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THE CALIFORNIA DIVISION OF WORKERS’ COMPENSATION MEDICAL DATA TRAINING

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

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  1. THE CALIFORNIADIVISION 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 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

  5. Section GTesting and production phases of medical EDIPage 34

  6. 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

  7. 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

  8. 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

  9. Step 2. Complete the structural test phase Implementation Guide, Page 37

  10. General Structure of ANSI Transmission Implementation Guide, Page 35

  11. 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~

  12. 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

  13. Transaction Set Acknowledgment Code • A = Accepted • E = Accepted, but errors were noted • R = Rejected Implementation Guide, Page 38

  14. 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~

  15. 997 acknowledgment error messages Implementation Guide, Page 37

  16. 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~

  17. 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

  18. Step 3Billing Scenarios • Outpatient drug dispensing • Inpatient Hospital • HCFA Pharmaceutical (no adjustment) • HCFA Pharmaceutical (with adjustment) • NCPDP Pharmaceutical • Durable medical Equipment • Dental

  19. Step 3 Bill Submission Reason Codes Original 00 Cancel 01 Replace 05 Implementation Guide, Page 40

  20. Step 3. Complete the detailed test phase Implementation Guide, Page 41

  21. 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

  22. 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~

  23. Application Acknowledgment Code • TR = Transaction Rejected • TE = Transaction Accepted with Error • TA = Transaction Accepted Implementation Guide, Page 42

  24. 824 TR = Transaction Rejected Implementation Guide, Page 42

  25. 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

  26. Form HCFA-1500 or CMS-1500

  27. Form HCFA-1450 or UB-92

  28. American Dental Association Claim Form

  29. NCPDP Universal Claim Form

  30. 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

  31. 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

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