Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 1.1. Workers' Compensation Information Systems

§9701. Definitions.

The following definitions apply in this article:

(a) Bona Fide Statistical Research. The analysis of existing workers' compensation data for the purpose of developing or contributing to basic knowledge regarding the California workers' compensation system.

(b) California EDI Implementation Guide for First and Subsequent Reports of Injury. Contains California specific reporting requirements and information excerpted from the IAIABC EDI Implementation Guide for First, Subsequent, Acknowledgment Detail, Header & Trailer Records, Release 1, issued February 15, 2002, by the International Association of Industrial Accident Boards and Commissions. The California EDI Implementation Guide for First and Subsequent Reports of Injury is posted on the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, and is available from the Division of Workers' Compensation upon request.

(1) For reporting prior to November 15, 2011, use the California EDI Implementation Guide for First and Subsequent Reports of Injury, Version 2.1, dated February 2006, which is incorporated by reference.

(2) For reporting on or after November 15, 2011, but before the date of the California EDI Implementation Guide for First and Subsequent Reports of Injury, Version 3.1, dated March 27, 2018, use the California EDI Implementation Guide for First and Subsequent Reports of Injury, Version 3.0, dated November 15, 2011, which is incorporated by reference.

(3) For reporting on or after March 27, 2018, use the California EDI Implementation Guide for First and Subsequent Reports of Injury, Version 3.1, dated March 27, 2018, which is incorporated by reference.

(c) California EDI Implementation Guide for Medical Bill Payment Records. Contains the California-specific protocols and excerpts from the IAIABC EDI Implementation Guide for Medical Bill Payment Records, explains the technical design and functionality of the WCIS system, testing options for the trading partners, instructions regarding the medical billing data elements, and reporting standards and requirements. The California EDI Implementation Guide for Medical Bill Payment Records is posted on the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, and is available from the Division of Workers' Compensation upon request.

(1) For reporting prior to April 6, 2016, use the California EDI Implementation Guide for Medical Bill Payment Records, Version 1.1, dated November 15, 2011, which is incorporated by reference.

(2) For reporting prior to September 27, 2017, use the California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, dated April 6, 2016, which is incorporated by reference. For reporting on or after September 27, 2017, use the California EDI Implementation Guide for Medical Bill Payment Records, Version 2.0, dated September 27, 2017, which is incorporated by reference. This Guide adopts ASC (Accredited Standards Committee) X12 Implementation Acknowledgement for Health Care insurance (999) dated February 2011.

(d) California Jurisdiction Code. A California-specific code that identifies a medical procedure, service, or product that is not identified by a current HCPCS code. California Jurisdiction Codes are either set forth and/or incorporated by reference in California Code of Regulations, title 8, section 9795, regarding reasonable fees for medical-legal expenses, section 9789.11, regarding fees for physician services rendered on or after July 1, 2004, and before January 1, 2014, sections 9789.12.1-9789.19, regarding fees for physician services rendered on or after January 1, 2014, or in California EDI Implementation Guide for Medical Bill Payment, Release 1.1.

(e) Claim. An injury as defined in Division 4 of the Labor Code, occurring on or after March 1, 2000, that has resulted in the receipt of one or more of the following by a claims administrator:

(1) Employer's Report of Occupational Injury or Illness, as required by California Code of Regulations, title 8, sections 14004-14005.

(2) Doctor's First Report of Occupational Injury or Illness, as required by California Code of Regulations, title 8, sections 14006-14007.

(3) Application for Adjudication filed with the Workers' Compensation Appeals Board under Labor Code section 5500 and California Code of Regulations, title 8, section 10408.

(4) Any information indicating that the injury requires medical treatment by a physician as defined in Labor Code section 3209.3.

(f) Claims Administrator. A self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, California Insurance Guarantee Association (CIGA), or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

(g) Claims Administrator's Agents. Any entity contracted by the claims administrator to assist in adjusting the claim(s) including third party administrators, bill reviewers, utilization review vendors, and electronic data interchange vendors.

(h) Closed Claim. A claim in which future payment of indemnity benefits and/or provision of medical benefits cannot be reasonably expected to be due.

(i) Data Elements. Information identified by data number (DN) and defined in the dictionary of the IAIABC EDI Implementation Guide, Release 1. Data elements set forth in California Code of Regulations, title 8, section 9702 must be transmitted on all claims, where applicable, as indicated in section 9702. The data elements set forth in the IAIABC EDI Implementation Guide, Release 1 that are not enumerated in section 9702 are optional and may, but need not be, submitted on any or all claims.

(j) Electronic Data Interchange. (“EDI”). A computer to computer exchange of data or information in a standardized format acceptable to the Administrative Director.

(k) Health Care Organization (“HCO”). Any entity certified as a health care organization by the Administrative Director pursuant to Labor Code sections 4600.5 and 4600.6.

(l) HCPCS. Acronym for the Healthcare Common Procedure Coding System.

(m) IAIABC EDI Implementation Guide, Release 1. EDI Implementation Guide for First, Subsequent, Acknowledgment Detail, Header & Trailer Records, Release 1, issued February 15, 2002, by the International Association of Industrial Accident Boards and Commissions. The IAIABC EDI Implementation Guide, Release 1, can be obtained from the IAIABC at either the IAIABC website at http://www.iaiabc.org, or the IAIABC office located at 7780 Elmwood Avenue, Suite 207, Middleton, Wisconsin 53562; Telephone: [phone].

(n) IAIABC Workers' Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0, by the International Association of Industrial Accident Boards and Commissions. The IAIABC Workers' Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0, February 1, 2015 Publication can be obtained from the IAIABC at either the IAIABC website at http://www.iaiabc.org, or the IAIABC office located at 7780 Elmwood Avenue, Suite 207, Middleton, Wisconsin 53562; Telephone: [phone].

(1) For reporting prior to the designated effective date (see subdivision (c)(1)), use the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1.1, July 1, 2009, which is incorporated by reference.

(2) For reporting on or after the designated effective date (see subdivision(c)(2)), use the IAIABC Workers' Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0, February 1, 2015 Publication, which is incorporated by reference.

(o) Indemnity Benefits. Payments conferred, including those made by settlement, for any of the following: temporary disability indemnity, permanent disability indemnity, death benefits, vocational rehabilitation maintenance allowance, and employer-paid salary in lieu of compensation.

(p) Individually Identifiable Information. Any data concerning an injury or claim that is linked to a uniquely identifiable employee, employer, claims administrator, or any other person or entity.

(q) International Association of Industrial Accident Boards and Commissions (“IAIABC”). A professional association of workers' compensation specialists, located at 7780 Elmwood Avenue, Suite 207, Middleton, Wisconsin 53562, which is, in addition to other activities, engaged in the production and publication of EDI standards for filing workers' compensation information. Note: IAIABC asserts ownership of such EDI standards which are published in various ways and include Implementation Guides with instructions on their use, technical and business specifications and coding information to permit the transfer of data between regulatory bodies and regulated entities in a uniform and consistent manner.

(r) WCIS. The Workers' Compensation Information System established pursuant to sections 138.6 and 138.7 of the Labor Code.

Note: Authority cited: Sections 133, 138.6 and 138.7, Labor Code. Reference: Sections 138.6 and 138.7, Labor Code.

HISTORY

1. New section filed 10-6-99; operative 11-5-99 (Register 99, No. 41).

2. Amendment filed 3-22-2006; operative 4-21-2006 (Register 2006, No. 12).

3. Amendment filed 11-15-2010; operative 11-15-2011 (Register 2010, No. 47).

4. Repealer of subsection (c)(1), subsection renumbering, amendment of newly designated subsection (c)(1), new subsection (c)(2), amendment of subsections (d) and (n), repealer and new subsection (n)(1) and amendment of subsection (n)(2) filed 4-6-2015; operative 4-6-2016 (Register 2015, No. 15).

5. Amendment of subsection (b)(2), new subsection (b)(3) and amendment of subsections (c)(2), (m), (n), (n)(2) and (q) filed 3-27-2017; operative 9-27-2017 (Register 2017, No. 13).