Title 8, California Code of Regulations Sections 9701 and 9702

Workers Compensation Information System (WCIS)

California Electronic Data Interchange (EDI) Implementation Guide

for Medical Bill Payment Records

Version 2.0

(April 6, 2016) (September 27, 2017)

CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS Christine Baker, Director

DIVISION OF WORKERS COMPENSATION

Destie OverpeckGeorge Parisotto, Acting Administrative Director

California EDI Implementation Guide for Medical Bill Payment Records

Title 8, California Code of Regulations Sections 9701 and 9702

ii

Dear Claims Administrators: The California Division of Workers Compensation (DWC) is pleased to introduce the new version of the CA Implementation Guide for Medical Bill Payment Records, Release 2.0. This guide is based on the IAIABC Release 2 Medical Bill Record with some variation to accommodate California specific rules. With the new version of the guide, California is migrating from using American National Standards Institute (ANSI) X12 4010 format to ANSI X12 5010 format for collecting medical bill data. This migration will bring significant transaction improvements that address the industrys needs, and it corrects problems encountered in the 4010 version. In general, the new version of the guide is believed to be efficient and easier to implement. Moreover, it puts the CA WCIS data collection in synch with the divisions electronic billing regulation that went into effect in October 2012. It will also bring the WCIS data collection in compliance with the current industry standard of doing business between providers and insurers. As in the past, the Mmedical bill record data collected by the WCIS will be integrated with the data the division currently collects for First Reports of Injury (FROI) and Subsequent Reports of Injury (SROI). These two databases will have a wealth of information that can help the division make informed policy decisions. The data in WCIS is only as good as what you, our Trading Partner, transmit to it. I urge you to submit complete and accurate data. Reliable data will assist the division make well-founded decisions that will benefit both the injured worker and the employer community. The California Electronic Data Interchange (EDI) Implementation Guide for Medical Bill Payment Records will be posted on our web site at http://dir.ca.gov/dwc/wcis.htm. I hope this revised version of the CA Implementation Guide will help you submit the mandated information to the CA WCIS. The California DWC is dedicated to open communication as a cornerstone of a successful partnership between you and the division. I hope this guide will be a useful instrument that will help you submit accurate data. Sincerely, Destie Overpeck George Parisotto, Acting Administrative Director Division of Workers Compensation

California EDI Implementation Guide for Medical Bill Payment Records

Title 8, California Code of Regulations Sections 9701 and 9702

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Table of Contents

Section I: Electronic Data Interchange (EDI) in California ............................................... 1Introduction ................................................................................................................... 1California Workers' Compensation Information System (WCIS) history ........................ 1Sending data to the WCIS ............................................................................................. 2

Section II: Trading Partner Profile ................................................................................... 4Who should complete the Trading Partner Profile? ....................................................... 4

MEDICAL ELECTRONIC DATA INTERCHANGE TRADING PARTNER PROFILE . 5PART A. Trading partner background information: ............................................... 5PART B. Trading partner contact information:....................................................... 5PART C. Trading partner transmission specifications: ............................................. 6PART D. Receiver Information (to be completed by DWC): .................................. 7

Instructions for completing the Trading Partner Profile ................................................. 8PART A. Trading partner background information: ................................................... 8PART B. Trading partner contact Information: ...................................................... 9PART C. Trading partner transmission specifications: .......................................... 9PART D. Receiver information (to be completed by DWC): ................................ 10

Section III: The SFTP transmission mode ..................................................................... 12Data transmission with secure file transfer protocol (SFTP) ....................................... 12Trading partner source IP address .............................................................................. 12Testing SFTP connectivity .......................................................................................... 12Sending data through SFTP ........................................................................................ 13Receiving acknowledgment files through SFTP .......................................................... 13

Section IV: EDI medical testing ..................................................................................... 14Overview of the EDI medical testing process .............................................................. 14Testing connectivity ..................................................................................................... 14Transmission/functional EDI medical testing ............................................................... 15Functional EDI medical testing communication loop ................................................... 15The 999 Implementation Acknowledgment EDI medical testing error messages ........ 15Transaction/bill level EDI testing ................................................................................. 23Transaction level EDI testing communication loop ...................................................... 23824 application acknowledgment error messages ...................................................... 24Medical bill cancellation, bill correction, bill replacement testing ................................. 24

California EDI Implementation Guide for Medical Bill Payment Records

Title 8, California Code of Regulations Sections 9701 and 9702

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Testing balancing rules ............................................................................................... 25Production Status ........................................................................................................ 25

Section V: Supported transactions and ANSI file structure ........................................... 26Supported transactions ............................................................................................... 26Health care claim transaction sets .............................................................................. 26ANSI definitions ........................................................................................................... 27California-adopted ANSI 999 loops, segments, and errors summary .......................... 28California-adopted ANSI 837 loops, segments, and data elements summary ............ 28California-adopted ANSI 824 loops, segments, and data elements summary ............ 35

Section VI: Required medical data elements ................................................................. 37Medical data elements by name and source ............................................................... 37

Section VII: Medical data element requirements ........................................................... 43Bill submission reason code values ............................................................................ 43Standard requirement code values: ............................................................................ 44Medical Data Elements Requirement Table ................................................................ 45

Section VIII: California-adopted IAIABC data edits and California specific data edits and error messages ............................................................................................................. 56

California Edit Matrix ................................................................................................... 56Error codes for 824 acknowledgments ........................................................................ 56

Section IX: System specifications ................................................................................. 67Electronic transmission types ...................................................................................... 67999 Functional processing and sequencing ................................................................ 67837 Detailed Transaction processing and sequencing ................................................ 68Correcting Transaction set (ST-SE) level errors (BSRC=00) (AAC=TR) ..................... 69Correcting data elements (BSRC=00) (AAC= TA and IR) ........................................... 70Cancelling critical data elements (BSRC=01) (AAC=TA and IA) ................................. 70Updating non critical data elements (BSRC=02) (AAC=TA and IA) ............................ 70Subsequent Payment Action or Denial (BSRC=05) (AAC=TA and IA) ...................... 71Matching transmissions, transactions, claims and medical bills .................................. 72Matching 837 Health Care Claim(s) to 824 Application Advice(s) ............................... 72Matching