulletins

Available Aat: National Uniform Billing Committee

American Hospital Association

840 Lake Shore Drive

Chicago, IL 60697

Abstract: Revenue codes are a classification of hospital charges in a standard grouping that is controlled by the National Uniform Billing Committee.

Values: 001 = Total Charge

010 – 069 = Reserved for national assignment

070 – 079 = Reserved for State Use

100 = All inclusive rate and board plus ancillary

101 = All inclusive rate and board

110 = Private room and board general classification

111 = Private room and board medical/surgical/GYN

112 = Private room and board OB

113 = Private room and board pediatric

114 = Private room and board psychiatric

115 = Private room and board hospice

116 = Private room and board detoxification

117 = Private room and board oncology

118 = Private room and board rehabilitation

119 = Private room and board other

120 = Two bed semi-private room & board general classification

121 = Two bed semi-private room & board medical/surgical/GYN

122 = Two bed semi-private room & board OB

123 = Two bed semi-private room & board pediatric

124 = Two bed semi-private room & board psychiatric

125 = Two bed semi-private room & board hospice

126 = Two bed semi-private room & board detoxification

127 = Two bed semi-private room & board oncology

128 = Two bed semi-private room & board rehabilitation

129 = Two bed semi-private room & board other

130 = 3 & 4 bed semi-private room & board general classification

131 = 3 & 4 bed semi-private room & board medical/surgical/GYN

132 = 3 & 4 bed semi-private room & board OB

133 = 3 & 4 bed semi-private room & board pediatric

134 = 3 & 4 bed semi-private room & board psychiatric

135 = 3 & 4 bed semi-private room & board hospice

136 = 3 & 4 bed semi-private room & board detoxification

137 = 3 & 4 bed semi-private room & board oncology

138 = 3 & 4 bed semi-private room & board rehabilitation

139 = 3 & 4 bed semi-private room & board other

140 = Deluxe private general classification

141 = Deluxe private medical/surgical/GYN

Revenue billed code

Revenue paid code (Continued)

142 = Deluxe private OB

143 = Deluxe private pediatric

144 = Deluxe private psychiatric

145 = Deluxe private hospice

146 = Deluxe private detoxification

147 = Deluxe private oncology

148 = Deluxe private rehabilitation

149 = Deluxe private other

150 = Room & board ward general classification

151 = Room & board ward medical/surgical/GYN

152 = Room & board ward OB

153 = Room & board ward pediatric

154 = Room & board ward psychiatric

155 = Room & board ward hospice

156 = Room & board ward detoxification

157 = Room & board ward oncology

158 = Room & board ward rehabilitation

159 = Room & board ward other

160 = Other room & board general classification

164 = Other room & board sterile environment

167 = Other room & board self care

169 = Other room & board other

170 = Nursery general classification

171 = Nursery newborn level 1

172 = Nursery newborn level 2

173 = Nursery newborn level 3

174 = Nursery newborn level 4

179 = Nursery newborn other

180 = Leave of absence general classification

181 = Reserved

182 = Leave of absence patient convenience – charges billable

183 = Leave of absence therapeutic leave

184 = Leave of absence ICF mentally retarded – any reason

185 = Leave of absence nursing home (hospitalization)

189 = Leave of absence other

190 = Sub acute care general classification

191 = Sub acute care level 1

192 = Sub acute care level 2

193 = Sub acute care level 3

194 = Sub acute care level 4

199 = Sub acute care other

200 = Intensive care general classification

201 = Intensive care surgical

Revenue billed code

Revenue paid code (Continued)

202 = Intensive care medical

203 = Intensive care pediatric

204 = Intensive care psychiatric

206 = Intensive care intermediate ICU

207 = Intensive care burn care

208 = Intensive care trauma

209 = Intensive care other

210 = Coronary care general classification

211 = Coronary care myocardial infarction

212 = Coronary care pulmonary care

213 = Coronary care heart transplant

214 = Coronary care intermediate CCU

219 = Coronary care other

220 = Special charges general classification

221 = Special charges admission

222 = Special charges technical support

223 = Special charges UR service charge

224 = Special charges late discharge medically necessary

229 = Special charges other

230 = Incremental nursing charge general classification

231 = Incremental nursing charge nursery

232 = Incremental nursing charge OB

233 = Incremental nursing charge ICU (includes transitional care)

234 = Incremental nursing charge CCU (includes transitional care)

235 = Incremental nursing charge hospice

239 = Incremental nursing other

240 = All inclusive ancillary general classification

249 = All inclusive ancillary other

250 = Pharmacy general classification

251 = Pharmacy generic drugs

252 = Pharmacy non-generic drugs

253 = Pharmacy take home drugs

254 = Pharmacy drugs incident to other diagnostic services

255 = Pharmacy drugs incident to radiology

256 = Pharmacy experimental drugs

257 = Pharmacy non-prescription

258 = Pharmacy IV solutions

259 = Pharmacy other

260 = Therapy general classification

261 = Therapy infusion pump

262 = Therapy IV therapy/pharmacy services

263 = Therapy IV therapy/drug/supply/delivery

264 = Therapy IV Therapy/supplies

Revenue billed code

Revenue paid code (Continued)

269 = Therapy IV other

270 = Medical/surgical supplies general classification

271 = Medical/surgical supplies non-sterile supply

272 = Medical/surgical supplies sterile supply

273 = Medical/surgical supplies take home supplies

274 = Medical/surgical supplies prosthetic/orthotic devices

275 = Medical/surgical supplies pace maker

276 = Medical/surgical supplies intraocular lens

277 = Medical/surgical supplies oxygen – take home

278 = Medical/surgical supplies other implants

279 = Medical/surgical supplies other

280 = Oncology general classification

289 = Oncology other

290 = Durable medical equipment (DME) general classification

291 = Durable medical equipment (DME) rental

292 = Durable medical equipment (DME) purchase of new DME

293 = Durable medical equipment (DME) purchase of old DME

294 = Durable medical equipment (DME) supplies/drugs (HHAs only)

299 = Durable medical equipment (DME) other

300 = Laboratory general classification

301 = Laboratory chemistry

302 = Laboratory immunology

303 = Laboratory renal patient (home)

304 = Laboratory non-routine dialysis

305 = Laboratory hematology

306 = Laboratory bacteriology and microbiology

307 = Laboratory urology

309 = Laboratory other

310 = Laboratory pathological general classification

311 = Laboratory pathological cytology

312 = Laboratory pathological histology

314 = Laboratory pathological biopsy

319 = Laboratory pathological other

320 = Radiology diagnostic general classification

321 = Radiology diagnostic angiocardiography

322 = Radiology diagnostic arthrography

323 = Radiology diagnostic arteriography

324 = Radiology diagnostic chest x-ray

329 = Radiology diagnostic other

330 = Radiology therapeutic general classification

331 = Radiology therapeutic chemotherapy injected

332 = Radiology therapeutic chemotherapy oral

333 = Radiology therapeutic radiation therapy

Revenue billed code

Revenue paid code (Continued)

335 = Radiology therapeutic chemotherapy IV

339 = Radiology therapeutic other

340 = Nuclear medicine general classification

341 = Nuclear medicine diagnostic

342 = Nuclear medicine therapeutic

349 = Nuclear medicine other

350 = CT scan general classification

351 = CT scan head scan

352 = CT scan body scan

359 = CT scan other

360 = Operating room services general classification

361 = Operating room services minor surgery

362 = Operating room services organ transplant (other than kidney)

367 = Operating room services kidney transplant

369 = Operating room other

370 = Anesthesia general classification

371 = Anesthesia incident RAD

372 = Anesthesia incident to other diagnostic services

374 = Anesthesia acupuncture

379 = Anesthesia other

380 = Blood general classification

381 = Blood packed red cells

382 = Blood whole blood

383 = Blood plasma

384 = Blood platelets

385 = Blood Leucocytes

386 = Blood other components

387 = Blood other derivatives (cyoprecipitates)

389 = Blood other

400 = Other imaging services general classification

401 = Other imaging services diagnostic mammography

402 = Other imaging services ultrasound

403 = Other imaging services screening mammography

404 = Other imaging services positron emission tomography

409 = Other imaging services other

410 = Respiratory services general classification

412 = Respiratory services inhalation services

413 = Respiratory services hyperbaric oxygen therapy

419 = Respiratory service other

420 = Physical therapy general classification

421 = Physical therapy visit charge

422 = Physical therapy hour charge

423 = Physical therapy group rate

Revenue billed code

Revenue paid code (Continued)

424 = Physical therapy evaluation or re-evaluation

429 = Physical therapy other

430 = Occupational therapy general classification

431 = Occupational therapy visit charge

432 = Occupational therapy hourly charge

433 = Occupational therapy group rate

434 = Occupational therapy evaluation or re-evaluation

439 = Occupational therapy other

440 = Speech language pathology general classification

441 = Speech language pathology visit charge

442 = Speech language pathology hourly charge

443 = Speech language pathology group rate

444 = Speech language pathology evaluation or re-evaluation

449 = Speech language pathology other

450 = Emergency room general classification

451 = Emergency room EMTALA emergency medical screening services

452 = Emergency room ER beyond EMTALA screening

456 = Emergency room urgent care

459 = Emergency room other

460 = Pulmonary function general classification

469 = Pulmonary function other

470 = Audiology general classification

471 = Audiology diagnostic

472 = Audiology treatment

479 = Audiology other

480 = Cardiology general classification

481 = Cardiology cardiac cath lab

482 = Cardiology stress test

483 = Cardiology echocardiology

489 = Cardiology other

490 = Ambulatory surgical care general classification

499 = Ambulatory other

500 = Outpatient services general classification

509 = Outpatient services other

510 = Clinic general classification

511 = Clinic chronic pain center

512 = Clinic dental

513 = Clinic psychiatric

514 = Clinic OB/GYN

515 = Clinic pediatric

516 = Clinic urgent care

517 = Clinic family practice

519 = Clinic other

Revenue billed code

Revenue paid code (Continued)

520 = Free standing clinic general clinic

521 = Free standing clinic rural health

522 = Free standing clinic rural health home

523 = Free standing clinic family practice

526 = Free standing clinic urgent care

529 = Free standing clinic other

530 = Osteopathic services general classification

531 = Osteopathic services therapy

539 = Osteopathic services other

540 = Ambulance general classification

541 = Ambulance supplies

542 = Ambulance medical transport

543 = Ambulance heart mobile

544 = Ambulance oxygen

545 = Ambulance air

546 = Ambulance neo-natal

547 = Ambulance pharmacy

548 = Ambulance telephone transmission EKG

549 = Ambulance other

550 = Skilled nursing general classification

551 = Skilled nursing visit charge

552 = Skilled nursing hourly charge

559 = Skilled nursing other

560 = Medical social services general classification

561 = Medical social services visit charge

562 = Medical social services hourly charge

569 = Medical social services other

570 = Home health aide general classification

571 = Home health aide visit charge

572 = Home health aide hourly charge

579 = Home health aide other

580 = Other visits general classification (home health)

581 = Other visits visit charge (home health)

582 = Other visits hourly charge (home health)

589 = Other visits other

590 = Units of services general classification (home health)

599 = Units of services other

600 = Oxygen general classification (home health)

601 = Oxygen state/equip/supply/or cont (home health)

602 = Oxygen state/equip/supply under 1LPM (home health)

603 = Oxygen state/equip/supply over 4 LPM (home health)

604 = Oxygen portable add-on (home health)

610 = MRI general classification

Revenue billed code

Revenue paid code (Continued)

611 = MRI brain (including brain stem)

612 = MRI spinal cord (including spine)

619 = MRI other

621 = Medical/surgical supplies incident to radiology (ext of 270 codes)

622 = Medical/surgical supplies incident to other diag svcs(ext 270 code)

623 = Medical/surgical supplies surgical dressings (ext 270 codes)

624 = Medical/surgical supplies investigational device (ext 270 codes)

630 = Drugs requiring specific identification general classification

631 = Drugs requiring specific identification single source drug

632 = Drugs requiring specific identification multiple source drug

633 = Drugs requiring specific identification restrictive prescription

634 = Drugs requiring specific identification erythropoeitin < 10,000 units

635 = Drugs requiring specific identification erythropoeitin > 10,000 units

636 = Drugs requiring specific identification drugs detailed coding

637 = Drugs requiring specific identification self-administrable drugs

640 = Home IV therapy services general classification

641 = Home IV therapy services non-routine nursing

642 = Home IV therapy services IV site care, central line

643 = Home IV therapy services IV start/chg, peripheral line

644 = Home IV therapy services non-routine nursing, peripheral line

645 = Home IV therapy services training patient caregiver, central line

646 = Home IV therapy services training disabled patient, central line

647 = Home IV therapy services training patient/caregiver, peripheral line

648 = Home IV therapy services training disabled patient, peripheral line

649 = Home IV therapy services other

650 = Hospice services general classifications

651 = Hospice services routine home care

652 = Hospice services continuous home care2

653 = Reserved

654 = Reserved

655 = Hospice inpatient care

656 = Hospice general inpatient care (non-respite)

657 = Hospice physician services

659 = Hospice other

660 = Respite care general classification

661 = Respite care hourly charge/skilled nursing

662 = Respite care hourly charge/home health aide/homemaker

670 = Outpatient special residence charges general classification

671 = Outpatient special residence charges hospital based

672 = Outpatient special residence charges contracted

679 = Outpatient special residence charges other

680 – 689 = Not assigned

690 – 699 = Not assigned

Revenue billed code

Revenue paid code (Continued)

700 = Cast room general classification

709 = Cast room other

710 = Recovery room general classification

719 = recovery room other

720 = Labor room/delivery general classification

721 = Labor room/delivery labor

722 = Labor room/delivery delivery

723 = Labor room/ delivery circumcision

724 = Labor room/delivery birthing center

729 = Labor room/delivery other

730 = EKG/ECG general classification

731 = EKG/ECG holter monitor

732 = EKG/ECG telemetry

739 = EKG/ECG other

740 = EEG general classification

749 = EEG other

750 = Gastro-intestinal services general classification

759 = Gastro-intestinal services other

760 = Treatment or observation room general classification

761 = Treatment or observation room treatment

762 = Treatment or observation room observation

769 = Treatment or observation other

770 = Preventative care services general classification

771 = Preventative care services vaccine administration

779 = Preventative care services other

780 = Telemedicine general classification

789 = Telemedicine other

790 = Lithotripsy general classification

799 = Lithotriptsy other

800 = Inpatient renal dialysis general classification

801 = Inpatient renal dialysis hemodialysis

802 = Inpatient renal dialysis peritoneal (non-CAPD)

803 = Inpatient renal dialysis continuous ambulatory peritoneal (CAPD)

804 = Inpatient renal dialysis continuous cycling peritoneal (CCPD)

809 = Inpatient renal dialysis other

810 = Organ acquisition general classification

811 = Organ acquisition living donor

812 = Organ acquisition cadaver donor

813 = Organ acquisition unknown donor

814 = Organ acquisition unsuccessful organ search donor bank chg

819 = Organ acquisition other

820 = Hemodialysis general classification

821 = Hemodialysis composite or other rate

Revenue billed code

Revenue paid code (Continued)

822 = Hemodialysis home supplies

823 = Hemodialysis home equipment

824 = Hemodialysis maintenance 100%

825 = Hemodialysis support services

829 = Hemodialysis other

830 = Peritoneal dialysis general classification

831 = Peritoneal composite or other rate

832 = Peritoneal home supplies

833 = Peritoneal home equipment

834 = Peritoneal maintenance 100%

835 = Peritoneal support services

839 = Peritoneal other

840 = CAPD outpatient general classification

841 = CAPD composite or other rate

842 = CAPD home supplies

843 = CAPD home equipment

844 = CAPD maintenance 100%

845 = CAPD support services

849 = CAPD other

850 = CCPD Outpatient general classification

851 = CCPD composite or other rate

852 = CCPD home supplies

853 = CCPD home equipment

854 = CCPD maintenance 100%

855 = CCPD support services

859 = CCPD other

860 – 869 = Reserved for dialysis (national assignment)

870 – 879 = Reserved for dialysis (state assignment)

890 – 899 = Reserved for national assignment

900 = Psychiatric/psychological treatments general classification

901 = Psychiatric/psychological treatments electroshock treatment

902 = Psychiatric/psychological treatments milieu therapy

903 = Psychiatric/psychological treatments play therapy

904 = Psychiatric/psychological treatments activity therapy

909 = Psychiatric/psychological treatments other

910 = Psychiatric/psychological services general classification

911 = Psychiatric/psychological services rehabilitation

912 = Psychiatric/psychological svc partial hospitalization < intensive

913 = Psychiatric/psychological svc partial hospitalization intensive

914 = Psychiatric/psychological services individual therapy

915 = Psychiatric/psychological services group therapy

916 = Psychiatric/psychological services family therapy

917 = Psychiatric/psychological services bio feedback

Revenue billed code

Revenue paid code (Continued)

918 = Psychiatric/psychological services testing

919 = Psychiatric/psychological other

920 = Other diagnostic services general classification

921 = Other diagnostic services peripheral vascular lab

922 = Other diagnostic services electromyelogram

923 = Other diagnostic services pap smear

924 = Other diagnostic services allergy test

925 = Other diagnostic services pregnancy test

929 = Other diagnostic services other

930 – 939 = Not assigned

940 = Other therapeutic services general classification

941 = Other therapeutic services recreational therapy

942 = Other therapeutic services education/training

943 = Other therapeutic services cardiac rehabilitation

944 = Other therapeutic services drug rehabilitation

945 = Other therapeutic services alcohol rehabilitation

946 = Other therapeutic services complex medical equipment routine

947 = Other therapeutic services complex medical equipment ancillary

949 = Other therapeutic services

950 – 959 = Not assigned

960 = Professional fees general classification

961 = Professional fees psychiatric

962 = Professional fees ophthalmology

963 = Professional fees anesthesiologist (MD)

964 = Professional fees anesthetist (CRNA)

969 = Professional fees other

971 = Professional fees laboratory

972 = Professional fees radiology diagnostic

973 = Professional fees radiology therapeutic

974 = Professional fees radiology nuclear medicine

975 = Professional fees operating room

976 = Professional fees respiratory therapy

977 = Professional fees physical therapy

978 = Professional fees occupational therapy

979 = Professional fees speech pathology

981 = Professional fees emergency room

982 = Professional fees outpatient services

983 = Professional fees clinic

984 = Professional fees medical social services

985 = Professional fees EKG

986 = Professional fees EEG

987 = Professional fees hospital visit

988 = Professional fees consultation

Revenue billed code

Revenue paid code (Continued)

989 = Professional fees private duty nurse

990 = Patient convenience items general classification

991 = Patient convenience items cafeteria/guest tray

992 = Patient convenience items private linen service

993 = Patient convenience items telephone/telegram

994 = Patient convenience items TV/radio

995 = Patient convenience items non-patient room rentals

996 = Patient convenience items late discharge fee

997 = Patient convenience items admission kits

998 = Patient convenience items beauty shop/barber

999 = Patient convenience items other

Claim adjustment group codes

Source: IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 41, 20029.

Available at:

Source: Washington Publishing Company

Available at:

CO The amount adjusted due to a contractual obligation between the provider and the payer. It is not the patient’s responsibility under any circumstances.

MA The amount adjusted is due to state regulated fee schedules.

Note: MA is the code value assigned by ANSI for Medicare, this code is not being used by Medicare.

OA The amount adjusted is due to bundling or unbundling of services.

PI These are adjustments initiated by the payer, for such reasons as billing errors or services that are considered not “reasonable or necessary”. The amount adjusted is generally not the patient’s responsibility, unless the workers’ compensation state law allows the patient to be billed.

PR The amount adjusted is the patient’s responsibility. This will be used for denials, due to workers’ compensation coverage issues.

Claim adjustment reason codes

Source: IAIABC EDI Implementation Guide for Medical Bill Payment

Records, Release 1.1, July 41, 20029.

Available at:

Source: Washington Publishing Company

Available at:

California state medical license numbers

Source: CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS

Available at: CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS (DCA)

400 R Street

Sacramento, CA



Abstract: The California DCA licenses medical providers including: Acupuncture, Behavioral Sciences, Chiropractic, Dental, Medical, Occupational Therapy, Optometry, Osteopathic, Pharmacy, Physical Therapy, Podiatry, Psychiatric Technicians, Psychology, Registered Nursing, Respiratory Care, Speech-Language Pathology and Audiology, Vocational Nursing, Hearing Aid Dispensers, Dental Auxiliaries, Physician Assistant, Registered Dispensing, and Opticians

National plan and provider enumeration system

Source: Centers for Medicare and Medicaid Services

Available at: NPI Enumerator

P.O. Box 6059

Fargo, ND 58108-6059

1-800-465-3203



Abstract: The National Medical Provider Enumeration System contains the National Provider Identification Number and Taxonomy Code for Medical Providers.

Section O: California-adopted IAIABC data elements

Numerically-sorted list of California-adopted IAIABC data elements

A numerically-sorted list of California-adopted IAIABC data elements is located in the table below. Alphabetically-sorted lists are located in the data elements by source table (Section K), in the data element requirement table (Section K) and in the data edit table (Section L). Hierarchically-sorted lists are located in the loop, segment and data element summary for the ANSI 837 and the 824 (Section H).

|DN |Data Element Name |

|5 |JURISDICTION CLAIM NUMBER |

|6 |INSURER FEIN |

|7 |INSURER NAME |

|15 |CLAIM ADMINISTRATOR CLAIM NUMBER |

|31 |DATE OF INJURY |

|42 |EMPLOYEE SOCIAL SECURITY NUMBER |

|43 |EMPLOYEE LAST NAME |

|44 |EMPLOYEE FIRST NAME |

|45 |EMPLOYEE MIDDLE NAME/INITIAL |

|98 |SENDER ID |

|99 |RECEIVER ID |

|100 |DATE TRANSMISSION SENT |

|101 |TIME TRANSMISSION SENT |

|102 |ORIGINAL TRANSMISSION DATE |

|103 |ORIGINAL TRANSMISSION TIME |

|104 |TEST/PRODUCTION INDICATOR |

|105 |INTERCHANGE VERSION ID |

|108 |DATE PROCESSED |

|109 |TIME PROCESSED |

|110 |ACKNOWLEDGMENT TRANSACTION SET ID |

|111 |APPLICATION ACKNOWLEDGMENT CODE |

|115 |ELEMENT NUMBER |

|116 |ELEMENT ERROR NUMBER |

|152 |EMPLOYEE EMPLOYMENT VISA |

|153 |EMPLOYEE GREEN CARD |

|156 |EMPLOYEE PASSPORT NUMBER |

|187 |CLAIM ADMINISTRATOR FEIN |

|188 |CLAIM ADMINISTRATOR NAME |

|208 |MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER |

|209 |MANAGED CARE ORGANIZATION NAME |

|266 |TRANSACTION TRACKING NUMBER |

|500 |UNIQUE BILL ID NUMBER |

|DN |Data Element Name |

|501 |TOTAL CHARGE PER BILL |

|502 |BILLING TYPE CODE |

|503 |BILLING FORMAT CODE |

|504 |FACILITY CODE |

|507 |PROVIDER AGREEMENT CODE |

|508 |BILL SUBMISSION REASON CODE |

|509 |SERVICE BILL DATE(S) RANGE |

|510 |DATE OF BILL |

|511 |DATE INSURER RECEIVED BILL |

|512 |DATE INSURER PAID BILL |

|513 |ADMISSION DATE |

|514 |DISCHARGE DATE |

|515 |CONTRACT TYPE CODE |

|516 |TOTAL AMOUNT PAID PER BILL |

|518 |DRG CODE |

|521 |PRINCIPAL DIAGNOSIS CODE |

|522 |ICD-9 CM DIAGNOSIS CODE |

|523 |BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER |

|524 |PROCEDURE DATE |

|525 |ICD-9 CM PRINCIPAL PROCEDURE CODE |

|526 |RELEASE OF INFORMATION CODE |

|527 |PRESCRIPTION BILL DATE |

|528 |BILLING PROVIDER LAST/GROUP NAME |

|532 |BATCH CONTROL NUMBER |

|535 |ADMITTING DIAGNOSIS CODE |

|537 |BILLING PROVIDER PRIMARY SPECIALTY CODE |

|542 |BILLING PROVIDER POSTAL CODE |

|543 |BILL ADJUSTMENT GROUP CODE |

|544 |BILL ADJUSTMENT REASON CODE |

|545 |BILL ADJUSTMENT AMOUNT |

|546 |BILL ADJUSTMENT UNITS |

|547 |LINE NUMBER |

|550 |PRINCIPAL PROCEDURE DATE |

|552 |TOTAL CHARGE PER LINE |

|553 |DAYS/UNITS CODE |

|554 |DAYS/UNITS BILLED |

|555 |PLACE OF SERVICE BILL CODE |

|557 |DIAGNOSIS POINTER |

|559 |REVENUE BILLED CODE |

|561 |PRESCRIPTION LINE NUMBER |

|562 |DISPENSE AS WRITTEN CODE |

|563 |DRUG NAME |

|564 |BASIS OF COST DETERMINATION CODE |

|DN |Data Element Name |

|565 |TOTAL CHARGE PER LINE – RENTAL |

|566 |TOTAL CHARGE PER LINE – PURCHASE |

|567 |DME BILLING FREQUENCY CODE |

|570 |DRUGS/SUPPLIES QUANTITY DISPENSED |

|571 |DRUGS/SUPPLIES NUMBER OF DAYS |

|572 |DRUGS/SUPPLIES BILLED AMOUNT |

|574 |TOTAL AMOUNT PAID PER LINE |

|576 |REVENUE PAID CODE |

|579 |DRUGS/SUPPLIES DISPENSING FEE |

|586 |RENDERING LINE PROVIDER FEIN |

|589 |RENDERING LINE PROVIDER LAST/GROUP NAME |

|592 |RENDERING LINE PROVIDER NATIONAL PROVIDER ID |

|593 |RENDERING LINE PROVIDER POSTAL CODE |

|595 |RENDERING LINE PROVIDER PRIMARY SPECIALTY CODE |

|599 |RENDERING LINE PROVIDER STATE LICENSE NUMBER |

|600 |PLACE OF SERVICE LINE CODE |

|604 |PRESCRIPTION LINE DATE |

|605 |SERVICE LINE DATE(S) RANGE |

|615 |REPORTING PERIOD |

|626 |HCPCS PRINCIPAL PROCEDURE BILLED CODE |

|629 |BILLING PROVIDER FEIN |

|630 |BILLING PROVIDER STATE LICENSE NUMBER |

|634 |BILLING PROVIDER NATIONAL PROVIDER ID |

|638 |RENDERING BILL PROVIDER LAST/GROUP NAME |

|642 |RENDERING BILL PROVIDER FEIN |

|643 |RENDERING BILL PROVIDER STATE LICENSE NUMBER |

|647 |RENDERING BILL PROVIDER NATIONAL PROVIDER ID |

|649 |RENDERING BILL PROVIDER SPECIALTY LICENSE NUMBER |

|651 |RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE |

|656 |RENDERING BILL PROVIDER POSTAL CODE |

|667 |SUPERVISING PROVIDER NATIONAL PROVIDER ID |

|678 |FACILITY NAME |

|679 |FACILITY FEIN |

|680 |FACILITY STATE LICENSE NUMBER |

|681 |FACILITY MEDICARE NUMBER |

|682 |FACILITY PROVIDER NATIONAL PROVIDER ID |

|688 |FACILITY POSTAL CODE |

|699 |REFERRING PROVIDER NATIONAL PROVIDER ID |

|704 |MANAGED CARE ORGANIZATION FEIN |

|712 |MANAGED CARE ORGANIZATION POSTAL CODE |

|714 |HCPCS LINE PROCEDURE BILLED CODE |

|715 |JURISDICTION PROCEDURE BILLED CODE |

|717 |HCPCS MODIFIER BILLED CODE |

|DN |Data Element Name |

|718 |JURISDICTION MODIFIER BILLED CODE |

|721 |NDC BILLED CODE |

|726 |HCPCS LINE PROCEDURE PAID CODE |

|727 |HCPCS MODIFIER PAID CODE |

|728 |NDC PAID CODE |

|729 |JURISDICTION PROCEDURE PAID CODE |

|730 |JURISDICTION MODIFIER PAID CODE |

|731 |SERVICE ADJUSTMENT GROUP CODE |

|732 |SERVICE ADJUSTMENT REASON CODE |

|733 |SERVICE ADJUSTMENT AMOUNT |

|736 |ICD-9 CM PROCEDURE CODE |

|737 |HCPCS BILL PROCEDURE CODE |

Section P: Lump sum bundled lien bill payment

California law allows the filing of a lien against any sum to be paid as compensation for the “reasonable expense incurred by or on behalf of the injured employee” for medical treatment (see Labor Code section 4903(b)). The DWC\WCIS has adopted IAIABC medical lien codes as the standard for reporting bundled lump sum medical bills (See 8 C.C.R. § 9702(e)). The six codes below, describe the type of lump sum settlement payment made by the claims payer after the filing of a lien with the Workers’ Compensation Appeals Board (WCAB). Reportable lump sum medical liens originate from medical bills filed on DWC WCAB Form 6. (The medical lien form is located at .)

|Code |Description |

|MDS10 |Lump sum settlement for multiple bills where the amount of reimbursement is in dispute between the claims payer and the |

| |healthcare provider. |

|MDO10 |Final order or award of the Workers’ Compensation Appeals Board requires a lump sum payment for multiple bills where the |

| |amount of reimbursement is in dispute between the claims payer and the healthcare provider |

|MDS11 |Lump sum settlement for multiple bills where liability for a claim was denied but finally accepted by the claims payer |

|MDO11 |Final order or award of the Workers’ Compensation Appeals Board requires a lump sum payment for multiple bills where claims |

| |payer is found to be liable for a claim which it had denied liability. |

|MDS21 |Lump sum settlement for a single medical bill where the amount of reimbursement is in dispute between the claims payer and |

| |the healthcare provider. |

|MDO21 |Final order or award of the Workers’ Compensation Appeals Board requires a lump sum payment for a single medical bill where |

| |the amount of reimbursement is in dispute between the claims payer and the healthcare provider |

Medical bill reporting process bundled lump sum medical bills

1. Sender transmits all original disputed medical bill(s), including all lines, utilizing a BSRC "00".

2. The DWC sends a 997 "A" and a “TA” 824 acknowledgement to sender.

3. Sender changes the value of data elements (Lien Settlement amount) on the original bill(s) submitted in step 1.

4. Sender transmits the updated bill (Lien Settlement), with all individual lines on all bills bundled as one lump sum payment, as a BSRC "00".

5. DWC sends a 997 "A" and a “TA” 824 acknowledgement to sender.

Medical lump sum data requirements

Lump sum bundled bill medical lien payments are reported utilizing Bill Submission reason Code 00 (original). Individual Lump sum medical lien payments are required to utilize one of three possible IAIABC 837 file structures in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1 July 1, 2009 (). If the bundled medical bills are being reported as a professional or a pharmaceutical lump sum payment then the SV1 segment is utilized to report the appropriate IAIABC medical lien code (Scenario 10) as a jurisdictional procedure code. If the bundled medical bill(s) are being reported as an institutional lump sum payment then the SV2 segment is utilized to report the appropriate IAIABC medical lien code (Scenario 11) as a jurisdictional procedure code. If the bill(s) being reported are mixture of professional, pharmaceutical, or institutional lump sum payments then the SVD segment is utilized to report the appropriate IAIABC medical lien code (Scenario 12) as a jurisdictional procedure code.

Appendix A: Major changes in the medical implementation guide

List of changes from version 1.0 to version 1.1 by section

Section A: Deleted Components of the WCIS. Changed the four-step testing procedure to a five-step testing procedure.

Section B: Minor grammatical corrections; EDI Service Provider information in Section B was expanded to include information from the deleted Section J. The listing of EDI Service Providers is now available online. Delete User Groups.

Section C: Updated references to new Sections (J,K,L,M,N,O,P) and to listing of EDI Service Providers, which is now provided online. Removed references to VAN transmission option. Removed references to the optional matching of medical data on paper bills to electronic reports.

Section D: No Change

Section E: No Change

Section F: Updated the Trading Partner Profile to use a WCIS-hosted FTP as the sole transmission mode. Updated WCIS zip code to 94612-1491.

Section G: Changed the four-step testing procedure to the five-step testing procedure. Minor updates and corrections. Removed references to VAN transmission option. Removed references to parallel pilot procedure and the WCIS paper pilot identification form.

Section H: Added two national provider loops and segments to 837 file structure. Added five new national provider identification data elements.

Section I: FTP transmission mode updated. Removed references to VAN transmission option.

Section J: Deleted. Information on EDI service providers is available online so it can be updated more easily.

Section K: Renamed Section J.

Section L: Renamed Section K. Added five new national provider identification data elements. Updated the element requirement table and sorted it alphabetically by data element name.

Section M: Renamed Section L Changed the medical provider entity requirements. Added five new national provider identification data elements. Deleted the California-specific edits.

Section N: Renamed Section M. Update procedure for matching medical bills to FROI claims. Minor grammatical corrections.

Section O: Deleted the IAIABC information, which is available online.

Section P: Renamed Section N. Deleted IAIABC code lists. Added web links for code lists and made corrections. Added a reference to the Washington Publishing Company. Added a reference to the National Plan and Provider Enumeration System.

Section Q: Deleted the Medical EDI glossary and acronyms

Section R: Deleted the Standard Medical Forms.

Added new Section O: California-adopted IAIABC data elements

Added new Section P: Lump sum bundled lien bill payment

Added Appendix A: Major changes in the California medical implementation guide.

Section Q

MEDICAL EDI GLOSSARY AND ACRONYMS

Medical bill payment records glossary......................................................................... 118

Medical bill payment records common acronyms........................................................ 122

Medical bill payment records glossary

ACQUIRED FILE

Definition: A claim previously administered by a different claim administer

Revision Date: 06/07/95

ACKNOWLEDGMENT RECORD (AK1)

Definition: A transaction returned as a result of an original report. It contains enough data elements to identify the original transaction and any technical and business issues found with it.

Revision Date: 09/25/96

AMERICAN NATIONAL STANDARDS INSTITUTE (ANSI)

Definition: A private nonprofit membership organization that acts as administrator and coordinator for the United States private sector voluntary standardization system. Further information can be obtained at .

Revision Date: 04/28/99

ANSI ASC X12

Definition: American National Standards Institute, Accredited Standards Committee for Electronic Data Interchange. They are standards development organization. The ANSI X12 organization includes subgroups that specialize in distinct sector of the economy, or support the EDI development process.

Revision Date: 04/28/99

BATCH

Definition: A set of records containing one header record, one or more detailed transaction records, and one trailer record.

Revision Date: 09/25/96, 07/01/97

BILL

Definition: The actual medical bill that a health care provider submits to the carrier that provides medical information pertaining to the work related injury. This medical bill is matched to a workers’ compensation claim.

Revision Date: 04/28/99

CARRIER

Definition: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer.

Revision Date: 05/26/92

CLAIM ADMINISTRATOR

Definition: Insurance Carrier, Third Party Administrator, State Fund, Self-Insured.

Revision Date: 07/01/97

CLAIMANT

Definition: The claimant is the same as the employee and is the person who received the health care. If the claimant is person who has elected coverage, then the claimant will also be the employer.

Revision Date: 04/28/99

CONTRACT MEDICAL

Definition: Contract medical care costs are the actual costs incurred by the carrier under medical contracts with physicians, hospitals, and others, which cannot be allocated for a particular claim.

Revision Date: 08/09/95

DATA ELEMENT

Definition: A single piece of information (e.g. Date of Birth)

Revision Date: 07/01/97

EDIT MATRIX

Definition: Identifies edits to be applied to each data element. Senders will apply them before submitting a transaction and receivers will confirm during processing.

Revision Date: 09/25/96

ELEMENT REQUIREMENT TABLE

Definition: A receiver specific list of requirement codes for each data element depending on the Bill Submission Reason Code.

Revision Date: 09/25/96

EMPLOYEE

Definition: A person receiving remuneration for their services.

Revision Date: 07/01/97

EMPLOYER

Definition: POC: any entity (e.g. DBA, AKA etc) of the insured. Multiple entities can exist for an insured.

Revision Date: 07/01/97

EVENT TABLE

Definition: Table designed to provide information integral for a sender to understand the receiver’s EDI reporting requirements. It relates EDI information to events and under what circumstances they are initiated.

FEIN

Definition: Identifies the Federal Employers Identification Number, Corporations/Business US Federal Tax ID, Individuals US Social Security number.

Revision Date: 07/01/97

FORMATS

Definition: The technical method used to exchange information (e.g. IAIABC Flat and Hard Copy, WC Pols, ANSI X12. The business requirements remain constant. The technology is different.

Revision Date: 07/01/97

HCPCS

Definition: Acronym for the Health Care Financing Administration (HCFA) Common Procedure Coding System. This coding list had three levels. Level I is the Physicians’ Current Procedural Terminology (CPT) codes that are developed and are maintained by the American Medical Association (AMA). These codes are five numeric digits. Level II codes contain other codes that are needed in order to report all other medical services and supplies, which are not included within CPT code list. These codes begin with a single alpha character followed by four numeric digits. Level III contain codes that are developed and maintained by state Medicare carriers. These codes begin with W through Z followed by four numeric digits.

Revision Date: 04/28/99

HCPCS MODIFIERS

Definition: Health care providers to identify circumstances that alter or enhance the description of the medical service rendered use Modifiers. If the modifier is used with the CPT codes (Level I), the modifier will be two numeric digits (i.e. 22 Unusual Procedural Services).

If the modifier is used with the Level II codes, the modifier will be a two alphabetic digits or one alphabetic digit followed by one numeric digit.

Revision Date: 04/28/99

HEADER RECORD (HD1)

Definition: The record that precedes each batch. This and the trailer record are an “envelop” that surround a batch of transactions.

Purpose: To uniquely identify a sender, as well as the date/time a batch is prepared and the transaction set contained within the batch.

Note: See ANSI implementation guide for specifics on transmission process.

Revision Date: 09/25/96, 07/01/97

IAIABC

Definition: International Association of Industrial Accident Boards and Commissions, which is a group comprised of jurisdictions, insurance carriers and vendors who are involved in workers’ compensation. Further information may be obtained from .

Revision Date: 04/28/99

ICD-9 CM

Definition: The International Classification of Diseases, Ninth Revision, Clinical Modification. This is a classification that group related disease entities and procedures for the reporting of statistical information. The clinical modification of the ICD-9 CM was developed by the National Center for Health Statistics for use in the United States. Further information may be obtained at .

Revision Date: 04/28/99

IMPLEMENTATION DATE, “FROM”

Definition: The effective begin date of the production level indicator for a trading partner.

Revision Date: 09/25/96

IMPLEMENTATION DATE, “THRU”

Definition: The effective end date of the production level indicator for a trading partner.

Revision Date: 09/25/96

IMPLEMENTATION GUIDE

Definition: User-friendly specifications issued by an industry organization such as the IAIABC. Sets the objectives and parameters of Trading Partner Agreements. May also be exchanged between partners for their unique requirements.

Revision Date: 07/01/97

JURISDICTION

Definition: A governmental entity which exercises control over the workers’ compensation system by enacting and enforcing laws and regulations. A Jurisdiction is usually referred to by its political boundary, such as the State of Idaho, Commonwealth of Massachusetts, or District of Columbia.

Revision Date: 07/01/97

MEDICAL BILL/PAYMENT REPORT

Definition: The IAIABC’s adaptation of the ANSI 837 Transaction Set for use in the workers’ compensation environment and includes the IAIABC’s flat file layout. The Medical Bill/Payment Report is used to submit health care information, charges, and reimbursements to a jurisdiction from a payer.

Revision Date: 04/28/99

PILOT/PARALLEL

Definition: Dual reporting during test phase (current processing/IAIABC EDI standards). Production data (real claims) are loaded into test system. IAIABC data does not satisfy the receivers’ reporting requirements. This is a temporary testing phase as defined by the trading partners with production as the final goal.

Revision Date: 09/25/96, 07/01/97

PRODUCTION

Definition: A trading partner is sending production data (real claims). The data is loaded into the jurisdiction production system. No dual reporting (paper/EDI) to receiving party from sending party. IAIABC data satisfies the receiver’s reporting requirements.

Revision Date: 09/25/96

PROVIDER

Definition: In a generic sense, the Provider is the entity that originally submitted the bill or encounter information to the Payer. Specific loops are used for the various types of providers. For example, there are separate loops used for Billing Provider, Rendering Provider, Supervising Provider, Facility Provider, etc.

Revision Date: 04/28/99

QUEUE

Definition: A log of claim events due for transmission. There are several ways to implement this log. For example, it can be an indicator on the main claims administration application which would alter “be read” to “compose a transmission batch”, or it can be a separate file with all the necessary information created at the time an event occurs.

Revision Date: 07/01/97

RECORD

Definition: A group of related data elements. One or more records will form a transaction. The Record Type Qualifier identifies a record.

Revision Date: 07/01/97

REPORT

Definition: It is equivalent to a transaction. Refer to diagram under Transmission definition.

Revision Date: 07/01/97

REPORT DUE CRITERIA

Definition: The criteria that determines the latest date that a report must be completed and submitted for a specific trigger to be considered timely. Used in Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT DUE VALUE

Definition: A value that is used to modify or define a Report Due Criteria. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT LIMIT NUMBER

Definition: When present, this value reflects the maximum number of periodic reports required. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT REQUIREMENT CRITERIA

Definition: Criteria used in conjunction with Report Requirement Effective Date (From and Thru), to determine whether the corresponding event requirements are applicable for a particular claim. An example of Report Requirement Criteria is “Date of Injury” where different events may apply depending on its value; this where the From and Thru dates come into play. They identify the specific event, which applies to a claim. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT REQUIREMENT EFFECTIVE DATE, “FROM”

Definition: The first date that a claim meeting the Report Requirement Criteria will be reported for a specific report trigger. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT REQUIREMENT EFFECTIVE DATE, “THRU”

Definition: The last date that a claim meeting the Report Requirement Criteria will be reported for a specific report trigger. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT TRIGGER CRITERIA

Definition: Criteria used in conjunction with Report Trigger Value to determine if an event must be triggered for a claim covered according to the Report Requirement Criteria, and Report Requirement Effective Dates. If multiple conditions can independently trigger an event, then each condition must be listed separately. An example of Report Requirement Criteria is “Indemnity Benefits Paid” and when associated with the corresponding Report Trigger Value will whether a report must be triggered for a particular claim. Used in the Event Table.

Revision Date: 09/25/96, 07/01/97

REPORT TRIGGER VALUE

Definition: Used in conjunction with Report Trigger Criteria in Event Table. It determines whether a report must be triggered.

Revision Date: 09/25/96, 07/01/97

REQUIREMENT CODE

Definition: Defines the level of reporting required by the receiver

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 is normally optional, but becomes mandatory under conditions established by the receiver, e.g. If the Benefit Type Code indicates death benefits, then the Date of Death becomes mandatory. The receiver must provide senders with a document describing the specific circumstances, which cause a conditional element to become mandatory.

O = Optional. The data element may not be sent. If it is sent, are applied to it, but unsuccessful edits do not reject the transaction.

Revision Date: 07/01/97

SELF-INSURED

Definition: A jurisdictional approved or acknowledged employer, group fund, or association assuming financial risk and responsibility for their employee’s workers’ compensation claims.

Revision Date: 07/01/97

SUBSCRIBER

Definition: In the ANSI 837 Transaction Set, this would be the owner of the health insurance policy. Generally, in workers’ compensation, the claimant’s employer at the time of the injury is the subscriber. This is a good illustration of adapting the ANSI 837 Transaction Set to the workers’ compensation business need.

Revision Date: 04/28/99

THIRD PARTY ADMINISTRATOR

Definition: A business entity providing claim services on behalf of the insurer or self-insured.

Revision Date: 07/01/97

TRAILER RECORD (TR1)

Definition: A record that designates the end of a batch of transactions. It provides a count of records/transactions contained within a batch.

Revision Date: 09/25/96

TRANSACTION

Definition: Consists of one or more records. It is intended to communicate a bill event.

Revision Date: 07/01/97

TRANSMISSION

Definition: Consists of one or more batches sent or received during a communication session. See diagram on the following page.

Revision Date: 07/01/97

Medical bill payment records common acronyms

EDI Electronic Data Interface

WCIS Workers Compensation Information System

DWC Division of Workers Compensation

FROI First Report of Injury

SROI Subsequent Reports of Injury

VAN Value Added Network

FTP File Transfer Protocol

ANSI American National Standards Institute

IAIABC International Association of Industrial Accident Boards and Commissions

IS Information Systems

FEIN Federal Employers Identification Number

TP Trading Partner

BSRC Bill Submission Reason

Section R: Standard Medical Forms

Standardized billing / electronic billing 124

Form HCFA-1500 or form CMS-1500 125

CMS form 1450 or UB92 126

American Dental Association 127

NCPDP universal claim form 128

Standardized billing / electronic billing

Standardized Electronic Billing implies an “Electronic Standard Format". The adopted California standard electronic format is the ASCX12N standard format developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute (See Section G – Test Pilot and Production Phases of Medical EDI and Section- H – Supported Transactions and ANSI File Structure).

Standard Paper Forms are defined as:

Form HCFA-1500 or form CMS-1500 means the health insurance claim form maintained by Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services (CMS) for use by heath care providers.

CMS form 1450 or UB92 means the health insurance claim form maintained by CMS for use by heath facilities and institutional care providers.

American Dental Association, 1999 Version 2000 means the uniform dental claim form approved by the American Dental Association for use by dentists.

NCPDP universal claim form means the National Council for Prescription Drug Programs (NCPDP) claim form or its electronic counterpart.

Form HCFA-1500 or CMS-1500

[pic]

CMS form 1450 or UB92

[pic]

NCDPD Universal Claim Form

Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc. 1988, 1992, 2005 NCPDP. The Universal Claim Form is a copyrighted document. It cannot be copied. The Universal Claim Form may be purchased from Moore North America, Inc. Contact is Jeremy Wynn. Phone (602) 220-4908. Email Jeremy.Wynn@

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State of California

Department of Industrial Relations

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DWC Use Only – Special Transmission Specifications For This Profile:

837

Structural

Transmission

DWC/

WCIS

997 Acknowledgment

Trading Partner

Trading Partner

824 Acknowledgment

DWC/

WCIS

837 - Detailed

Transmission

With Real Medical Bill Payment Data

American Dental Association

WCIS

FTP

Server

Claim Administrator Claims Systems

WCIS

Data Base Server

Claim Administrator Claims Systems

Van

Service Provider

WCIS

FTP

Server

WCIS

VAN

Server

WCIS

Data Base Server

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