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THE 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

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the california division of workers compensation medical data training

THE CALIFORNIADIVISION OF WORKERS’ COMPENSATIONMEDICAL DATA TRAINING

WCIS Medical Data Collection

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

slide4

California Implementation Guide

Table of Contents

  • Electronic data interchange in California – an overview
  • Where to get help
  • Implementing medical EDI
  • Authorizing statutes – Labor Code
  • WCIS regulations
  • Trading partner profile
  • Testing and production phases of medical EDI
  • Supported transactions and ANSI file structure
  • Transmission modes

Implementation Guide, Page 3

overview of the four stages
Overview of the Four Stages
  • Stage one: EDI trading partner profile
    • The trading partner provides an EDI trading partner profile to the DWC at least 30 (thirty) days before the first submission of electronic data.
  • Stage two: structural testing
    • 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
    • During the detailed test phase, the trading partner’s submissions are analyzed for data completeness, validity, and accuracy.
  • Stage four: production
    • During production, data transmissions will be monitored for completeness, validity, and accuracy.

Implementation Guide, Page 35

step 1 complete a medical edi trading partner profile
Step 1. Complete a medical EDI trading partner profile
  • Specify Transmission mode
    • (value added network (VAN)
    • file transfer protocol (FTP).
  • Specify Sender/receiver identifications
  • Specify file format (ANSI X12 837)

Implementation Guide, Page 35

step 2 complete the structural test phase
Step 2. Complete the structural test phase
  • Establish Van or FTP connectivity
  • Trading partners send a structurally correct ANSI 837 transmission
  • Trading partners receive and process a 997 functional acknowledgment.

Implementation Guide, Page 35-38

step 2 complete the structural test phase9
Step 2. Complete the structural test phase

Implementation Guide, Page 37

slide10

General Structure of ANSI Transmission

Implementation Guide, Page 35

details of the 997 header trailers
Details of the 997 Header/Trailers
  • ISA*00**00**ZZ*450483908*ZZ*943160882*051011*1345*U*00401*000000197*0*P~
  • GS*HC*450483908*943160882*20051011*1345*197*X*004010~
  • ST*997*0001~

WHERE THE 997 FUNCTIONAL ACKNOWLEDGEMENT GOES

  • SE*123*0001~
  • GE*1*197~
  • IEA*1*000000197~
general structure of 997
General structure of 997
  • 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

Implementation Guide, Page 38

transaction set acknowledgment code
Transaction Set Acknowledgment Code
  • A = Accepted
  • E = Accepted, but errors were noted
  • R = Rejected

Implementation Guide, Page 38

997 with no errors
997 with no errors

ISA*00* *00**ZZ*943160882*ZZ*450483908051122*1202*U*00401*000000045*0*P~

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

ST*997*0058~AK1*HC*1~AK2*837*1504~AK5*A~AK9*A*1*1*1~SE*4*0058~GE*1*68~

IEA*1*000000045~

997 acknowledgment error messages
997 acknowledgment error messages

Implementation Guide, Page 37

997 with 1 error
997 with 1 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*997*0058~AK1*HC*1~AK2*837*1504~AK3*BHT*1**8~Segment has data element errorsAK4*2**1~ Mandatory data element missingAK5*R~AK9*R*1*1*0~SE*6*0058~GE*1*68~

IEA*1*000000045~

step 3 complete the detailed test phase
Step 3Complete the detailed test phase
  • Complete data
    • all required medical bill payment data elements
  • Valid data
    • data must consist of allowable values
  • Accurate data
    • NO errors.

Implementation Guide, Page 39

step 3 billing scenarios
Step 3Billing Scenarios
  • Outpatient drug dispensing
  • Inpatient Hospital
  • HCFA Pharmaceutical (no adjustment)
  • HCFA Pharmaceutical (with adjustment)
  • NCPDP Pharmaceutical
  • Durable medical Equipment
  • Dental
step 3 bill submission reason codes
Step 3 Bill Submission Reason Codes

Original 00

Cancel 01

Replace 05

Implementation Guide, Page 40

step 3 complete the detailed test phase20
Step 3. Complete the detailed test phase

Implementation Guide, Page 41

general structure of 824
General structure of 824
  • ST Transaction Set Header
  • Loop ID: N1A Sender Information
  • Loop ID: N1B Receiver Information
  • Loop ID: OTI Original Identification
  • Loop ID LM Code Source Information
  • Loop ID: LQ Industry Code
  • SE Transaction Set Trailer
details of the 824 header trailers
Details of the 824 Header/Trailers
  • ISA*00**00**ZZ*450483908*ZZ*943160882*051011*1345*U*00401*000000197*0*P~
  • GS*HC*450483908*943160882*20051011*1345*197*X*004010~
  • ST*824*9876541~

WHERE THE 824 DETAILED ACKNOWLEDGEMENT IS CONTAINED

  • SE*432*987654~
  • GE*1*197~
  • IEA*1*000000197~
application acknowledgment code
Application Acknowledgment Code
  • TR = Transaction Rejected
  • TE = Transaction Accepted with Error
  • TA = Transaction Accepted

Implementation Guide, Page 42

824 tr transaction rejected
824 TR = Transaction Rejected

Implementation Guide, Page 42

parallel pilot procedure
Parallel pilot procedure
  • WCIS Pilot-Parallel Phase
  • Attn: WCIS Contact
  • Department of Industrial Relations
  • EDI Unit, Information Systems
  • 1515 Clay Street, 19th Floor
  • Oakland, CA 94612

Implementation Guide, Page 43

slide26

Form

HCFA-1500 or

CMS-1500

slide27

Form

HCFA-1450 or

UB-92

slide29

NCPDP Universal

Claim Form

slide30

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 REPORTS MAILED -------------------------------------

NUMBER OF PAPER MEDICAL REPORTS MAILED ---------------------------

PREPARED BY ---------------------------------------------------------------------------

PHONE -------------------------------------------------------------------------------------

Implementation Guide, Page 45

from test to production status
From test to production status
  • Sender submits Trading Partner Agreement
  • Sender tests FTP or VAN connectivity
  • Sender transmits numerous ANSI 837 bill types
  • Sender receives and processes a 997 from the DWC
  • Sender receives and processes a 824 from the DWC
  • Sender transmits a Cancellation of bills in step 3
  • Sender transmits a Replacement of a bill in step 3
  • Sender becomes a Certified Trading Partner