WCIS

1. Workers’ Compensation Information System WCIS Division of Workers’ Compensation

2. California L.C. §138.6 Workers' Compensation Information System • The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions

3. WWW.IAIABC.ORG

4. California Code of Regulations Chapter 4.5 Division of Workers' Compensation Subchapter 1 Administrative Director-Administrative Rules Article 1.1 Workers’ Compensation Information System 9702. Electronic Data Reporting (a) Each claims administrator shall transmit data elements, by electronic data interchange in the manner set forth in the…. California EDI Implementation Guide for Medical Bill Payment Records

5. Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1.0 December 2005

6. L.C. §138.6 Goals for WCIS Medical Data • Assist the department to manage the workers' compensation system in an effective and efficient manner. • Facilitate the evaluation of the efficiency and effectiveness of the benefit delivery system. • Assist in measuring how adequately the system indemnifies injured workers and their dependents • Provide statistical data for research into specific aspects of the workers' compensation program.

7. WCIS Electronic Data Collection • First Reports of Injury – March, 2000 • Subsequent Reports of Injury – July, 2000 • Medical/Bill Payment Reports – March, 2006

8. Medical Data Collection Insurance Carriers Injured Worker Electronic Data Interface Electronic Data Interface DWC WCIS Medical Providers

9. Providers Payers Jurisdictions EligibilityVerification Pre-Authorizationand Referrals Service BillingClaim Submission Claims Status Inquiries AccountsReceivable (AR) Functions EnrollmentPre-Certification &Adjudication Claims Acceptanceand ReportingRequirements Claims Adjudication Accounts Payable Functions Maintain a Bona fide database of detailed medical bill payment records which corresponds to the FROI, SROI, UEF,DEU, and WCAB In California Function 270 (Eligibility Inquiry) 271 (Eligibility Information) 278 (Referral Authorization and Certification) 148 (First Report of Injury)* 837 Health Care Claim. 837 (Claims Submission) 997 Functional Acknowledgement. 275 (Claims Attachment)* 276 (Claim Status Inquiry) 277 (Claim Status Response) 824 Detailed Acknowledgement 835 (HealthCare Claim Payment Advice) The Nationally Accepted EDI Medical Data System E-Billing Regulations WCIS Regulations

10. What is EDI? • Electronic Data Interchange • Standardized electronic exchange of files/data between computers • Standard Set of Codes • Standard Set of Data Elements

11. Standard Electronic File FormatsAmerican National Standards Institute (ANSI) • ANSI – 837 Health Care Claim • ANSI – 997 Functional Acknowledgment • ANSI – 824 Detailed Acknowledgment

12. Standard Non-Medical Code Sets • Place of Service Bill/Line Codes • IAIABC • Revenue Billed/Paid Codes • IAIABC • Claim Adjustment Group Codes • IAIABC • Claim Adjustment Reason Codes • IAIABC • California Medical License Numbers • California Department of Consumer Affairs • California Medical Facility License Numbers • California Department of Health Services

13. Standard Medical Code Sets • HCPCS • Centers for Medicare & Medicaid Services • ICD_9 • Centers for Medicare & Medicaid Services • CPT • American Medical Association • NDC • First databank • DRG • US Government printing Office • Medical Provider Codes • American Medical Association

14. Standard Medical Data Elements Standard Paper Medical Bill Types • UB92/HCFA1450 • CMS-1500 Form (formerly HCFA1500) • American Dental Association • Universal Pharmacy Form

15. Other Medical Data Sources • Insurers • Payers • Jurisdictional Licensing Boards • Senders

16. Part II WHY EDI? • Opportunity to modernize the sector • Opportunity to lower per unit costs • Opportunity to lower total medical delivery costs

17. Become fitter, leaner, and ready to meet future challenges • The Challenge: • Over $5.3 billion in medical costs 2002 • Estimated 15% goes to administration • Lack of e-commerce • The Opportunity: • Retool tired processes • Chance to Reengineer processes

18. Lowering Per Unit Costs • Reduced Accounts Payable/Reporting Cycle • Improved Accuracy (5% data entry errors) • Lower Cost Transactions • Reduce/Eliminate paperwork • Reduce Operational Costs (office supplies, postal costs, and telephone charges)

19. Workgroup for Electronic Data Interchange (WEDI)

20. Part III Nuts & Bolts • Understanding the Transactions Cycle • Trading Partner Agreement • Adopted ANSI Structure • Technical Assistance

21. Transaction Cycle

22. Trading Partner Agreements Define exactly how to exchange transactions • Communication methods • Submitter/Receiver IDs • Delimiters • Frequency • Turnaround Expectations • Transactions to be exchanged

23. 837 Health Care Claim Transmission Claim Professional Claims Professional Claims Facility A series of envelopes Dr Smith Dr Smith Provider Patient Patient Patient Claim Claim Claim Bill Line 1 Line 2 Line 3 Procedure or a product Line 1 Line 2 Line 3 Line 1 Line 2 Line 3

24. ISA*00* *00* **ZZ*003000 *ZZ*WHY INC *020524*1718*U*00401*000000001*0*T:~ GS*HC*0003000*WHY INC*20030114*1615*1*X*004010X098~ ST*837*0001~ BHT*0019*00*0001*2003014*1645*CH~ REF*87*004010X098~ MN1*41*2*MARY SMITH CLEARINGHOUSE*****46*0003000~ PER*IC*MARY SMITH*TE*9135551234*FX*6123334567*ED*6125559876~ NM!*40*2*MEDICARE PART B*****46* WHY INC~ HL*1*20*1~ MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24*123456789~ N3*PO BOX 1234~ N$*SALISBURY*MO*660453565*US~ REF*1C*09876~ PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE*9135551234*FX* 6123334567TE* 6125559876~ HL*2*1*22*0~ HL * SBR*P*18**MEDICARE PART B*****MB~ NM!*IL*1*BENNING*CARRIE****MI*134-56-7890A~ N3*PO BOX 123~ N4*NEOMA*MO*67799*US~ DMB*D8*19330324*M~ MN1*PR*2*MEDICARE PART B*****PI*00065~ N3*1000 MAIN ST~ N$*ST LOUIS*MO*66666*US~ CLM*MEDBGOOD-MIS1*1500***11::1*Y*C*Y*Y*B******P~ RE*X4*32D1234567~ NTE*ADD*CLAIM NOTE TEXT~ HI*BK:3999~ NM1*DN*1*FOLLARD*BEN*J**M.D.*24-111223333~ PRV*RF*ZZ*101Y00000N~ RED*1C*B11277 NM!*82*1*TREPED*HOWARD****24*88899-1111~ PRV*PE*ZZ*101Y00000N~ RED*1C*2327870~ LX*1 SV1*HC:99213*15000*UN*1*11**1:::**N~ DTP*472*DB*81298399~ RE*X4*32D1234567~ SE*36*0001~ GE*1*1~ IEA*1*000000001~ What Your Computer Sees During an 837 Transaction

25. Part IV Implications for Payers • Identify points of change\impact • Develop internal systems • Out sourcing to a vender

26. Points of Impact • Review existing workflows per transaction • Can workflow be improved/automated? • Can information returned be better utilized/automated? • Do you use non-standard codes in these processes? • Is there value in implementing transactions which you do not currently conduct electronically? • Is there value in implementing transactions not currently required by the California DWC?

27. Internal Systems • Do you need to changes your direct data entry systems • Data content (data elements) must meet the data content portion of the California electronic standard • Systems will also need to be capable of receiving data transfers from the DWC • Coming soon-If provider chooses to send data electronically, payer must accept • Do you have a crosswalk from standard code sets to ones used by your internal systems?

28. Questions to ask a software vendor • Will your vendor be DWC compliant by the mandated deadlines? • What are your service level agreements for continued support? • New versions • Training • Will the required code sets be submitted? • How much lead time is required to install and test the software? • What is the minimum hardware requirement for servers and workstations to run the California compliant version?

29. Part V Where are you now?  Assigned a “point person” for your office? • Completed an Action Plan? • Work toward completing your Gap Analysis? • Communicated with vendors, billing services, or the DWC concerning 3/18/06? • Test Internally? • Scheduled External Testing? • Staying abreast of upcoming requirements?

30. Where are you?

31. Where are you?

32. Where are you?

33. DWC\WCIS Help • WCIS web site (www.dir.ca.gov) • WCIS Trading Partner Liaisons • WCIS e-mail (wcis@dir.ca.gov) • WCIS Medical EDI Training

34. WCIS Trading Partner Liaisons Damon Chen 510-286-6753 dchen@dir.ca.gov Johnny Lee 510-286-6772 jlee@dir.ca.gov Elisema Cantu 510-286-6763 ecantu@dir.ca.gov

35. WCIS Medical EDI Training • Training Conference in Los Angels Area • Training Conference in Oakland Area • Web Based step by step training • Help Desk by telephone or email