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WCIS

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

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WCIS

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

  2. www.dir.ca.gov Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1.0 December 2005

  3. 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 Page 3

  4. Section HSupported transactions and ANSI file structurePage 46

  5. Supported transactions • 837 Health care claim transaction set • submit health care claim billing information • regulatory agencies to monitor the rendering, billing and/or payment of health care services within a specific health care/insurance industry segment • 824 acknowledgment set • sent to each trading partner after each health care claim transaction set (837) is evaluated for errors. Page 47

  6. ANSI definitions • Loop: • A group of segments that may be repeated. • Looping structure is insurer, claim, bill level, and line level. • Segment ID: • Groups of logically related data elements • Provider information • Service adjustment information • Date information • Data element • Format: • AN String: Any characters from the basic or extended character sets • ID Identification code • R Decimal number Page 48

  7. ANSI delimiters * Data element delimiter : Sub data element delimiter ~ End of stringdelimiter EXAMPLE (Diagnosis code on a HCFA 1500) HI*BK:952.9~ Page 48

  8. Data Element INSURER FEIN – DN6 Definition: The Federal Employment Identification Number (FEIN) of the carrier or self-insured assuming responsibility for workers’ compensation claims. Revised: 09/26/98 Business Need: To identify the insurer to the jurisdiction system. Source: Payor Format: ANSI A/N 2/80 IAIABC A/N 9 Imp Note: As there exists a one to one relationship between an Insurer State ID and the Insurer FEIN, this will replace Insurer State ID. If a state utilizes a unique Insurer State ID, they must build a crosswalk table prior to testing/implementation.

  9. Example of an ANSI Segment SEGMENT: NM1 Individual or Organizational Name LOOP: 2010AA Repeat: 2 USAGE: Situational MAX USE: 1 PURPOSE: To supply the full name of an individual or organizational entity. This segment can contain two loops for reporting organizations: Loop 1 = Carrier or Self-Insured Loop 2 = Claim Administrator. EXAMPLE: NM1*IR*2*County of Los Angeles*****FI*111223333~

  10. Example of an ANSI Loop SEGMENT: NM1 Individual or Organizational Name LOOP: 2010AA Repeat: 2 USAGE: Situational MAX USE: 1 PURPOSE: To supply the full name of an individual or organizational entity. This segment can contain two loops for reporting organizations: Loop 1 = Carrier or Self-Insured Loop 2 = Claim Administrator EXAMPLE: NM1*IR*2*County of Los Angeles*****FI*111223333~ NM1*CX*2*Best in the West*****FI*333322211~

  11. IAIABC ANSI Qualifier(Previous example of a Loop) LOOP: 2010AA Repeat: 2 Segment INSURER/SELF-INSURED/CLAIM ADMINISTRATOR INFORMATION Loop 1 = Carrier or Self-Insured Loop 2 = Claim Administrator. DATA ELEMENT SUMMARY NM101 98 ENTITY IDENTIFIER CODE M ID 2/3 Code identifying an organization entity, a physical location, property or an individual. The Entity Identifier in NM101 applies to all segments in loop 2010. Required CA = Carrier IR = Self Insured CX = Claim Administrator NM102 1065 ENTITY TYPE QUALIFIER M ID 1/1 Code, qualifying the type of entity. NM102 qualifies NM103. Required 2 = Non-Person Entity NM103 1035 NAME LAST OR ORGANIZATION NAME O AN 1/35 Identifies individual last name or organization name. Situational DN7 Insurer Name (Carrier or Self-Insured) DN188 Claim Administrator Name

  12. California Manual California EDI Implementation Guide For Medical Bill Payment Records December, 2005 Section H 49 – 54 Insert 1 California 837 Loop structure

  13. General Billing Scenario 1 Insurer 1 Claim 1 Bill

  14. General Billing Scenario 1 Insurer Multiple Claims per insurer Multiple Bills per Claim

  15. General Billing Scenario Multiple Insurers 1 Claim per insurer Multiple Bills per Claim

  16. C O N T I N U E D General Billing Scenario Multiple Insurers Multiple Claim per insurer Multiple Bills per Claim

  17. A Detailed Hieararchy Example Insert 2

  18. California Manual California EDI Implementation Guide For Medical Bill Payment Records December, 2005 Section H 54 – 55 Insert 3 824 Loop Structure

  19. California specific OTI LOOP: OTI Repeat: >1 SEGMENT: OTI Original Transaction Identification USAGE: Required MAX USE: 1 PURPOSE: To identify the edited transaction set and the level at which the results of the edit are reported, and to indicate the accepted, rejected, or accepted with change edit result. EXAMPLE: OTI*TA*55*001520***19960617*1230***MED~ DATA ELEMENT SUMMARY OTI01 110 APPLICATION ACKNOWLEDGMENT CODE M ID 1/2 Required Code indicating the application system edit results of the business data. DN111 Application Acknowledgment Code BA = Batch Accepted BR = Batch Rejected TR = Transaction Rejected TE = Transaction Accepted with Error(s) TA = Transaction Accepted

  20. California specific OTI (Continued) EXAMPLE: OTI*TA*55*001520***19960617*1230***MED~ DATA ELEMENT SUMMARY OTI02 128 REFERENCE NUMBER QUALIFIER M ID 2/3 Required Code qualifies the Reference Number. 55 = Sequence Number OTI03 127 REFERENCE NUMBER M AN 1/30 Required Reference number or identification number as defined for a particular Reference Transaction Set, or as specified by the Reference Number Qualifier. This is the response to an inbound 837 and will contain the Unique Bill ID Number from Loop 2300 REF02 or Batch Control Number from BHT03. If transaction level acknowledgment use DN500 Unique Bill ID Number If batch level acknowledgment use DN532 Batch Control Number

  21. California specific OTI (Continued) EXAMPLE: OTI*TA*55*001520***19960617*1230***837~ DATA ELEMENT SUMMARY OTI06 373 DATE O DT 8/8 Situational Date (CCYYMMDD). OTI06 is the date of the original transmission from the inbound 837. DN102 Original Transmission Date OTI07 337 TIME O TM 4/8 Situational Time expressed in 24 hour clock time as follows: HHMM or HHMMSS, or HHMMSSD or HHMMSSDD, H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99). OTI07 is the time of the original transmission from the inbound 837. DN103 Original Transmission Time OTI10 143 TRANSACTION SET IDENTIFIER CODE O ID 3/3 Required Code uniquely identifies a Transaction Set. DN110 Acknowledgment Transaction Set ID 837 = Health Care Claim (Medical Transactions)

  22. California LQ LOOP: LQ Repeat: 100 SEGMENT: LQ Industry Code USAGE: Situational MAX USE: 1 PURPOSE: Code to transmit standard industry codes. If LQ01 is present, LQ02 is required. EXAMPLE: LQ*FZ*058~ DATA ELEMENT SUMMARY LQ01 1270 CODE LIST QUALIFIER CODE O ID 1/3 Required Code identifying a specific industry code list. FZ = Edit Error Code LQ02 1271 INDUSTRY CODE X AN 1/30 Required Code indicates a code from a specific list. DN116 Element Error Number

  23. SEGMENT: RED Related Data LOOP: LQ Repeat: 100 USAGE: Situational MAX USE: 1 PURPOSE: To provide business data related to an item within a transaction to which a business application editing process has been applied, and an error condition has resulted. For IAIABC purposes the RED segment will also be used to transmit the DN of the element in error and a copy of the bad data. For matching purposes, one or more of the following fields may be sent as supplemental data: DN6 Insurer FEIN DN16 Employer FEIN DN187 Claim Administrator FEIN DN15 Claim Administrator Claim Number DN5 Jurisdiction Claim Number DN500 Unique Bill ID Number DN266 Transaction Tracking Number. EXAMPLE: RED*112233**IB**A9*0500~ RED*3**IB**A9*0547~ RED*XYZ**IB**GJ*0714~

  24. SEGMENT: RED Related Data DATA ELEMENT SUMMARY RED01 352 DESCRIPTION M AN 1/80 A free form description clarifies the related data elements and their content. This field will contain either the actual supplemental data to further identify the record in error or it will contain the contents of the bad data element. If this is used for supplemental data, RED05 will have a value of “A9". If this is used for a bad copy of the data element, RED05 will have a value of “GJ”. RED03 559 AGENCY QUALIFIER CODE X ID 2/2 Code, which identifies the agency assigning the codes values. IB = IAIABC Error Code List RED05 1270 CODE LIST QUALIFIER CODE X ID 1/3 Code identifying a specific industry code list . A9 = Supplemental Data GJ = Reject Indicator Code RED06 1271 INDUSTRY CODE X AN 1/30 Code indicating a code from a specific industry code list. DN115 Element Number If RED05 = A9 then use the IAIABC data element number associated with supplemental information in RED01 If RED05 = GJ then use the IAIABC data element number associated with the invalid data in RED01

  25. 824 with no errors ISA*00* *00**ZZ*943160882*ZZ*450483908 *051121*1227*U*00401*000000045*0*P*~ GS*01*943160882*450483908*20051121*1227*68*X*004010~ ST*824*0015~ BGN*11*MED01*20051121*1227~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TA*55*00001***20051109*1627***837~ DTM*009*20051121*153124~ SE*7*0015~ GE*1*68~ IEA*1*000000045~

  26. 824 with an insurer level error(1 Bill = 1 OTI segment) 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*12345**IB**A9*532~ RED*999999999**IB**GJ*06~ SE*11*0015~ GE*1*68~ IEA*1*000000045~

  27. 824/insurer level error/100 Bill case 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*999999999**IB**GJ*06~ OTI*TR*55*00002***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*999999999**IB**GJ*06~ . . OTI*TR*55*00100***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*1**IB**A9*532~ RED*999999N99**IB**GJ*06~ SE*110*0015~ GE*1*68~ IEA*1*000000045~ 100 Bills = 100 OTI Segments

  28. 824 with an claim level error (1 Bill = 1 OTI segment) 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*111111111**IB**GJ*42~ SE*12*0015~ GE*1*68~ IEA*1*000000045~

  29. 824 / claim level error / 100 Bill case 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1111111N1**IB**GJ*42~ OTI*TR*55*00002***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1111111N1**IB**GJ*42~ . . OTI*TR*55*00100***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*040~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1111111N1**IB**GJ*42~ SE*112*0015~ GE*1*68~ IEA*1*000000045~ 100 Bills = 100 OTI Segments

  30. 824 with an Bill level error 1 error in 1 Bill 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*Q**IB**GJ*507~ SE*14*0015~ GE*1*68~ IEA*1*000000045~

  31. 824 with an Line level error 1 error in 1 line of 1 Bill 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153134~ LM*IB~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ SE*14*0015~ GE*1*68~ IEA*1*000000045~

  32. MultipleLine errorsSame bill (00001)Same line (1)Same error (058) Different Data Element 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1**IB**A9*547~ RED*TY**IB**GJ*732~ SE*9*0015~ GE*1*68~ IEA*1*000000045~

  33. N = 20 Error ruleLimit of 20 LQ per OTILimit of 20 errors per bill OTI*TR*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*2**IB**A9*547~ RED*MO**IB**GJ*553~ . . . LQ*FZ*058~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*20**IB**A9*547~ RED*W1**IB**GJ*732~ OTI*TR*55*00002***20051109*162751***837~

  34. OTI*TA*55*00001***20051109*162751***837~ OTI*TA*55*00002***20051109*162751***837~ OTI*TR*55*00003***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*1**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*00003**IB**A9*0500~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ OTI*TR*55*00004***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*1**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*00003**IB**A9*0500~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ OTI*TA*55*00005***20051109*162751***837~ OTI*TR*55*00006***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*058~ RED*1**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**A9*15~ RED*00003**IB**A9*0500~ RED*1**IB**A9*547~ RED*MO**IB**GJ*553~ OTI*TA*55*00007***20051109*162751***837~ OTI*TA*55*00008***20051109*162751***837~ . . General StructureTR = Rejected Bills 20 errors ruleTA = Accepted Bills

  35. 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.

  36. 824 with an 039 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*20051121*162751~ N1*10**FI*943160882~ N4***946121413~ N1*40**FI*450483908~ N4***239640040~ OTI*TE*55*00001***20051109*162751***837~ DTM*009*20051121*153124~ LM*IB~ LQ*FZ*039~ RED*12345**IB**A9*532~ RED*234567891**IB**A9*06~ RED*CA23456**IB**GJ*15~ SE*12*0015~ GE*1*68~ IEA*1*000000045~

  37. Unmatched data element process (BSRC=00)(ACC=TE) • Sender transmits original bill, including all lines, utilizing a BSRC "00". • DWC finds no matching FROI. • DWC sends a “TE” 824 acknowledgement with an 039 error to sender. • Sender takes no action. • DWC continues matching process and includes the event in a data quality report.

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