Workers' Compensation Information System - California Department ...

Workers' Compensation Information System (WCIS)
California EDI Implementation Guide
for
Medical Bill Payment Records
Version 1.0
July 2005 CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS
John Rea, acting director
DIVISION OF WORKERS' COMPENSATION June 1, 2005 Dear Claims Administrators: Welcome to the California Division of Workers' Compensation electronic data
interchange (EDI) for medical bill payment records. The California Division
of Workers' Compensation (DWC) is pleased to introduce its system for
receiving workers' compensation medical bill payment records data via EDI.
The detailed medical data will be integrated with other data in the
workers' compensation information system (WCIS) to provide a rich resource
of information for analyzing the performance of California's workers'
compensation system. The manual, California EDI Implementation Guide for Medical Bill Payment
Records, is intended to be a primary resource for the DWC's "trading
partners" - administrators of California workers' compensation claims. Some
organizations already have substantial experience transmitting EDI data to
the DWC with first and subsequent reports of injury. For existing and new
trading partners, the medical implementation guide can serve as a reference
for California-specific medical record protocols. Although, the California
DWC adheres to national EDI standards, the California medical record
implementation guide does have minor differences from other states. The California EDI Implementation Guide for Medical Bill Payment Records
will be posted on our Web site at www.dir.ca.gov/dwc/wcis.htm. I hope the
start-up of medical record EDI reporting in California is smooth and
painless, both for the division and its EDI trading partners. The California DWC is dedicated to open communication as a cornerstone of a
successful start-up process, and this guide is a key element of that
communication. Sincerely,
Andrea L. Hoch
DWC administrative director
Workers' Compensation Information System (WCIS)
CALIFORNIA EDI IMPLEMENTATION GUIDE
for Medical Bill Payment Records
Version 1.0
July 2005 Table of contents
Page A Electronic data interchange in California - an overview 4
B Where to get help - contacting WCIS and other information sources .10
C Implementing medical EDI - a manager's guide 13
D Authorizing statutes - Labor Code 19
E WCIS regulations 23
F Trading partner profile 24
G Test, pilot and production phases of medical EDI 34
H Supported transactions and ANSI file structure 47
I Transmission modes 57
J EDI service providers 61
K Events that trigger required medical EDI reports 67
L Required medical data elements 70
M Data edits 81
N System specifications 90
O IAIABC information 94
P Code lists 98
Q Medical EDI glossary and acronyms 117
R Standard medical forms 124 Section A
Electronic Data Interface in California - An Overview Electronic Data Interchange - EDI 5 Benefits of EDI within Workers' Compensation 5 Workers' Compensation Information System History 6 Components of the WCIS 6 California EDI Requirements 7 Sending Data to the WCIS 8 Four Stages of EDI - From Testing to Production 9 Stage One: EDI Trading Partner Profile 9 Stage Two: Testing 9 Stage Three: Pilot 9 Stage Four: Production 9
Electronic Data Interchange - EDI Electronic Data Interchange (EDI) is the computer-to-computer exchange of
data or information in a standardized format. In workers' compensation,
EDI refers to the electronic transmission of claims information from Claims
Administrators (insurers, self-administered self-insured employers, and
third party administrators) to a State Workers' Compensation Agency. Data are transmitted in a format standardized by the International
Association of Industrial Accident Boards and Commissions (IAIABC). The
IAIABC is a professional association of workers' compensation specialists
from the public and private sectors and has spearheaded the introduction of
EDI in workers' compensation. (For further details, see Section P - IAIABC
Information.) All data elements to be collected are reviewed for a valid
business need, and definitions and formats are standardized. EDI is in use in workers' compensation nationwide. Currently, over twenty
states and more than 200 insurance companies and claims administrators are
routinely transmitting data by EDI. Several states have established legal
mandates to report data by EDI, including Indiana, Iowa, Kentucky, Montana,
Nebraska, New Mexico, South Carolina, Texas, and California. Benefits of EDI within Workers' Compensation . Allows state agencies to respond to policy makers' questions regarding
their state programs
EDI allows states to evaluate the effectiveness and efficiency of their
workers' compensation system by providing comprehensive and readily
accessible information on all claims. This information can then be made
available to state policy makers considering any changes to the system.
. Avoids costs in paper handling
EDI reduces costs in the processing of paper documents for the claims
administrator and the jurisdiction: mail processing costs, duplicated
data entry costs, shipping costs, filing costs, and storage costs.
. Increases data quality
EDI has built-in data quality checking procedures that are triggered when
data are received by the state agency. Many claims administrators adopt
the national standard data-checking procedures for in-house systems to
reduce the costly data-correction efforts that result when erroneous data
are passed among the parties to a claim.
. Simplifies reporting requirements for multi-state insurers
EDI helps Claims Administrators cut costs by having a single system for
internal data management and reporting.
Workers' Compensation Information System History
The California Legislature enacted sweeping reforms to California's
workers' compensation system in 1993. The reform legislation was preceded
by a vigorous debate among representatives of injured workers, their
employers, insurance companies, and medical providers. All parties agreed
that changes were due, but they could not reach agreement on the nature of
the problems to be corrected nor on the likely impact of alternative reform
proposals. One barrier to well-informed debate was the absence of
comprehensive, impartial information about the performance of California's
workers' compensation system. Foreseeing that debate about the strengths and weaknesses of the system
would continue, the Legislature directed the Division of Workers'
Compensation (DWC) to put together comprehensive information about workers'
compensation in California. The result is the WCIS - the Workers'
Compensation Information System. The WCIS has been in development since
1995, and its design has been shaped by a broad-based advisory committee.
The WCIS has four main objectives:
. help DWC manage the workers' compensation system efficiently and
effectively,
. facilitate the evaluation of the benefit delivery system,
. assist in measuring benefit adequacy, and
. provide statistical data for further research.
Components of the WCIS The WCIS encompasses three major components. The core of the system is
standard data on every California workers' compensation claim.
Historically the data was collected in paper form: employer and physician
First Reports of Injury (FROI), benefit notices, and similar data.
Beginning in 2000, the DWC began to collect standardized electronic data on
the FROI via the WCIS EDI system. Beginning in 2006, the WCIS EDI system
was expanded to include Medical EDI transmissions. The WCIS will also use information from the DWC's existing case tracking
system. The DWC has extensive computerized files on adjudicated cases and
on claims that have been submitted for disability evaluation. The existing
DWC information will be linked with EDI data to help shed light on the
differences between adjudicated and non-adjudicated cases. Finally, the WCIS will conduct periodic surveys of a sample of injured
workers, employers, and medical providers. The surveys will supplement the
standard data, and allow the WCIS to address a wide variety of policy
questions.
California EDI Requirements
California's WCIS regulations define EDI reporting requirements for claims
administrators. A claims administrator is an insurer, a self-insured
employer, or a third-party administrator. In brief, Claims Administrators are required to submit the following: First Reports: First Reports of Injury (FROI) have been transmitted by EDI
to the DWC since March 1, 2000 First Reports must be transmitted to the
WCIS no later than 5 days after knowledge of the claim. Subsequent Reports: Subsequent Reports of Injury (SROI) have been
transmitted by EDI to the DWC since July 1, 2000. Subsequent reports
must be submitted within 10 business days of whenever benefit payments to
an employee are started, changed, suspended, restarted, stopped, delayed,
denied, closed, reopened, or upon notification of employee representation. Medical Bill/Payment Reports: Medical Bill Payment Reports began to be
transmitted to the DWC in January, 2006. Medical Bill Payment Reports must
be transmitted to the DWC within 90 days after the Medical Bill Payment is
made by Insurers to medical service and equipment providers. The required
data elements are listed in Section L-Required data Elements of this guide
and in the California Medical Data Dictionary
(http://w