Answers to frequently asked questions about California EDI Implementation Guide for Medical Bill Payment Records Version 2.0

About getting started

Q: When will the California EDI Implementation Guide for Medical Bill Payment Records Version 2.0 become effective?

A: April 6, 2016.

Q. Can claims administrators request a variance to delay their medical bill payment record reporting obligations?

A: No. The one year period between the date of adoption of the California Version 2.0 regulations and the effective date of California Version 2.0 was provided for trading partners to complete the necessary preparation to start reporting on April 6, 2016.

Q: Are the data elements required in California Version 2.0 the same data elements required in California Version 1.1?

A: While most of the data elements collected in California Version 1.1 are also collected in California Version 2.0 there are some new data elements added and some old ones deleted. Please refer to section VII of the California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, April 6, 2016 for the required data elements.

Q. Will there be parallel reporting of medical bill data using California Version 1.1 and California Version 2.0.

A: No. Starting April 6, 2016, the WCIS will accept only data reported using the California Version 2.0 standard.

Q: We are currently reporting medical bill data to WCIS. Do we need to fill a new Trading Partner Profile Form before April 6, 2016?

A: Yes. The WCIS has started accepting new Trading Partner Profile Forms. A fillable Trading Partner Profile form is available on the WCIS website.

Q: Who must fill a Trading Partner Profile (TPP) form?

Claims administrators, employers and third party administrators who send their own data to WCIS may fill the TPP form, with the business and the technical contact from within their organization.

Claims administrators, employers and third party administrators that designate their data reporting to a vendor may send the TPP form with the business contact from within their organization and the technical contact from the vendor’s organization.

Data transmitters that are not claims administrators, employers or third party administrators may fill TPP form with the business and technical contact from within their organization. In addition, attach name and contact information of the claims administrators whose data you are reporting to WCIS.

Q: We are currently reporting medical bill data. Do we still need to go through testing to start reporting California Version 2.0?

A: Yes. Trading partners should test and pass reporting of all bill types and all Bill Submission Reason Codes (00, 01, 02 and 05) prior to submitting data in production. Trading partners who will report one bill type only, for example pharmacy bill, are required to test for and pass for that bill type only. Refer to Section IV of California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, April 6, 2016.

Q. Do claims administrators who have designated data reporting to a vendor need to go through testing?

A: No. However, the designated vendor must pass the testing phase prior to data transmission.

Q: What are the steps I should follow for testing?

A: Please refer to Section IV of California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, April 6, 2016.

Q: How does a trading partner know when they are done testing?

A: You will be notified by your EDI contact when your test is completed and will be asked to change the Test/Production Indicator in ISA 15 segment from “T” to “P”.

Q: What is the transmission mode for reporting medical bill data to WCIS?

A: The only method to report medical bill data to WCIS is via SFTP (SSH [Secure Shell] File Transfer Protocol). The WCIS does not have any other alternative mode of reporting data.

Q: Are there any character that should not exist in the reported data?

A: California uses tilde ~, asterisks *, and colon : as delimiters. Avoid using these characters in your reported data. In addition California also uses the | pipe in data processing and it should not exist in any 837 file. If a | is included in your file, the entire file will be rejected.

Q: Does the WCIS have a file naming convention?

A: Yes, the WCIS follows the following file naming convention including the .txt extension.

FileType_SenderFEIN_9DigitZipcode_Date_Time_TestProductionIndicator_ThreeDigitCounter

e.g. 837_123456789_946125698_20140113_135012_T_001.txt

Q: Where can I obtain the different code sets used in reporting Medical Bill Data?

A: Refer to Section X of the California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, April 6, 2016.

Q: What is the reporting format for SENDER_ID?

A: SENDER_ID (DN0098) = SENDER FEIN (9 digits) _ sender’s postal codes (5 digits) for example 123456789_98765

Q. What is the time format in ISA and GS segments?

A: The time format in the GS segment must match ISA segment time format (HHMM).

Q. What is the date format in the ISA and GS segments?

A: The ISA date format is YYMMDD and the GS date format is CCYYMMDD.

Q. What value should I use in ISA06 Interchange Sender ID?

A: ISA06=NM109 (of loop 1000A)

ISA06 = 9 digit FEIN followed by an underscore (_) followed by 5 digit postal code e.g. 123456789_12345

Q: What are the date and time format for Date Transmission Sent (DN0100) and Time Transmission Sent (DN0101) in the BHT segment?

A: The date format is (CCYYMMDD) and the time format is (HHMM) and both data elements must be the same as the interchange date and time in the ISA segment.

Q: Can a negative value be reported for DN0501 Total Charge per Bill and DN0516 Total Paid per Bill?

A: Negative values may be reported on DN 0516 Total Amount Paid Per Bill but may not be reported on DN0501 Total Charge Per Bill.

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About Bill Submission Reason Codes(BSRC)

Q: If I have a bill that was reported and accepted using Version 1.1 format and I receive a credit or change on that bill after the implementation date of Version 2.0, would you expect the cancellation to come through your system as a CA Version 1.1 or 2.0?

A: This will be reported using CA version 2.0. In CA Version 2.0 note that credit or change, is reported with BSRC 02 Correction or BSRC05 Replacement and not BSRC01 Cancellation.

Use BSRC 05 Replacement if the credit or change is due to additional payment. Use BSRC 02 Correction if there is a change in data elements other than critical data elements DN0006 Insurer FEIN or DN0500 Unique Bill Identification Number. Use BSRC 01 Cancellation if the change involves critical data elements DN0006 Insurer FEIN or DN0500 Unique Bill Identification Number.

Q: When do I use BSRC 01 Cancellation?

A: Use a BSRC 01 Cancellation when a bill has been accepted which should not have been submitted to the jurisdiction or when the transaction contained error in critical data elements DN0006 Insurer FEIN or DN0500 Unique Bill Identification Number. To correct critical data elements use BSRC 01 Cancellation using the previously submitted critical data followed by a 00 Original containing the accurate or corrected data. Do not reuse the value in DN0500 Unique Bill Identification Number with the value of DN0006 Insurer FEIN.

Q. How do I report a reconsidered bill with additional payment to the provider on a bill previously reported and accepted?

A: Resubmit this bill using BSRC 05 Replacement with the following requirements: 1) total charge per bill must be the same as the amount reported in previously accepted bill, 2) total amount paid per bill must include both additional and prior payments, 3) total amount paid per line must include both additional and prior payments, 4) bill and line adjustments must include prior payments/adjustment and current adjustments, 5) date of the bill will be the date provider submitted request for reconsideration or appeal, 6) date insurer received bill will be the date the insurer or claims administrator received the request for reconsideration or appeal, 7) prior actual amount paid will be the total amount paid to the provider prior to the request for reconsideration or appeal.

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About types of reported medical bills

Q. What medical bill types are reported to WCIS?

A: Professional, institutional, dental, pharmacy, and lien bills are reported to WCIS.

Q. When did WCIS start collecting medical bill data?

A: The WCIS started collecting medical bill data on September 22, 2006, for all bills with a date of injury of March 1, 2000 and a date of service on or after September 22, 2006.

Q: What happens if a bill with a date of injury prior to March 1, 2000 and a date of service after September 22, 2006 is reported to WCIS?

A: As long as the corresponding FROI is reported and accepted in WCIS, the medical bill will be matched with the FROI and the bill will be processed. However, if the FROI for the bill has not been accepted then the medical bill will be rejected.

Q: What is the time line for reporting medical Bills?

A: According to the WCIS regulations (Title 8 CCR 9702 (e)), all paid, denied and settled bills should be reported to WCIS within 90 calendar days of the bill payment, denial or settlement.

Q: Are bills denied for being incomplete reported to WCIS?

A: No. Incomplete bills that receive a 277CA as incomplete are not reported. Note these are different from bills denied after final determination of the bill. The latter are reportable to WCIS.

Q: Are interpreter bills reportable to WCIS? If yes, what code is used?

A: Yes. Interpreter bills are reportable to WCIS. Use code T1013.

Q. Are transportation bills reported to WCIS?

A: Yes. Medical transportation costs are reported to WCIS using the appropriate HCPCS code.

Q: Are copy service bills reported to WCIS?

A: No. Copy service bills are not reportable under WCIS medical bill reporting.

Q: Are there any provider types excluded from the state reporting requirement, such as ambulance or home health providers, since the billed information tends to differ from that of a medical doctor?

A: No. The state expects all provider types that have a corresponding AMA taxonomy code and description to report medical bills to the WCIS. For example:

  • AMBULANCE / TRANSPORT SERVICES - 341600000X
  • HOME HEALTH CARE SERVICE - 163WH0200X

Q: Are medical bills for injuries to longshoremen (Longshore and Harbor Workers’ Compensation Program) and seamen (Jones Act) to be reported to the California WCIS?

A: Usually not. Claims that are exclusively administered under the Federal Workers' Compensation Statues, such as the Longshore and Harbor Workers' Compensation program, are exempt from WCIS reporting as are bills for other federal programs. In cases of concurrent jurisdiction, where the injury falls within the jurisdiction of both a federal statute and the California workers' compensation laws, claim information, benefit payments and medical bills should be reported to WCIS, especially if a case is opened with the WCAB and a settlement is brought for approval.

Q: Do claim administrators report medical bills that are denied?

A: Yes, denied medical bills are reportable. The requirement is for the payer to report the detailed medical payment records with a zero in the Total Amount Paid Per Bill (DN0516) if the entire bill is denied. The payer reports the Bill Adjustment Group Code (DN0543) and the Bill Adjustment Reason Code (DN0544) in the 2320 CAS segment indicating the reason for the denial. For any line that is denied on a bill, the Total Amount Paid Per Line (DN0574) is equal to zero. The payer reports the Service Adjustment Group Code (DN0731) and the Service Adjustment Reason Code (DN0732) in the 2430 CAS segment indicating the reason for the denial.

Q: For denied bills, is it necessary to report line items?

A: Yes, line item reporting is required for denied bills.

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About Providers

Q: What is reported when a provider does not have a National Provider Identification (NPI)?

A: The reporting requirement of an NPI is triggered by whether the provider is eligible for an NPI or not. For providers that are not eligible for an NPI, report the license number. If the provider is eligible to neither have an NPI nor a license number, report license number 999999999.

Q: The WCIS collects information on DN 0667 Supervising Provider National Provider ID and DN 0699 Referring Provider NPI but not DN 0663 Supervising Provider State License Number or DN0695 Referring Provider State License Number. What is reported to WCIS if the Supervising Provider or the Referring Provider is not eligible for an NPI?

A: If the DN0663 Supervising Provider or the DN0695 Referring Provider is not eligible for an NPI, leave DN0667 blank.

Q: Is there a registry of National Provider ID where one can look for a provider’s NPI?

A: Yes. See the link below. Invalid NPI reported to WCIS will be rejected. https://npiregistry.cms.hhs.gov/

Q: According to the WCIS implementation documentation for Loop 2310A (Billing Provider Segments), the provider NPI is supplied in the NM1 segment and the FEIN is in the REF segment. However, the current format has them reversed (FEIN in NM1 and NPI in REF). Can you clarify that the new documentation is correct?

A: Yes, this is correct. In California Version 2.0, the NPI is reported on NM1 segment while the FEIN is reported on REF segment.

Q: What is the reporting difference between Billing Provider and Rendering Bill Provider?

A: Billing provider information is reported on Loop 2310A and applies to all lines reported on a bill. Rendering Bill provider information is reported on Loop 2310B and is required when the rendering bill provider is not the billing provider and only if Loop2420 does not have the rendering line provider information.

Loop 2310A Billing Provider and Loop 2310B Rendering Bill Provider apply to all service lines in Loop 2400. Loop 2310A Billing Provider must always be reported. You do not need to report Loop 2310B Rendering Bill Provider if the Billing Provider is also the Rendering Bill Provider and you do not populate Loop 2420 Rendering Line Provider. If you populate Loop 2420 Rendering Line Provider, all information on Loop 2310B Rendering Bill Provider will be overwritten because it can no longer be considered as the provider for all service lines in Loop 2400.

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About Provider Agreement Code

Q: Which Provider Agreement Codes (DN507) are accepted by the WCIS?

A: The following Provider Agreement Codes are accepted by the WCIS:

  • "H" = HMO Agreement
  • "N" = No Agreement;
  • "P" = Participation agreement; use this code when the service was rendered by an MPN provider. The Provider and the injured worker must be member of the same MPN.
  • "Y" = PPO Agreement

Q: Where can I get the MPN ID and MPN FEIN?

A: Get the MPN approval number for the MPN from the claims administrator. The first 9 digits of the MPN approval number are the FEIN of the MPN and the last 4 digits of the MPN approval number digits are the MPN ID.

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About Durable Medical Equipment

Q: How are durable medical equipment (DME) rental and purchase reported?

A: DME bills are reported on professional bills, in the SV1 segment. If a bill has a DME rental as well as a purchase of a DME, the rental is reported on one line and the purchase is reported on a different line.

Q: What is the difference between a hospital outpatient bill and a hospital inpatient bill?

A: Please refer to the NUBC’s definition of outpatient and inpatient in the National Uniform Billing Committee Official Data Specification Manual which is available for purchase.

Q: Could you please verify that the following codes (MDS10, MDO10, MDS11, MDO11, MDS21 and MDO21) will continue to be used with Version 2.0 for lump sum/medical lien payments and no codes will be removed or added?

A: The MD set of California Specific codes will not be used in California Version 2.0.

Q: We will be sending the SF, SP or AW value with Release 2.0, but if we continue to use the MD codes on the lines to pay the lien will they reject as invalid codes?

A: On Lien bills, California does not accept line level information. If lines are reported on a lien bill, the bill will be rejected.

Q. I have a bill accepted on BSRC 00 Original and need to submit BSRC 01 Cancellation. Do I need to send DN0511 Date Insurer Received Bill, DN0510 Date of Bill, DN0512 Date Insurer Paid Bill, and the required segments in loop 2310A Billing Provider Information when these are listed as NA in the CA guide?

A: Yes. Segments having these data elements are required segments under the X12 format and must be submitted in the correct format. These will be validated in 999 but not in 824.

Q: Is there a specific list of modifiers considered jurisdictional modifiers for DN0717 and DN0718?

A: Refer to the California Official Medical Fee Schedule.

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About pharmacy bills

Q: Are compound drugs reported to WCIS? If yes, how are compound drug reported in California Version 2.0?

A: Pharmacy dispensed compound drugs will be reported in the SV4 segment using the IAIABC Release 2 standards. DN0762Compound Drug Indicator “Y’ will be reported in SV410.

e.g. LX1 SV4*123457*N4:49884077905***1*****Y~ The dispensing fee, if billed together for all compounds, will be reported on one of the lines and the amount will be reported in the DN0579 Drugs/Supplies Dispensing Fee. If it is billed separately, then it will be reported on each service line of each compound.

Physician dispensed compound drugs are reported on Loop 2410. The different compounds of a drug are linked using the prescription number. If there is no prescription number, “link sequence number” is used to link the different components of a compound drug.

Q: Are compounding fees allowed for pharmaceutical compounds in California? If yes, how are they reported?

A: Yes, compounding fees are allowed according to California Labor Code §5307.1 (e) 2. For prescription bills, compounding fee can be reported on Loop 2400 using DN0579 Drugs/Supplies Dispensing Fee.

Q: For compound drugs reported on professional bills there is no data element value to link the ingredients. If submitter is supposed to derive ‘VY’ Link Sequence Number how should it be done?

A: REF01 VY= Link Sequence Number is not a data element. It is a number the data reporter creates and assigns to compound drug components. It should be unique to each compound drug on a bill but the same Link is assigned to all the components of a compound drug. The WCIS does not have specification on how Trading Partners should generate this linkage number. However the segment must follow the ID2/3 data specification of the IAIABC Guide.

Q: Can you please describe the full segments for the DN 0548 Billed DRG and DN0549 Paid DRG? It looks like they go into the HI segment under loop 2300?

A: Yes, they both go in the HI segment of 2300. This example shows DN0549 Paid DRG code of 416 and a DN0548 Billed DRG code of 417.

Example: HI*DR:416:::::417~

Q: What are the reference identification qualifiers to be used for identifying the DN0015 Claim Administrator Claim Number and the DN0005 Jurisdiction Claim Number?

A: The reference identification qualifier is ‘Y4’ for DN0005and ‘Y1’ for DN0015. All bills should contain both the REF*Y1*DN0015~ segment for Claim Administrator Claim Number and the REF*Y4* DN0005~ segment for Jurisdiction Claim Number

Q. If we have a repackaged drug where the repackaged NDC dispensed is not in the Medi-Cal database and the original labeler NDC is also not in the Medi-Cal database, we are to select an NDC with the average wholesale price of the lowest priced therapeutically equivalent drug to determine reimbursement. When reporting the NDC, which is a required data element for the Medical Bill Payment Record Reporting, what NDC should be sent to WCIS? Would it be the NDC used to determine reimbursement or the NDC that was on the provider/physician bill but was not used to make a payment determination?

A: On the NDC billed field DN0721 NDC Billed Code, report the “repackaged NDC” and “Original” codes regardless of the NDC being on the Medi-Cal drug list. For the “Paid NDC” field, normally the repackaged NDC will be reported but in cases where the repackaged NDC is not on the Medi-Cal drug list and the DWC regulations allows you to pay the “therapeutic equivalent drug” NDC, then the “therapeutic equivalent drug” NDC will be reported to WCIS on DN0728 NDC Paid Code.

Q: Is DN0699 Referring Provider National Provider ID reported on pharmacy bills? If yes, what is reported on this field?

A: Yes. The prescribing doctor’s NPI is reported as the Referring Provider NPI.

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About medical lien bills

Q: For Lien bills what date is reported for DN 0509 Service Bill Date?

A: Use the date of the lien filing.

Q: DN0293 (Lump Sum Payment Settlement Code) is listed as a mandatory field. The valid values are ‘SP’ (settlement partial), ‘SF’ (settlement full), and ‘AW’ (Award). How is this reported?

A: DN0293 should be reported only if a bill is a lien bill. DN0293 is reported on segment REF*SMC*DN0293~ at the bill level.

Q: In reviewing the Lien Bill Data Element Requirement Table in the CA EDI guide, for DN0760 (Prior Actual Paid Amount), there is an MC (Mandatory/Conditional) in the 00 – Original column. We would not have prior paid amounts on an original bill, so should this be changed to NA (Not Applicable)?

A: The 00 in this case would be the first lien bill you are submitting to WCIS. If you have not paid any amount on the bill prior to the bill being contested, then the condition for the requirement is not met so you will not report DN0760 Prior Actual Paid Amount for this particular bill.

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About matching

Q: Which data elements are used to match a medical bill to a reported and accepted FROI?

A: The WCIS uses a combination of DN0005 JCN, DN0015 Claim Administrator Claim Number and DN0006 Insurer FEIN to match a medical bill with a FROI.

Q: Which data elements are used to match previously submitted bills with a different Bill Submission Reason Codes? For example, matching a 02 Correction with a reported and accepted 00 Original?

A: A combination of DN0006 Insurer FEIN, DN0016 Employer FEIN, and DN0500 Unique Bill ID Number is used to match previously submitted bills according to CA version 2.0 standards. A combination of DN0006 and DN0500 Unique Bill ID Number is used to match previously submitted bills according to CA version 2.0 standards.

Q: In California version 1.1, if a bill had no error but did not match to a FROI we get a TE- Accepted with error acknowledgment. Will the WCIS use the Version 2.0 equivalent, IE, if a bill does not have a matching FROI?

A: The California Medical Version 2.0 does not use IE. The bill will be rejected.

Q: I have an original bill with a 00 Original BSRC accepted and later it was changed by a 02 Correction with a change in DN0501 Total Charge Per Bill. I am reporting a 05 Replacement. Does the DN0501 Total Charge per Bill remain the same for the 00 Original and 05 Replacement?

A: No. The DN0501 Total Charge Per Bill amount on the 05 Replacement must match that reported on the 02 Correction.

Q: I have a 00 Original bill accepted. I am reporting a 05 Replacement must the DN0501 Total Charge per Bill be the same for the 00 Original and 05 Replacement?

A: Yes.

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About balancing payment at line and bill level pay

Q: What are the different rules to individually balance the charged amounts and paid amounts in WCIS for all bills?

A: Use the following formula to balance payments for all bill types except lien bills:

DN0516 Total Paid Per Bill = sum of DN0574 Total Paid Per Line.

Use the following formula to balance charge amounts for professional, dental and institutional bills:

DN0501 Total Charge Per Bill = sum of DN0552 Total Charge Per Line.

Use the following formula to balance charge amounts for pharmacy bills:

DN0501 Total Charge Per Bill = sum of DN0572 Drug/Supplies Billed Amount.

Q: Should I balance the bill level charge, payment and adjustment amounts?

A: Yes. Use the following formula for all bill types:

DN0501 Total Charge Per Bill = DN0516 Total Paid Per Bill + (sum (DN0545 Bill Adjustment Amount) + sum (DN0733 Service Adjustments Amount))

Q. I have a bill that was not adjusted at the bill level. Will I do a line level balancing?

A: Yes. Use the following formula for professional, dental and institutional bills:

DN0552 Total Charge Per Line = DN0574 Total Paid Per Line + sum of DN0733 Service Adjustment Amounts.

Use the following formula for pharmacy bills:

DN0572 Drugs/Supplies Billed Amount = DN0574 Total Paid Per Line + sum of DN0733 Service Adjustment.

Q. Are we required to send bill level adjustment with a value of $0 if the bill was not adjudicated at the bill level but adjusted only at the line level?

A: If the bill is adjudicated at the line level only, the bill level adjustment will not be reported. It will be null.

Q. If total paid amount is greater than total billed amount because of self-executing penalties, how should we handle DN0733 (Service Adjustment Amount) for the balancing rules? Can we report a negative number in order to balance?

A: Yes, negative numbers are accepted as adjustments. Negative adjustments increase the payment.

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About Data Reporting by DN Number

Admission Hour (DN0622)

Q: DN0622 (Admission Hour) and DN0623 (Discharge Hour) are not required fields for the 4010. Will they be required with the 5010 version?

A: Yes.

Billing Provider FEIN (DN0629)

Q: Is Billing Provider FEIN required for all bill types?

A: Yes.

Billing Type Code (DN0502)

Q: When do I report DN0502 Billing Type Code in Version 2.0?

A: In Version 2.0 DN0502 Billing Type Code is reported for aggregate summary bill only.

Claim Administrator Claim Number (DN0015)

Q: Could you please clarify reporting of “Take Over “Workers’ compensation claims from a prior Insurer? Do we need to retain the original Insurer's claim number and report it or would a new “Take Over Carrier” Claim Number be reported?

A: Prior to reporting medical bills on acquired claims, the acquired claim must first be reported on a FROI according to the WCIS FROI/SROI Guide. Once the FROI is reported then you can use the new claim number on medical bill reporting. Use 2010CA to report the new claim number (REPLACEMENT CLAIM ADMINISTRATOR CLAIM NUMBER) on REF02. The qualifier that is reported on REF01 for the new claim number will be 9E=Replacement Claim Number. On any subsequent reporting for this claim, you will report only the new claim number.

Date of Injury (DN0031)

Q. How is the Date of Injury for cumulative injuries defined in CA Workers’ Compensation Information System?

A: According to California Labor code section 5412. “The date of injury in cases of occupational diseases or cumulative injuries is that date upon which the employee first suffered disability therefrom and either knew, or in the exercise of reasonable diligence should have known, that such disability was caused by his present or prior employment.”

Q: Does WCIS have a different validation logic for cumulative injuries?

A: Yes. The WCIS checks against the FROI database to see if a claim is a cumulative injury, i.e. Nature of Injury between (60 and 80). If this is true, WCIS does not enforce the rule “Date of Injury must be greater than, Date of service”.

Diagnosis Code (DN0522)

Q: There is no field to populate the ICD in NCPDP form. Is the ICD required on pharmacy type bills?

A: No, DN0522 Diagnosis code is not required for Pharmacy bills.

Q: Are diagnosis codes reported with decimal in California Version 2.0?

A: No. Diagnosis codes are not reported with a decimal.

Insurer FEIN (DN0006)

Q: Is DN 0006 Insurer FEIN mandatory?

A: Yes, Insurer FEIN (DN 0006) is a mandatory data element.

Q: Is Insurer FEIN used for matching?

A: Yes. A combination of JCN, claim administrator claim number and insurer FEIN is used to match a medical bill with a FROI.

Managed care organization FEIN (DN0704)

Q: Where can I find the MPN FEIN?

A: Obtain the MPN approval number from the claims administrator. The first 9 digits of the approval number is DN0704 and the last 4 digits are DN0208.

Outpatient Reason for Visit Code (DN0520)

Q: Can you list the DNs required when DN0520 Outpatient Reason for Visit Code is reported?

A: DN0520 Outpatient Reason for Visit Code is reported on outpatient institutional bills only when all of the following three conditions are met: DN0504 Facility Code is in (13, 78, 85); DN0576 Revenue Paid Code is in (0450, 0516, 0526, 0726); and, DN0577 Admission Type Code is in (1, 2, 5).

Principal Diagnosis Code (DN0521)

Q: You have DN0522 listed as Mandatory for professional bills. DN 0521 Principal Diagnosis Code should be mandatory but DN0522 may or may not exist.

A: IAIABC’s IRR MED 803 was approved to remove DN0521 from professional bills. Following that the WCIS does not require DN0521 on professional bill instead DN0522 in WCIS was made a required element. The first diagnosis on a professional bill is reported on HI01.

Procedure Code Description (DN0551)

Q: Should DN0551 Procedure Code Description be reported for all bills?

A: DN0551 Procedure Code Description is reported to WCIS only for unlisted procedures.

Q: For module 2 you have multiple “Paid DNs” listed as Mandatory elements. Typically, I would not be sending these DN's for a rejected bill (not Paid). We send spaces for “Paid DNs” on a rejected bill for example DN 0576 Revenue Paid Code. Are you changing this logic for version 2.0?

A: In CA Version 2.0 “Paid DNs” must be reported and not filled with spaces for rejected bills. “Paid DNs” for rejected bills will repeat the same code as shown on the “Charged DN”. For example, DN0576 Revenue Paid Code on a rejected bill will be the same as the DN0559 Revenue Billed Code.

Q: What is the length of DN 0576 Revenue Paid Code and DN0559 Revenue Billed Code in version 2.0?

A: The length for DN0559 Revenue Billed Code and DN 0576 Revenue Paid Code is 4 characters. The WCIS uses code lists adopted by the DWC e-billing rules. In this case refer to the National Uniform Billing Committee Official Data Specification Manual.

Provider Agreement Code (DN0507)

Q: If the medical provider belongs to a DWC-approved medical provider network (MPN), but the injured worker receiving the medical services does not belong to the same MPN as the provider, then should the code "P" be sent to the WCIS for the provider agreement code (DN507)?

A: No, a code "P" should only be sent when the provider and the injured worker receiving the service both belong to the same, DWC-approved MPN.

If the medical provider has a PPO agreement with the payer, enter "Y" ; if neither the medical provider or the injured worker belong to the same MPN, or the payer does not have a PPO agreement with the provider enter "N."

Rendering Bill Provider FEIN (DN0642)

Q: Does every bill need to contain a Rendering Bill Provider FEIN?

A: Rendering Bill Provider FEIN is required when the Rendering Bill Provider FEIN is different from the Billing Provider FEIN.

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About Acknowledgements

Q: Does the WCIS acknowledge every 837 file it receives?

A: Yes. Every 837 file will first be acknowledged with a 999 acknowledgment and if free of envelope level error, followed by an 824 acknowledgment. If there is an error in the interchange envelope a 999 with only the TA1 segment will be generated.

Q: Will a file with the wrong file naming convention be processed?

A: No. The file will neither be process nor acknowledged. If you do not receive an acknowledgment for a file, contact your EDI Contact Person.

Q: Will the WCIS generate a 997 acknowledgment in Version 2.0?

A: No. In California Medical Version 2.0, the 999 acknowledgment has replaced the 997 acknowledgment WCIS used in California Medical Version 1.1.

Q: What conditions would prompt an IE code to be assigned to a transaction?

A: California Medical Version 2.0 does not use the IE Accepted with error code.

Q: Where can I find 824 error codes used in CA Version 2.0?

A: Please refer to Section VIII of California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, April 6, 2016.

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About Electronic Billing

Q: Does California have workers' compensation regulations that require the adoption of standardized medical billing forms and electronic billing standards?

A: Yes, the DWC has adopted regulations for standardized paper billing forms, standardized paper explanation of review and e-billing standards.

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March 2016