This information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at http://www.dir.ca.gov/od_pub/disclaimer.html.


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


§9701. Definitions.
Workers' compensation information systems Web site

(a) The following definitions apply in this article:

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.

California EDI Implementation Guide for First and Subsequent Reports of Injury. California EDI Implementation Guide, Version 2.1, dated February 2006, 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, Version 2.1, dated February 2006, is posted on the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, will be made available by the Division of Workers' Compensation upon request, and is incorporated by reference.

California EDI Implementation Guide for Medical Bill Payment Records. California EDI Implementation Guide for Medical Bill Payment Records, Version 1.0, dated December 2005, 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 data elements for medical billing, and copies of the required medical billing electronic forms. The California EDI Implementation Guide for Medical Bill Payment Records, Version 1.0, dated December 2005, is posted on the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, will be made available by the Division of Workers' Compensation upon request, and is incorporated by reference.

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 Title 8, California Code of Regulations ss 14004-14005.

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

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

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

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.

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.

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

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 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.

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

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.

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. Sections 4, 5, 6, and the Appendix of EDI Implementation Guide, Release 1, are linked to the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, and are hereby incorporated by reference.

IAIABC EDI Implementation Guide for Medical Bill Payment Records. IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1, approved July 4, 2002, by the International Association of Industrial Accident Boards and Commissions. Sections 1 through 3, and 5 through 11 of the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 1, are linked to the Division's Web site at http://www.dir.ca.gov/dwc/WCIS.htm, and are incorporated by reference.

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.

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.

International Association of Industrial Accident Boards and Commissions ( "IAIABC"). A professional association of workers' compensation specialists, located at 5610 Medical Circle, Suite 14, Madison, Wisconsin 53711, 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.

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).

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