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CALIFORNIA 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

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slide2

Workers’ Compensation Information System

WCIS

Division of Workers’ Compensation

slide3

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

edi service providers
EDI service providers
  • Providers of consultation
  • Technical support
  • VAN service
  • Software products
  • Organizations providing data collection services
california event table
California Event Table
  • Bill Submission Reason Codes
  • OO is a Original 
    • Within 90 days of date paid
      • Daily, Weekly, Monthly, Quarterly 
  • O1 is a Cancellation (Reversal of an \'00\' transaction)
    • within 90 days of the original submission
      • Immediately
  • O5 is a Replacement 
    • Replacement of a claim administrator claim number previously submitted.  
      • immediately
data dictionaries www dir ca gov dwc wcis
Data Dictionarieswww.dir.ca.gov/dwc/WCIS
  • IAIABC EDI Implementation Guide for Medical Bill Payment Records
    • Section 9.1 Medical Bill Payment Records
    • Section 9.2 Medical Bill Payment Records System
  • California medical bill payment dictionary
    • Subset of the IAIABC Data Dictionaries
      • 125 Data Elements
    • Combination of System and Data Elements
      • 15 System Data Elements
      • 110 medical Data Elements
sources of medical data elements
Sources of Medical Data Elements
  • UB92/HCFA1450 /CMS 1500
  • CMS-1500 Form (formerly HCFA1500)
  • Insurers
  • Payers
  • Health Care Provider
  • Jurisdictional Licensing Boards
  • Senders
sources of data for 837
Sources of Data for 837

Payer/

Accounts

payable

Insurer

Dental Bills

Look-up

Tables

Legacy Files

Claims

Sender

837 Medical Bill Payment Records File

Pharmaceutical

Bills

Professional

Bills

UB92

Medical Bills

Jurisdiction Licensing Boards

DME Bills

slide14

California Manual

California EDI Implementation Guide

For

Medical Bill Payment Records

December, 2005

Section L

70 – 73

Source Table

medical data element requirement table
Medical data element requirement table

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 makes a conditional data element mandatory.

slide16

California Manual

California EDI Implementation Guide

For

Medical Bill Payment Records

December, 2005

Section L

74 – 80

Element Requirement Table

slide19

California Mandatory Segments (BSRC = 00)

BHT*0080*00*0123*19960618*0932~

NM1*10*2******FI*123456789~

N4***751230064~

NM1*40*2******FI*987654321~

N4***751230064~

DTP*582*RD8*19970201-19970228~

NM1*CA*2*PREMIEREINSURANCE COMPANY OF NORTH*****FI*111223333~

DTP*558*D8*19920101~

NM1*CC*1*DOE*SALLY*J***34*012345678~

REF*Y1*528779999~

CLM*A37YH556*500**MO*11:B*Y**********P***00~

DTP*050*D8*19970115~

DTP*666*D8*19970115~

REF*DD*13579~

REF*2I*TJ98UU321~

NM1*82*1*WELBY*MARCUS*C**SR*FI*123456789~

PRV*PE*S3*203BP0400Y~

N4***751230064~

REF*OB*PSY00001574~

LX*1~

slide21

California Mandatory Segments (BSRC = 01)

BHT*0080*00*0123*19960618*0932~

NM1*10*2******FI*123456789~

N4***751230064~

NM1*40*2******FI*987654321~

N4***751230064~

DTP*582*RD8*19970201-19970228~

NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~

REF*Y1*528779999~

CLM*A37YH556*500**MO*11:B*Y**********P***01~

REF*DD*13579~

slide23

California Mandatory Segments (BSRC = 05)

BHT*0080*00*0123*19960618*0932~

NM1*10*2******FI*123456789~

N4***751230064~

NM1*40*2******FI*987654321~

N4***751230064~

DTP*582*RD8*19970201-19970228~

NM1*CA*2*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~

REF*Y1*528779999~

REF*Y1*999988746~

CLM*A37YH556*500**MO*11:B*Y**********P***05~

slide24

Example of a

Scenario 1

Bill

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