WCIS eNews No. 68
November 19, 2007

WCIS medical bill reporting requirements

DWC\WCIS staff has received information from trading partners indicating that some claims administrators have refrained from sending billing information for bills that comprise, or may become part of, a medical lien.  This claims administrator behavior is asserted to occur because the claims administrators do not intend to pay the bills.  Also, some claims administrators are excluding medical bills from the EDI process (that is, from transmittal of the billing information to the WCIS) and, instead, ask bill review companies just for review-only information about the bills.

These practices are not consistent with current WCIS reporting requirements, which require all medical bills with a date of service on and after September 22, 2006 to be reported.

The WCIS requirements regarding the reporting of medical billing does not distinguish between bills that may become part of medical liens or bills where payment is deferred by a claims administrator until a decision/settlement is reached. Title 8, California Code of Regulations section 9702(e) provides in pertinent part:

"On and after September 22, 2006, claims administrators handling one hundred and fifty (150) or more total claims per year shall submit to the WCIS on each claim with a date of service on or after September 22, 2006, the following data elements for all medical services for which the claims administrator has received a billing or other report of provided medical services. …The claims administrator shall submit the data within ninety (90) calendar days of the medical bill payment."

The notification to a medical provider that a submitted medical bill will either be contested or denied (for example, the notification required under Labor Code section 4603.2(b)), is considered a bill payment that triggers the 90 day reporting timeline in section 9702(e).  Under the IAIABC standards, a "zero payment," which is a denial of a provided medical service(s), is a payment that is reported under DN574, Total Amount Paid Per Line (value = 0).

The DWC greatly appreciates your cooperation and participation. If you have any questions or need help concerning this process, please contact your EDI liaison:

Elisema Cantu
email: ecantu@dir.ca.gov
phone: 510-286-6763
fax: 510-286-6862
Trading partner letters B, D-F, N, O, W-Y

Damon Chen
email: dcchen@dir.ca.gov
phone: 510-286-6753
fax: 510-286-6862
Trading partner letters C, G, H, M, P

Johnny Lee
phone: 510-286-6772
fax: 510-286-6862
Trading partner letters A, I-L, S-V, Z

Contents of this bulletin do not change existing regulatory requirements; they provide additional or revised detail about the technical implementation of those requirements. All technical changes will subsequently be reflected in other WCIS documentation. Any bulletin can be forwarded as needed, but should be forwarded in its entirety and without modification. If you have received a forwarded copy of this bulletin and are concerned about its authenticity, you can view this and previous bulletins on our WCIS web site: http://www.dir.ca.gov/dwc/wcis.htm.

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