1 / 24

CALIFORNIA DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING

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

mykelti
Download Presentation

CALIFORNIA DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CALIFORNIA DIVISION OF WORKERS’ COMPENSATIONMEDICAL DATA TRAINING WCIS Medical Data Collection

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

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

  4. 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

  5. Section JEDI service providersPage 60

  6. EDI service providers • Providers of consultation • Technical support • VAN service • Software products • Organizations providing data collection services

  7. Section KEvents that trigger required medical EDI reportsPage 66

  8. California Event Table • Bill Submission Reason Codes • OO is a Original  • Within 90 days of date paid • Daily, Weekly, Monthly, Quarterly  • O1 is a Cancellation (Reversal of an '00' transaction) • within 90 days of the original submission • Immediately • O5 is a Replacement  • Replacement of a claim administrator claim number previously submitted.   • immediately

  9. Section LRequired medical data elementsPage 69

  10. Data Dictionarieswww.dir.ca.gov/dwc/WCIS • IAIABC EDI Implementation Guide for Medical Bill Payment Records • Section 9.1 Medical Bill Payment Records • Section 9.2 Medical Bill Payment Records System • California medical bill payment dictionary • Subset of the IAIABC Data Dictionaries • 125 Data Elements • Combination of System and Data Elements • 15 System Data Elements • 110 medical Data Elements

  11. Sources of Medical Data Elements • UB92/HCFA1450 /CMS 1500 • CMS-1500 Form (formerly HCFA1500) • Insurers • Payers • Health Care Provider • Jurisdictional Licensing Boards • Senders

  12. Sources of Data for 837 Payer/ Accounts payable Insurer Dental Bills Look-up Tables Legacy Files Claims Sender 837 Medical Bill Payment Records File Pharmaceutical Bills Professional Bills UB92 Medical Bills Jurisdiction Licensing Boards DME Bills

  13. California Manual California EDI Implementation Guide For Medical Bill Payment Records December, 2005 Section L 70 – 73 Source Table

  14. Medical data element requirement table M = Mandatory The data element must be sent and all edits applied to it must be passed successfully or the entire transaction will be rejected. C = Conditional The data element becomes mandatory under conditions established by the Mandatory Trigger. O = Optional The data element is sent if available. If the data element is sent the data edits are applied to the data element. Mandatory Trigger: The trigger which makes a conditional data element mandatory.

  15. California Manual California EDI Implementation Guide For Medical Bill Payment Records December, 2005 Section L 74 – 80 Element Requirement Table

  16. California 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~ 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~

  17. California Mandatory Segments (BSRC = 01) 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*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~ REF*Y1*528779999~ CLM*A37YH556*500**MO*11:B*Y**********P***01~ REF*DD*13579~

  18. California Mandatory Segments (BSRC = 05) 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*PREMIERE INSURANCE COMPANY OF NORTH*****FI*111223333~ REF*Y1*528779999~ REF*Y1*999988746~ CLM*A37YH556*500**MO*11:B*Y**********P***05~

  19. Example of a Scenario 1 Bill

More Related