California division of workers compensation medical data training
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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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CALIFORNIA DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING

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California division of workers compensation medical data training

CALIFORNIA DIVISION OF WORKERS’ COMPENSATIONMEDICAL DATA TRAINING

WCIS Medical Data Collection


California division of workers compensation medical data training

Workers’ Compensation Information System

WCIS

Division of Workers’ Compensation


California 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 l required medical data elements page 69

Section LRequired medical data elementsPage 69


California division of workers compensation medical data training

Step 1 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~

H

DTP*558*D8*19920101~

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

REF*Y1*528779999~

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

DTP*050*D8*19970115~

DTP*666*D8*19970115~

REF*DD*13579~

REF*2I*TJ98UU321~

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

PRV*PE*S3*203BP0400Y~

N4***751230064~

REF*OB*PSY00001574~

LX*1~


California division of workers compensation medical data training

Step 2 Hierarchical Segments (BSRC = 00)

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

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

N4***751230064~

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

N4***751230064~

HL*1**20*1~

DTP*582*RD8*19970201-19970228~

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

HL*2*1*EM*1~

MN1*36*2~

HL*3*2*CL~

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~


Step 3 continued conditional data elements segments bsrc 00

Step 3 (continued)Conditional Data Elements/Segments (BSRC = 00)

  • Professional 837 Office visit with drugs dispensed

  • Institutional 837 Hospital/Surgical Scenario

  • Other Bill Types

    • Pharmaceutical utilizing a Professional 837

    • Pharmaceutical utilizing a NCPDP

    • Durable Medical Equipment

    • Dental utilizing a Professional 837

  • Various Generic Bill Adjustment Scenarios

    • Capitated treatment

    • Previous Provider Over payment

    • Provider Refund


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