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Division of Workers' Compensation (DWC)

Answers to frequently asked questions about reporting medical bill payment records to the California WCIS

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About getting started

Q. What version of the California EDI Implementation Guide for Medical Bill Payment Records is current?

A.  The California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: When should a trading partner profile be sent to DWC/WCIS?

A: Completing a trading partner profile form is the first step in reporting medical record EDI data to the WCIS; it also should be completed and sent when the information on the previously submitted profile has changed. See page 19 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: What is the California DWC/WCIS nine-digit zip code to be utilized in the medical billing trading partner profile?

A: 94612-1489

Q: What steps are used for testing?

A: There are five steps used for testing: (1) complete the medical EDI trading partner profile; (2) sender send FTP connectivity;; (3) sender transmits numerous ANSI 837 bill types; (4) production structural testing; (5) Detail testing. See pages 29-37 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Are there communication (transmission mode) alternatives available, such as web entry of the data?

A: No, there is only one communication mode for medical billing data: FTPS.

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

A: No. The deadline for applying for a variance has passed: the date of the variance request had to be prior to Sept. 22, 2006.

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About bills that should be reported and the timeline for corrected submissions

Q: Does SB826 allow for penalties on invalid or missing data reporting?

A: SB 826, which was signed into law by the Governor on October 7, 2011, amends Labor Code sections 138.6 and 138.7 by authorizing the Division of Workers' Compensation (DWC) to assess administrative penalties for the failure by a claims administrator to report accurate claim information to the Workers' Compensation Information system.

  1. Requires DWC to assess administrative penalties for WCIS data reporting violations.
  2. Requires DWC to promulgate a schedule of penalties capped at $5,000 against a claims administrator in any given year. The schedule shall provide for no more than $100 per violation for violations where a report is not submitted or not accepted, and no more than $50 per violation for violations involving errors or late filings.
  3. Requires that the penalty schedule establishes threshold rates of violations that shall be excluded from the calculation of penalty assessments. The threshold rates, to be determined by DWC, cannot be less than 3% of the reports filed by the claims administrator. SB 826 further authorizes DWC to establish higher thresholds for data elements (required claim information) that are not reasonably available.
  4. Requires DWC to publish an annual report on the compliance of claims administrators, and authorizes claims administrators to be named in the report.

The assessment of administrative penalties for non-compliant WCIS reporting constitutes a major shift in the manner by which the WCIS operates. From 2002 to the present, DWC solely relied upon its trading partners to submit complete and accurate data to WCIS, as there was no express statutory authority to directly penalize claims administrators for a failure to submit data or a failure to submit accurate data. SB 826 now provides DWC with a valuable enforcement tool to ensure the quality of the WCIS database.

DWC is currently analyzing both the language of SB 826 and the WCIS reporting system to determine the most efficient and cost-effective method for assessing penalties. We anticipate stakeholder input either through the annual WCIS Advisory Committee meeting or scheduled public forums. The hope is that an acceptable penalty structure will be in place by June 2013. Please check DWC's website on a regular basis for updates and information. To sign up for direct updates on WCIS, please sign up for the WCIS E-News by sending an email request to wcis@dir.ca.gov

Q: Are bills processed for payment with a date of service on or after Sept. 22, 2006 required to be reported in the EDI medical billing data to the WCIS?

A: Yes, on or after Sept. 22, 2006, claims administrators handling 150 or more total claims per year shall submit to the WCIS on each claim with a date of injury on or after March 1, 2000 and for each bill with a date of service on or after Sept. 22, 2006, data elements listed in the CA EDI Implementation Guide (Medical Bill Payment Records) for all medical services for which the claims administrator has received a billing or other report of provided medical services.

Q: Are bills processed for payment with a date of service prior to Sept. 22, 2006 or a date of injury prior to March 1, 2000 required to be reported as EDI medical billing data to the DWC?

A: No, it is not required to report these bills, but if reported the WCIS will validate and accept them.

Q: When should claims administrators submit medical bills to the WCIS?

A: The claims administrator shall submit the medical billing data within 90 calendar days of the medical bill payment.

Q: If the claims administrator is under the threshold of 150 claims in Sept. of a given year, but they exceed the 150 claim level by Dec., will they need to go back and report the billing data for those claims when they were under the 150 claim limit?

A: Yes.

Q: Are long-term asbestos claims to be counted toward the threshold of 150 claims for reporting purposes?

A: Yes. All open, closed and denied claims with a date of injury on or after March 1, 2000 would be included in the150 annual count.

Q: What is the timeframe for the resubmission of corrected data for which the trading partner has received a "TR" transaction rejected in the detailed 824 acknowledgement?

A: All corrected medical bills should be reported immediately after the correction is completed.

Q: What is the nature of penalties regarding medical bill reporting?

A: Currently, there are no regulations with respect to penalties for non-compliance with the DWC/WCIS reporting requirements for medical data. DWC is in the process of drafting administrative rules based on Labor Code sections138.6 and 138.7.

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About types of reported medical bills

Q: Are expenses incurred for medical deposition of a provider reportable to WCIS under the Medical Bill Payment Records reporting?

A: Yes. Medical depositions of providers are reportable to WCIS under the Medical Bill Payment Records using the appropriate HCPCS code, 99075.

Q: Are home health billings subject to state reporting because the CA fee schedule does not have any provision for home health services and these bills probably have not been reviewed by California OMFS?

A: Yes. The reporting regulation - 9702(e) - requires submitting "…data elements for all medical services for which the claims administrator has received a billing or other report of provided medical services." A home health services bill is not exempt from WCIS reporting; the fact that the service is not covered under the OMFS is really not a consideration.

Q: Are "First Aid" bills subject to reporting to the California WCIS?

A: Yes. If a medical provider bills for treatment, services, or medical supplies related to first aid and a FROI is filed with the DWC/WCIS.

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' Compensationprogram, are exempt from WCIS reporting. 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: Will detailed medical bill payment record EDI reporting replace the SROI annual reporting (AN) requirement?

A: No. The SROI annual report (AN) is different from detailed medical bill payment record data reporting. The SROI annual report contains the total dollars spent on a claim in a year, including dollars paid on both medical and indemnity benefits.

Q: Are medical record copying expenses reportable medical data elements?

A: No.

Q: Is third-party service provider information reportable medical data elements?

A: Yes. The billing provider information for DN528, DN629, DN630, and DN642 are reportable if the third-party billing provider is not the rendering provider.

Q: In addition to each medical bill, a small amount is paid to a bill review company. This amount is not included in the billed amount but is added to the paid amount. Does the DWC want this amount to be reported?

A: Yes. In general, overhead/administrative expenses are reportable in the SROI utilizing DN95, but not in the detailed medical bill payment reporting. The amount paid for bill review (administrative cost) should be attributed to each claim as a cost of administering the claim.

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: 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 (DN516), if the entire bill is denied. The payer reports the bill adjustment group code (DN543) and the bill adjustment reason code (DN544) 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 (DN574) is equal to zero. The payer reports the service adjustment group code (DN731) and the service adjustment reason code (DN732) in the 2430 CAS segment indicating the reason for the denial.

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About acknowledgments (997 and 824)

Q: Does the sender always receive a 997 before the 824?

A: Yes, the sender will always receive a 997 functional acknowledgment before receiving the 824 detailed acknowledgment from the DWC/WCIS. For a more complete description of the 997 functional acknowledgement and correcting any errors communications loop see pages 31 - 33 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: If a bill is submitted for a claim without a FROI on file, how will the WCIS handle these bills?

A: The DWC/WCIS will transmit an 824 detailed acknowledgment "TE" to the sender. See pages 77 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011. for a more complete description of the unmatched claims process.

Q: What does TE "No match on database" mean?

A: All claim administrator claim numbers (DN15) reported in the detailed medical reports are matched with a first report of injury in the WCIS. If no matching FROI is found, the WCIS sends a "TE" transaction accepted with errors in the OTI segment and a "039, no match on the database" error in the LQ segment of the 824 for each bill reported for the unmatched claim.

Q: Will the LM loop be included in the 824 files? It is not included in the CA guide on page 55.

A: The LM segment is included in the 824 detailed acknowledgment when a "TE" or "TR" is included in the OTI segment. If a "TA" is included in the OTI segment then the LM segment is not included in 824 detailed acknowledgment.

Q: Will the 824 return errors for data that are in 2010AA/Insurer loop, 2000B, 2010BA/Employer loop, 2000C, 2010CA /Claimant loop? Will the sender receive an OTI segment for each 2300 loop reported? What will the sender get back in the 824 if the data error is in one of the loops listed above?

A: For any loop above the 2300 loop, the sender will receive an OTI for each DN500 contained in the file that is hierarchically related to the 2010AA and 2010CA loops containing the error. The 824 will contain an LQ segment indicating the error code for the error and a copy of the bad data in the last RED segment.

Q: What does the phase "Duplicate Batch Header" in the RED segment containing the bad data mean?

A: When the sender transmits an 837 with an identical BHT segment containing the same data values for all the data elements, the WCIS puts the phrase "Duplicate Batch Header" in the RED segment containing the bad data field to indicate a duplicate BHT segment.

Q: What is the purpose of DN266?

A: The transaction tracking number, DN266, is a unique number assigned by the sender to each transaction (bill) being sent. The sender should never reuse the same transaction tracking number.

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About general - 837 transactions

Q: What fields are used to detect a duplicate medical bill?

A: The WCIS compares the insurer FEIN, claim administrator claim number, unique bill identification number, and the string of line number in each bill to detect duplicate medical bills. When the same data values for all the above-listed data elements occur, the WCIS puts the 057 error in the LQ segment and the unique bill identification number in the RED segment containing the bad data field in the 824 detailed acknowledgement.

Q: Is there a limit to the size of an 837 file that can be accepted by the WCIS?

A: Yes, the size of an 837 file cannot exceed one gigabyte.

Q: If the payer voids or cancels a check to a provider, is this information to be reported to the state?

A: Yes, if the following set of circumstances has occurred:

  1. The trading partner has transmitted an 837 to the California DWC/WCIS and has received an "A" in the 997 and a "TA" in the 824 for the affected bill.
  2. The trading partner corrects any bill contained in the original 837 by changing the amount paid to "zero" (i.e. cancels a check).
    The trading partner should follow the procedure entitled "Updating data elements (BSRC =01) (ACC=TA) on pages 74 and 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Some trading partners process medical bills from numerous medical providers, therefore, their 837 bill payment file will contain a mixture of dental, durable medical, HCFA, pharmacy, and UB bills. Should each bill type be contained within its own GS/GE envelope?

A: No. All bill types can be included in the same ST-SE transaction set. The 837 transmission should include only one ISA-IEA interchange control header/trailer and only one GS-GE functional group header/trailer.

Q: The 837 file can be created with the provider, subscriber, and patient information grouped or with the provider, subscriber, and patient information repeated. Which format is accepted by WCIS?

A: The California DWC/WCIS has adopted the hierarchical structure contained in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009, section 2. The IAIABC hierarchical structure groups medical bills/services by insurer, employer, and patient. The IAIABC structure does not group by provider, but instead requires the provider to be associated with each line on a medical bill.

Q: Will all the information trading partners need for 837s be found at the Washington Publishing Company in the following HIPAA versions: Professional version X098A1; Institutional, facility version X096A1; Dental version X097A1?

A: No. Trading partners should utilize section 2 - Medical Bill Payment Records ANSI Implementation Guide of the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009.

Q: What is the inbound naming convention for trading partners to use to send the 837?

A: In general, the California DWC/WCIS has no naming convention, although each trading partner's naming convention is verified during the connectivity phase of testing to insure no duplicate naming conventions between individual trading partners.

Q: Is the naming convention :<State indicator><Trading Partner Fein><Nine Digit Trading partner zip><Insurance carrier FEIN number><Record type><Test/Production indicator><Date><Time>.txt, acceptable?

A: Yes.

Q: In the California medical implementation guide (page 43), there is only a CAS segment for the 2320 loop. Should the sender include the SBR segment before the CAS segment?

A: The SBR segment is situational. If the CAS segment is utilized to report adjustment reason codes and adjustment amounts, then the SBR segment is required. If the CAS segment is not utilized to report adjustment reason codes and amounts then the SBR segment is not required.

Q: Can a blank or default value be sent in the 2310BA loop - employer NM1 segment (employer name)?

A: No. The California DWC/WCIS has adopted the IAIABC standard, which requires at a minimum the following string in the 2310BA Loop. NM1*36*2~

Q: Can trading partners report one total payment for several bundled medical bills paid at one time as the result of a resolved lien?

A: Yes, utilizing one of the six IAIABC-designated jurisdictional code values. For more details see pages 83 and 84 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: If the 837 file contains optional fields (data elements) that may create situational segments, will the 837 file with optional/situational segments pass the 997 structural edits?

A: Yes, situational segments can be transmitted. Page 59 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.states "O = Optional The data element is sent if available. If the data element is sent, the data edits are applied to the optional data element.”

Q: Does WCIS use "4010"?

A: Yes. Interchange version ID reported is 4010.

Q: What fields are used to detect duplicate batch transmissions?

A: The DWC/WCIS defines each ST-SE transaction set to be one batch. To detect duplicate batches the WCIS compares the batch control number, date transmission sent, time transmission sent, and sender ID to all other batches previously reported to the WCIS.. When the same data values for all the above-listed data elements occur, the WCIS puts the 057 error in the LQ segment and the phase "Duplicate Batch Header" in the RED segment containing the bad data field in the 824 detailed acknowledgment.

Q: What fields are used to detect a duplicate medical bill?

A: The WCIS compares the insurer FEIN, claim administrator claim number, unique bill identification number, and the number of lines in each bill to detect duplicate medical bills. When the same data values for all the above-listed data elements occur, the WCIS puts the 057 error in the LQ segment and the unique bill identification number in the RED segment containing the bad data field in the 824 detailed acknowledgment.

Q: If a situational segment is listed on the 837 summary on pages 60 thru 66 of the California guide, and the data element(s) listed under the segment is/are conditional, and the conditional elements are not passed, can the segment be omitted from the file, or does the segment need to be passed but the data element left blank?

A: Yes, situational segments can be omitted. For instance, if the sender were transmitting detailed "pharmaceutical" bill record payments, the sender would not be required to send the SV2 (Institutional) segment of the 2400 loop. There are numerous other situations where this rule would apply.

Q: If more than four diagnosis codes are listed on a physician bill and a trading partner's system can key in up to 30 diagnosis codes per bill, how many diagnosis codes can be sent per bill to the WCIS?

A: The California-adopted IAIABC 837 allows reporting of four diagnoses on a professional bill and 10 diagnoses on an institutional bill. Any more will result in an error message.

Q: Will repeating group codes in the CAS segments cause an error?

A: No. The number of repeats is specified in section 2 loop 2320 and loop 2430 of the IAIABC Implementation Guide for Medical Bill Payment Records, Version 1.1, July 1, 2009.

Q: With respect to the units on the CAS segment, is it the number of units reduced or is it the number of units billed on the original line?

A: The CAS segment contains DN546, which is the number of units reduced. The number of units billed, DN554, is contained in the SV1, SV2, and SV5 segments.

Q: Is the CAS segment at the bill level required when the paid amount is different than the billed amount?

A: Yes.

Q: If one line item is rejected in a multi-line bill, does the sender only correct and resend the rejected line item or the whole multi-line bill?

A: The entire multi-line bill. The sender should follow the procedure entitled "Updating data elements (BSRC=01)(ACC=TA) on pages 74 and 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Is a first report of injury (FROI) part of medical bills sent with an 837 or would that be a separate FROI/SROI report?

A: FROI reporting is a separate reporting requirement transmitted to the California DWC/WCIS in a separate electronic transmission (148) from the detailed medical bill payment record's 837 transmission.

Q: Is the insurer-claim administrator ID list required for medical bill EDI reporting as well, or only for FROI & SROI?

A: The claim administrator ID list is only required for FROI/SROI reporting, not for medical bill reporting.

Q:  Do trading partners need to include a list of all claim administrator FEINs with their trading partner profile?

A: Trading partners submitting medical billing data do not need to include an ID list of all claim administrator FEINs with their trading partner profile.

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About bill submission reason code - DN508 (00, 01, 05)

Q: What is the timeframe for the submission of bill submission 00 original medical billing data?

A: The claim administrator shall submit the data within 90 calendar days of the medical bill payment.

Q: What is the timeframe for the submission of a 01 cancellation?

A: For a 01 cancellation of an original bill, the data should be sent within 90 days of the date the 00 original submission was sent.

Q: If a trading partner sends a bill with an incorrect claim administrator claim number (DN15), how should this be corrected?

A: When an incorrect information including a claim administrator claim number or a FEIN was submitted, the 01 cancellation process should be used and the bill should be resubmitted with a 00. Please follow the procedure entitled "Updating data elements (BSRC=01)(ACC=TA)" on pages 74 and 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011...

Q: For an 05 Replacement to change the claim administrator claim number (DN15), is it necessary to send the same unique bill identification (DN500) to match up to the 00 original previously sent?

A: No, it is not necessary to send the unique bill identification (DN500) in the 2300 Loop Reference segment.

Q: On 00 Original submissions, does the WCIS track or store unique bill identifications (DN500)?

A: Yes, the WCIS stores the unique bill identification (DN500) in the database for all transmissions with a "TA" or "TE" in the 824. The WCIS also stores all bill and line information in the 01 cancellation.

Q: If an 00 original is submitted, then 01 is sent to cancel the original, can the new 00 original be sent with the same unique bill identification (DN500)?

A: Yes, if a 00 original is submitted, then 01 is sent to cancel the original, the new 00 original can be sent with the same unique bill identification (DN500).

Q: What if the date of injury for a given claim administrator claim number (DN15) is wrong, should the trading partner send an "01" to correct the date of injury?

A: Yes, follow the procedure entitled "Updating data elements (BSRC=01)(ACC=TA)" on pages 74 and 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Is it necessary to resubmit previously reported bills when submitting the 05 (Replace) to change the claim administrator claim number (DN15)?

A: No. follow the procedure entitled "Replacing a claim administrator claim number (BSRC=05) (ACC=TA)" on page 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Where can documentation detailing what loops/segments/elements required in the BSRC 01 record be obtained?

A: First, go through the medical data element requirement table on pages 60 through 66 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011. to compile a list of mandatory data elements for a BSRC = 01. The second step is to go through the ANSI summary table located on pages 39 through 45 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011. to determine which loops and segments the mandatory data elements for a BSRC = 01 are located, Finally, go to section 2 of the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July1, 2009, to add the ANSI requirements for each segment identified in the second step.

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About data reporting by data number (DN)

Bill adjustment reason code (DN544) and service adjustment reason Code (DN732)

Q: Does a trading partner only need to report at the service (line) level and not the bill level for pharmacy

A: No. Pharmacy bills are reported both at the line level and bill level.

Q: Why is there a need for both bill adjustment group codes (DN543) & bill adjustment reason codes (DN544) versus service adjustment group codes (DN731) & service adjustment reason codes (DN732)?

A: The California bill and line CAS segment mandatory triggers are "If paid amount is not equal to billed amount." If an adjustment occurs at the service level (i.e. the line level), it must occur at the bill level (sum of the line totals equals the bill total). A line-level adjustment cannot occur without a bill-level adjustment. If the sender sends one line per bill, then the line-level adjustment equals the bill-level adjustment.

Q: Can any of the five claim adjustment group codes be provided within the CAS segment?

A: Yes, any group codes included in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009, or published by the Washington Publishing Company can be provided within the CAS segment.

Q: Can the CAS adjustment amount be negative?

A: No, although the adjustment amount may be greater than the billed amount.

Q: Is California using only the latest approved ANSI adjustment reason codes?

A: No, the California DWC/WCIS has adopted the ANSI adjustment reason codes in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009 and the claim adjustment reason codes published by the Washington Publishing Company.

Q: If the group code and the reason code are the same for two adjustments (two line items in the same bill), is it necessary to have one CAS segment displaying the sum of two adjustments or are two CAS segments acceptable?

A: Each line adjustment should be reported separately.

Q: If a provider sends a bill with multiple lines and one of the lines on the bill was previously received and processed/paid, should the duplicate line be reported to the WCIS? Should the duplicate line be submitted with ANSI reason code "18" (duplicate) and zero amount paid?

A:  Yes, report the duplicate line. The amount paid would be zero. The claim adjustment reason code of 18 is acceptable or a B13, depending on the specific circumstances of the bill.

Billing provider NPI (DN634)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected

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Billing type code (DN502)

Q: How will DN502 for mixed bills be reported?

A: DN502 will not be reported for mixed bills. Bill type code (DN502) is only utilized in the CLM segment when the bill is an unmixed bill with 100 percent NDC codes, or with 100 percent HCPCS codes for durable medical equipment or supplies.

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Claim administrator claim number (DN15)

Q: If a claim administrator claim number (DN15) is sent in a bill incorrectly and needs changing, does the WCIS require the sender to send an "01" to cancel the original and resend the corrected claim administrator claim number in a new "00"?

A: Yes, follow the procedure entitled "Updating data elements (BSRC=01) (ACC=TA)" on pages 74 and 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Is DN15 mandatory?

A: Yes. Claim administrator claim number (DN15) is mandatory

Q. Does California consider DN15 a "critical claim element" for matching purposes in the WCIS database?

A: Yes. The claim administrator claim number (DN15) is utilized to match medical bill payment records to the FROI/SROI parts of the WCIS database.

Q: If a trading partner creates a new claim administrator claim number (DN15) every time a particular claim hits a certain dollar amount, does the trading partner need to send an "05"?

A: Yes, follow the procedure entitled "Replacement of a claims administrator claim number (BSRC=05)(AAC=TA)" on page 75 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

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Date of Injury (DN31)

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

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Employee SSN (DN42)

Q: What is the default for employee social security number (DN42)?

A: Use default values of all ‘999999999’ or ‘000000006’ if the injured worker is not a United States citizen and has no other identification (DN153, DN152, DN156). See page 62 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

Q: Do the CAS segments only apply to bill(s) that will be "zero pay"?

A: No. The CAS segments apply to all adjusted bills/lines, including the zero pay bill/lines.

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Facility NPI (DN682)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected.

Insurer FEIN (DN6)

Q: Is DN 6 mandatory.

A:Yes. Insurer FEIN (DN 6) is a mandatory data element.

Q: Does California use DN6 for matching purposes in WCIS?

Yes. The Insurer FEIN is utilized to match medical bill payment records to the FROI/SROI parts of the WCIS database.

Jurisdiction procedure billed code (DN715) and jurisdiction procedure paid code (DN729)

Q: Where can trading partners obtain the jurisdiction procedure codes that WCIS uses to edit DN715 & DN729?

A: The jurisdiction procedure codes that the WCIS uses to edit DN715 & DN729 are in a file on the DWC web site. Follow the link to physician services. Choose the excel spreadsheet for May 14, 2005 Table A 9789.11. In addition, you need to add:

ML101, ML102, ML103, ML104, ML105, ML106. The description of these codes are on the web site.

Additionally, the IAIABC has formulated new guidelines for reporting payment on "bundled" medical bill lien payments. The new guidelines provide for the following six codes to be added to the jurisdictional procedure paid code (DN729) to signify a "bundled" payment. Please add the six following codes (MDS10, MDO10, MDS11, MDO11, MDS21, MDO21) to your jurisdictional procedure paid code (DN729) look-up table as well as to your jurisdictional procedure billed code (DN715) look up table.

Code Description
MDS10 Lump sum settlement for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDO10 Jurisdiction orders a lump sum payment for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDS11 Lump sum settlement for multiple bills where liability for a claim was denied but finally accepted by the claims payer.
MDO11 Jurisdiction orders a lump sum payment for multiple bills where claims payer is found to be liable for a claim which it had denied liability.
MDS21 Lump sum settlement for a single medical bill where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDO21 Final order or award of the Workers' Compensation Appeals Board requires a lump sum payment for a single medical bill where the amount of reimbursement is in dispute between the claim payer and the healthcare provider.

Q: Are CPT codes required to be reported?

A: Yes.

Q: Does the WCIS distinguish between a jurisdiction code and a HCPCS code?

A: The WCIS makes no distinction between the two for reporting purposes.

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Managed care organization FEIN (DN704)

Q: Does the WCIS require the address information (N3 and N4) for loop 2310F or is it acceptable to send the name information (NM1 and N2) for loop 2310F instead?

A: The 2310F loop is utilized by the WCIS to gather information on California health care organizations (HCO). If the medical billing provider is a member of a California DWC-certified HCO (see Title 8, California Code of Regulations, Article 4, Certification Standards for Health Care Organizations), then the FEIN of the California DWC-certified HCO is sent as the managed care organization FEIN (DN704) in the 2310F loop, NM1 segment, field NM109. All other segments including the N2, N3 and N4 as well as all other data elements in the 2310F loop are optional.

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Provider agreement code (DN507)

Q: Is a medical provider network (MPN) flag required as being a participant if the allowance on the bill is 0.00?

A: Yes. Use provider agreement code "P" if both the provider and the injured worker belong to the same MPN regardless of the amount paid.

Q: Is an MPN flag required as being a participant if the allowance pays the full billed charge?

A: Yes. Use provider agreement code "P" if both the provider and the injured worker belong to the same MPN regardless of the amount paid.

Q: Is an MPN flag required as being a participant if there is a negotiated contract with the provider for a different discount other than the contract with the MPN network?

A: Yes, use provider agreement code "P" if the injured worker and the medical provider are both participants in the same MPN network even if the provider has a different discount other than the contract with the MPN network.

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; the service was provided within a medical provider network (MPN) approved by the DWC; in addition, the provider and the injured worker receiving the service both must belong to the same, DWC-approved MPN.
  • "Y" = PPO Agreement

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."

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Referring provider NPI (DN699)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected.

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Release of information code (DN526)

Q: Is DN526 release of information code required to be reported because workers' compensation is exempted from the HIPAA requirements?

A: No, the release of information code (DN526) is optional and not required to be reported.

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Rendering bill provider FEIN (DN642) and billing provider FEIN (DN629)

Q: What are the differences between a billing provider and a rendering bill provider that are located on the 837 layout?

A: The California DWC/WCIS requires the rendering bill provider information to be reported on each bill. The billing provider information is required only if different from the rendering bill provider information. The rendering bill provider in loop 2310B applies to all service lines in loop 2400. If no information is provided, then the billing provider is assumed to be the rendering bill provider for all services on the bill.

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Rendering bill provider NPI (DN647)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected.Back to top

Rendering bill provider state license number (DN643)

Q: Will trading partners be able to use default values for DN643 in the absence of a valid state license number for a provider?

A: In cases where the rendering provider state license number is unavailable or prohibitively costly to document, the California DWC/WCIS suggests following the IAIABC guidelines, which indicate default values should be sent to the jurisdiction as a string of 9s. A string of 9s is consistent with the California-adopted IAIABC data edits for DN643, "Must be A-Z, 0-9, or spaces." The suggested format is to utilize the format provided by the California Department of Consumer Affairs in the master file of all licensed medical providers in the State of California which is 8 digits (fields 9-16 license number) to be sent in REF02 127 in the 2310B Loop of the California-adopted IAIABC 837 transmission.

Q: If a trading partner sends a default value for the rendering bill provider state license number (DN643), can the trading partner send a default value for the taxonomy code as well?

A: No, a default value should not be sent for the taxonomy code.

Q: Currently, the rendering provider state license number is reported to the California Department of Consumer Affairs containing zeros, for example: PSY00009681. Is the current format acceptable to the WCIS, or must the zeroes be stripped out and only the "PSY9681" be reported?

A: The suggested format is provided by the California Department of Consumer Affairs in the master file of all licensed medical providers in California. This would include fields 6-8 license type and fields 9-16 license number including all zeros.

Q: On page 116, the California Medical Implementation Guide lists the Department of Consumer Affairs (DCA) as the source for licensed medical providers. In the DCA master file, each agency type has several license types (alpha prefix to the license number). Does the state have a list of prefixes that they will accept from each agency?

A: No. The California DWC/WCIS does not have a list of prefixes

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Rendering line provider NPI (DN592)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected.

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Supervising Provider NPI (DN667)

Q: Does the California WCIS accept the data elements for the national provider identification (NPI) numbers? 

A: Yes, the California WCIS accepts valid NPI numbers from trading partners.  Invalid NPI codes will be rejected.

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Total amount paid per bill (DN516) and per line (DN574)

Q: Can the paid amount be negative?

A: No. Neither DN516 nor DN574 would be reported as a negative value in the ANSI 837. DN516 or DN574 can be negative or positive within a payer's accounting framework, but not for reporting to WCIS.

Q: Are refunds to the payer allowed in the 837 medical bill reporting?

A: Yes. It is possible for the amount paid (DN516) to be greater than the amount billed (DN501).

Q: Can the charged amount (DN501) be negative?

A: No.

Q: Does a zero paid bill need to be reported separately within a claim?

A: No, all bills can be reported in the same 837 file in the same HL loop/segment.

Q: Do the LX segments (line items) need to be included for bills that were paid zero?

A: Yes, the line item detail is required.

About durable medical equipment

Q: With respect to durable medical equipment being reported on a physician invoice, if this occurs, is DN502 reported on a professional bill? Would DN567 be required for the professional bill?

A: If the bill is for durable medical equipment, then DN502 = DM.

  • If DN502 = DM and the durable medical equipment is "purchased," then DN566 is reported and DN567 is not reported.
  • If DN502 = DM and the durable medical equipment is "rented," then DN565 and DN567 are reported.

Q: For medical supply companies and durable medical equipment suppliers, how should state license numbers be reported?

A: In cases where the rendering provider state license number is unavailable or prohibitively costly to document, the California DWC/WCIS suggests following the IAIABC guidelines, which indicate default values should be sent to the jurisdiction as a string of 9s. The suggested format is to utilize the format provided by the California Department of Consumer Affairs in the master file of all licensed medical providers in the State of California, which is 8 digits (fields 9-16 license number) and is to be sent in REF02 127 in the 2310B Loop of the California-adopted IAIABC 837 transmission.

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About institutional bills

Q: Are admission date (DN513) and discharge date (DN514) mandatory for hospital invoices?

A: No, only if the patient is admitted and discharged. See page 60 and 61 of the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, November 15, 2011.

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

A: The third digit in the bill classification in field 4 of the UB04 will be a "1" or “2” for inpatient and a "3" for outpatient.

Q: California inpatient hospital bills are reduced based on a bill-level DRG code and not at the line-level revenue code. There is no line-level adjudication - only a bill-level DRG reduction. Should the savings or recommended allowance be spread over the lines because the reduction is at a DRG or bill level? How will total amount paid per line (DN574) be reported when there is only a bill-level payment, total amount paid per bill (DN516)?

A: Bill-level DRG adjustments should be reported in the bill-level CAS segment. The line-level detail of the bill would include the procedures utilized in the DRG grouping process. The total amount charged per line (DN552) and the total amount paid per line (DN574) for the line procedures can be zero.

Q: Is there a specific list of modifiers considered jurisdictional modifiers for DN717 and DN718?

A: The California official medical fee schedule (OMFS) physician fee schedule contains modifiers that are unique to California. The unique qualifiers may be sent as either jurisdictional or HCPCS modifiers.

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About pharmacy bills

Q: Is sterile water in a pharmaceutical compound allowed in California? If yes, how is it reported?

A: Yes. Sterile water is reported as an ingredient utilizing the appropriate NDC code, for instance NDC = 00409711807 "sterile water bulk" is acceptable in DN721, DN728.

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

A: Yes. Compounding fees including the amount charged, amount paid, and all adjusted amounts can be reported utilizing HCPCS_S9430 "Pharmacy compounding and dispensing services" in the SV1 segment. See DWC web site for the allowed amount.

Q: Are dispensing fees on a single prescription reportable? If yes, how are they reported?

A: Yes. Dispensing fees on a single prescription are reported with DN579_Drugs/Supplies Dispensing fee. See web site for the allowed amount.

Q: NCPDP edits - there are some data elements required only if pharmacy services are billed on the NCPDP form: Basis of cost determination, DAW, Dispense Fee. Will the state edit/check for all the data if one data element is reported?

A: No, the WCIS does not plan to "see one and then check all" for conditional data elements.

Q: Is the rendering bill provider primary specialty code (DN651) mandatory for pharmacy bills?

A: Yes. The code for a "retail pharmacy service provider: pharmacist" is 183500000X.

Q: If the NCPDP - specific data elements are not being captured on pharmacy bills, can the pharmacy bills be submitted as non-NCPDP (without the NCPDP- specific data elements)?

A: Yes. The California DWC/WCIS allows pharmacy bills to be reported in two alternative ways, either in a non-NCPDP format or a NCPDP format.

Q: Which of the following license numbers should be reported for pharmacy bills: the pharmacy license number, the pharmacist's license number, or the dispensing physician's license number?

A: The pharmacist's (person) license number is the rendering bill provider state license number (DN643). The pharmacy's (business) license number is the billing provider state license number (DN630). California does not collect information on the dispensing physician's license number on pharmacy bills.

Q: Is shipping and handling allowed for ancillary services in California? If yes, what code is it billed with?

A: Yes. For durable medical equipment, HCPCS_A9901 "DME delivery, set up, and/or dispensing service component of another HCPCS code" is acceptable.

Q: How should compound drugs be reported via the 837 in California?

A: Follow the NCPDP standard, which states: "supports compound prescription processing including up to 99 ingredients." It is recommended that not more than 25 ingredients be submitted at one time. Only one transaction per transmission is allowed when billing for a multi-ingredient.

Q: DN561 is dubbed a "prescription line number." What is this?

A: It is a unique number assigned by the dispenser to identify the prescription at the line level. It is located on the paper universal claim form and in the electronic NCPDP version 5.1.

Q: When are DN571 and DN554 reported?

A: If drugs are dispensed by a physician during an office visit (professional bill, DN502 not reported), then DN554 is reported. On a pharmacy bill if DN502 equals ‘RX’ or ‘MO’ then DN571 is reported.

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About lien bills

Q: For cases where liens exist and there are multiple liens for multiple bills for a lien claimant and all the liens are settled in one lump sum, how are these data reported to the WCIS?

A: Currently lien settlements are reported utilizing one of the six IAIABC-designated jurisdictional code values

Code Description
MDS10 Lump sum settlement for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDO10 Jurisdiction orders a lump sum payment for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDS11 Lump sum settlement for multiple bills where liability for a claim was denied but finally accepted by the claims payer.
MDO11 Jurisdiction orders a lump sum payment for multiple bills where claims payer is found to be liable for a claim which it had denied liability.
MDS21 Lump sum settlement for a single medical bill where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.
MDO21 Final order or award of the Workers' Compensation Appeals Board requires a lump sum payment for a single medical bill where the amount of reimbursement is in dispute between the claim payer and the healthcare provider.

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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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About relevant Web sites

Q: What is the Web site for the California DWC official medical fee schedule (OMFS)?

A: Official medical fee schedule (OMFS)

Medical-Legal Fee Schedule - Title 8 section 9795

Q: Where can HCPCS Level 1 codes and modifiers be obtained?

A: American Medical Association (AMA)

Q: Where can the HCPCS Level II codes and modifiers be obtained?

A: The Centers for Medicare & Medicaid Services (CMS) Obtain current HCPCS Level II codes at this Web page.

Q: Where can the rendering bill provider primary specialty codes (DN651) be obtained?

A: Here is the website:

Q: Where can the California state medical license numbers be obtained?

A: CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS (DCA)
400 R Street
Sacramento, CA

Q: Where can the revenue billed code (DN559) and revenue paid code (DN576) be obtained?

A: National Health Care Claim Payment/Advice Committee Bulletins

National Uniform Billing Committee
American Hospital Association
840 Lake Shore Drive
Chicago, IL 60697

Abstract: Revenue codes are a classification of hospital charges in a standard grouping that is controlled by the National Uniform Billing Committee.
The reference is located at:

National Uniform Billing Committee

Q: Where can bill adjustment reason codes (DN544) be obtained?

A: Claim Adjustment Reason Codes

Q: Where can the California physician OMFS codes and modifiers be obtained?

A: Official medical fee schedule - Physician services

Q: Where can the regulatory language for the analysis of accessibility that is driving the collection of the taxonomy codes be obtained?

A: Chapter 4.5 Division of Workers' Compensation. Subchapter 1 administrative director - administrative rules. Article 3.5 medical provider network. section 9767.5 access standards

Q: Where can the national provider ID numbers be obtained?

A: The source of the national plan and provider enumeration system is the Centers for Medicare and Medicaid Services

NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
1-800-465-3203

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September 2012