The division of workers compensation medical data training
This presentation is the property of its rightful owner.
Sponsored Links
1 / 32

THE DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING PowerPoint PPT Presentation


  • 89 Views
  • Uploaded on
  • Presentation posted in: General

THE DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING. WCIS Medical Data Collection. Workers’ Compensation Information System. WCIS . Division of Workers’ Compensation. www.dir.ca.gov. Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for

Download Presentation

THE DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


The division of workers compensation medical data training

THEDIVISION OF WORKERS’ COMPENSATIONMEDICAL DATA TRAINING

WCIS Medical Data Collection


The division of workers compensation medical data training

Workers’ Compensation Information System

WCIS

Division of Workers’ Compensation


The division of workers compensation medical data training

www.dir.ca.gov

Workers’ Compensation Information System (WCIS)

California EDI Implementation Guide

for

Medical Bill Payment Records

Version 1.0

December 2005


California implementation guide table of contents

California Implementation GuideTable of Contents

  • EDI service providers

  • Events that trigger required medical EDI reports

  • Required medical data elements

  • Data edits

  • System specifications

  • IAIABC information

  • Code lists and state license numbers

  • Medical EDI glossary and acronyms

  • Standard medical forms

Page 3


Section m data edits page 81

Section MData editsPage 81


Iaiabc detailed data edits

IAIABC Detailed Data Edits

Mandatory field not present

Must be numeric (0-9)

Must be a valid date (CCYYMMDD)

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

Must be a valid time (HHMMSS)

Must be <= date of injury

Must be >= date of injury

No match on database

All digits cannot be the same

Must be <= current date

Duplicate transmission/transaction

Code/ID invalid

Event table criteria not met

Invalid event sequence/relationship

Invalid data relationship

Must be>= date payer received bill

Must be >= from date of service

Must be <= thru service date

Pages 82-87


824 tr transaction rejected

824 TR = Transaction Rejected

Page 42


824 with an error

824 with an Error

ISA*00* *00**ZZ*943160882*ZZ*450483908 *051122*1202*U*00401*000000045*0*P*~

GS*01*943160882*450483908*20051122*1202*68*X*004010~

ST*824*0015~

BGN*11*MED01*20051122*1202~

N1*10**FI*943160882~

N4***946121413~

N1*40**FI*450483908~

N4***239640040~

OTI*TR*55*00001***20051109*1627***837~

DTM*009*20051121*153124~

LM*IB~

LQ*FZ*040~

RED~

.

.

RED~

SE*11*0015~

GE*1*68~

IEA*1*000000045~


California specific data edits

California Specific Data Edits

  • Must be numeric (error code = 028)

    • DWC specifies an more exact numerical value

      • Postal Codes

      • Units (days, minutes, number of pills etc)

      • Social security number

      • Lines numbers

  • Code/ID invalid (error code = 058)

    • DWC specifies exact IAIABC values in a lookup table

      • Bill Submission Reason Code (00 or 01 or 05)

      • Billing Format Code ( A or B)

      • Billing Type Code ( DM or MO or RX)

      • Diagnosis Pointer (1 or 2 or 3 or 4)

      • Service Adjustment Group Code ( CO or MA or OA or PI or PR)

Page 88


Section n system specifications page 69

Section NSystem SpecificationsPage 69


Bill submission sequencing

Bill Submission Sequencing

  • Bill submission reason codes (BSRC)

    • 00 Original

    • 01 Cancellation

    • 05 Replace

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

  • 01must be preceded by the initial (00) medical bill payment report.

  • 05must be preceded by the initial (00) medical bill payment report.

Page 90


Application acknowledgment codes

Application Acknowledgment Codes

  • 824 detailed acknowledgment

    • inform the Trading partner of the accepted or rejected status of each 837 transmission

    • TA

      • Transaction accepted

        • No Errors

    • TR

      • Transaction rejected

        • At least one error

    • TE

      • Transaction accepted with errors

        • No Claim Administrator Claim Number in the WCIS Database

Page 91


Dwc automated processes

DWC Automated Processes

  • Corrected data element

    • (BSRC=00)(ACC=TR)

  • Corrected medical bill

    • (BSRC=01)(ACC=TA)

  • Replacement of a claims administrator claim number

    • (BSRC=05)(ACC=TA)


Corrected data element process bsrc 00 acc tr

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

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

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

  • Sender corrects errors in the original bill.

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

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

Page 91


Corrected medical bill process bsrc 01 acc ta

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

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

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

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

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

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

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

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

Page 91


Replacement of a claims administrator claim number process bsrc 05 acc ta

Replacement of a claims administrator claim number process(BSRC=05)(ACC=TA)

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

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

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

  • 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.

Page 92


Duplicate transmissions transactions and medical bills

Duplicate transmissions, transactions, and medical bills

  • Transmission duplicates

    • ISA or GE functional groups contain the same key header information

  • Transaction duplicates

    • ST-SE transaction sets contain the same header information (DN532)

  • Bill duplicates

    • 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.

Page 92


The division of workers compensation medical data training

DWC 837 format

ISA-IEA (Interchange)

contains control information and identifies the sender and receiver.

GS-GE (Functional Group)

identifies the business purpose of

multi-functional transaction sets.

ST-SE (Transaction Set)

provides the business document contents.

Detailed

Segment

Detailed

Segment

Detailed

Segment

Page 93


Wcis matching rules

WCIS matching rules

Primary:

1.Jurisdiction claim number

Secondary match for medical bill payment reports to the FROI:

2a.Claim administrator claim numberInsurer 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 nameEmployee first name

Page 93


Unmatched transactions bsrc 00 acc te

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

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.

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

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

Page 93 - 94


Section o iaiabc information page 95

Section OIAIABCInformationPage 95


The division of workers compensation medical data training

IAIABC Information

  • Introduction

  • History of the IAIABC and EDI

  • What is EDI?

  • Standards

  • Software

  • Communications

Pages 95 - 99


Section p code lists and state license numbers page 99

Section PCode listsandState license numbersPage 99


Standard code sets

Standard Code Sets

  • Facility/Place of Service Codes (page 102)

    • IAIABC

  • Place of Service Bill/Line Codes (page 103)

    • IAIABC

  • Revenue Billed/Paid Codes (page 104)

    • IAIABC

  • Claim Adjustment Group Codes (page 116)

    • IAIABC

  • Claim Adjustment Reason Codes (11.25 -11.43)

    • IAIABC

  • California Medical License Numbers (page 116)

    • California Department of Consumer Affairs

  • California Medical Facility License Numbers

    • California Department of Health Services


Standard code sets1

Standard Code Sets

  • Zip Codes (page 100)

    • US Postal Service

  • HCPCS (page 100)

    • Centers for Medicare & Medicaid Services

  • ICD_9 (page 100)

    • Centers for Medicare & Medicaid Services

  • CPT (page 101)

    • American Medical Association

  • NDC (page 101)

    • First databank

  • DRG (101)

    • US Government printing Office

  • Medical Provider Codes (page 102)

    • Washington Publishing Company


California dwc code sets

California DWC Code Sets

  • Chapter 4.5

  • Division of Workers' Compensation

  • Subchapter 1

  • Administrative Director-Administrative Rules

  • Article 5.3__Official Medical Fee Schedule

    • §9789.10 through §9789.111

  • Article 5.5__Application of Official Medical Fee Schedule

    • §9790. through §9792.15

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

    • §9793. through §9795

  • Article 5.7__Fees for Interpreter Services

    • §9795.1 through §9795.4


California dwc code sets1

California DWC Code Sets

  • Official Medical Fee Schedule

    • Evaluation and Management99201 -- 99499

    • Anesthesiology00100 --01999

      99100 – 99140

    • Surgery10040 – 69979

    • Radiology70010 – 79999

    • Pathology and Laboratory80002 – 89399

    • Medicine90701 -- 99199

  • Official Hospital Fee Schedule

    • §9789.24

  • Pharmacy

    • §9789.40

  • Durable Medical Equipment

    • §9789.60


Dwc wcis medical code contact

DWC/WCIS Medical Code Contact

David HendersonWCIS Research UnitResearch Program Specialist II (Medical Data)Division of Workers' Compensation1515 Clay Street, 18th floorOakland, CA 94612 

Tel:   916-263-0942Fax: 916-263-0971 e-mail:[email protected]


The division of workers compensation medical data training

Form

HCFA-1500 or

CMS-1500


The division of workers compensation medical data training

Form

HCFA-1450 or

UB-92


The division of workers compensation medical data training

American Dental Association

Claim Form


The division of workers compensation medical data training

NCDPD Universal

Claim Form


  • Login