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

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§ 9702. Electronic Data Reporting.


(a) Each claims administrator shall transmit data elements, by electronic data interchange in the manner set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records, to the WCIS by the dates specified in this section. Each claims administrator shall, at a minimum, provide complete, valid, accurate data for the data elements set forth in this section. The data elements required in subdivisions (b), (c), (d) and (e) are taken from California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records. Claims administrators shall only transmit the data elements that are set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records. Each transmission of data elements shall include appropriate header and trailer records as set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records.
(b) Each claims administrator shall submit to the WCIS on each claim, within ten (10) business days of knowledge of the claim, each of the following data elements known to the claims administrator:
Data Element Name
DN
ACCIDENT DESCRIPTION /CAUSE
38
CAUSE OF INJURY CODE
37
CLAIM ADMINISTRATOR ADDRESS LINE 1
10
CLAIM ADMINISTRATOR ADDRESS LINE 2
11
CLAIM ADMINISTRATOR CITY
12
CLAIM ADMINISTRATOR CLAIM NUMBER
15
CLAIM ADMINISTRATOR POSTAL CODE
14
CLAIM ADMINISTRATOR STATE
13
CLASS CODE (3)
59
DATE DISABILITY BEGAN
56
DATE LAST DAY WORKED
65
DATE OF HIRE (1)
61
DATE OF INJURY
31
DATE OF RETURN TO WORK
68
DATE REPORTED TO CLAIM ADMINISTRATOR
41
DATE REPORTED TO EMPLOYER
40
EMPLOYEE ADDRESS LINE 1 (1)
46
EMPLOYEE ADDRESS LINE 2 (1)
47
EMPLOYEE CITY (1)
48
EMPLOYEE DATE OF BIRTH
52
EMPLOYEE DATE OF DEATH
57
EMPLOYEE FIRST NAME
44
EMPLOYEE LAST NAME
43
EMPLOYEE MIDDLE INITIAL (1)
45
EMPLOYEE PHONE (1)
51
EMPLOYEE POSTAL CODE (1)
50
EMPLOYEE STATE (1)
49
EMPLOYER ADDRESS LINE 1
19
EMPLOYER ADDRESS LINE 2
20
EMPLOYER CITY
21
EMPLOYER FEIN
16
EMPLOYER NAME
18
EMPLOYER POSTAL CODE
23
EMPLOYER STATE
22
EMPLOYMENT STATUS CODE (1)
58
GENDER CODE
53
INDUSTRY CODE
25
INITIAL TREATMENT CODE
39
INSURED REPORT NUMBER
26
INSURER FEIN
6
INSURER NAME
7
JURISDICTION
4
MAINTENANCE TYPE CODE
2
MAINTENANCE TYPE CODE DATE
3
MARITAL STATUS CODE (2)
54
NATURE OF INJURY CODE
35
NUMBER OF DEPENDENTS (2)
55
OCCUPATION DESCRIPTION
60
PART OF BODY INJURED CODE
36
POLICY EFFECTIVE DATE
29
POLICY EXPIRATION DATE
30
POLICY NUMBER
28
POSTAL CODE OF INJURY SITE
33
SALARY CONTINUED INDICATOR
67
SELF INSURED INDICATOR
24
SOCIAL SECURITY NUMBER (4)
42
THIRD PARTY ADMINISTRATOR FEIN
8
THIRD PARTY ADMINISTRATOR NAME
9
TIME OF INJURY
32
WAGE (1)
62
WAGE PERIOD (1)
63
_________________
(1) Required only when provided to the claims administrator.
(2) Death Cases Only.
(3) Required for insured claims only; optional for self-insured claims.
(4) If the Social Security Number (DN 42) is not known, use a string of eight zeros followed by a six.
Data elements omitted under this subsection because they were not known by the claims administrator shall be submitted within sixty (60) days from the date of the first report under this subsection.
(c) Each transmission of data elements listed under subdivisions (b), (d), (e), (f), or (g) of this section shall also include the following elements for data linkage:
Data Element Name
DN
AGENCY/JURISDICTION CLAIM NUMBER (2) (3) (4)
5
CLAIM ADMINISTRATOR CLAIM NUMBER (2) (3) (4)
15
DATE OF INJURY (3)
31
INSURER FEIN (4)
6
JURISDICTION (1)
4
MAINTENANCE TYPE CODE (1)
2
MAINTENANCE TYPE CODE DATE (1)
3
SOCIAL SECURITY NUMBER (3)
42
THIRD PARTY ADMINISTRATOR FEIN (4)
8
TRANSACTION SET ID (1)
1
_________________
(1) Jurisdiction (DN 4), Maintenance Type Code (DN 2), Maintenance Type Code Date (DN 3), and Transaction Set ID (DN 1) are required for transmissions under subdivisions (b), (d), (f), and (g).
(2) The Agency/Jurisdiction Claim Number (DN 5) will be provided by WCIS upon receipt of the first report under subdivision (b). The Agency/Jurisdiction Claim Number (DN 5) is required when changing a Claim Administrator Claim Number (DN 15); it is optional for other transmissions under this subsection.
(3) The Date of Injury (DN 31), Social Security Number (DN 42), and Claim Administrator Claim Number (DN 15) need not be submitted if the Agency/Jurisdiction Claim Number (DN 5) accompanies the transmission, except for transmissions required under Subsection (f). If the Social Security Number (DN 42) is not known, use a string of eight zeros followed by a six.
(4) If the Agency/Jurisdiction Claim Number (DN 5) is not provided, trading partners must provide the Claim Administrator Claim Number (DN 15) and the Third Party Administrator FEIN (DN 8), or, if there is no third party administrator, the Insurer FEIN (DN 6).
(d) Each claims administrator shall submit to the WCIS within fifteen (15) business days the following data elements, whenever indemnity benefits of a particular type and amount are started, changed, suspended, restarted, stopped, delayed, or denied, or when a claim is closed or reopened, or when the claims administrator is notified of a change in employee representation. Submissions under this subsection are required only for claims with a date of injury on or after July 1, 2000, and shall not include data on routine payments made during the course of an uninterrupted period of indemnity benefits.
Data Element Name
DN
BENEFIT ADJUSTMENT CODE
92
BENEFIT ADJUSTMENT START DATE
94
BENEFIT ADJUSTMENT WEEKLY AMOUNT
93
CLAIM ADMINISTRATOR POSTAL CODE
14
CLAIM STATUS
73
CLAIM TYPE
74
DATE DISABILITY BEGAN
56
DATE OF MAXIMUM MEDICAL IMPROVEMENT
70
DATE OF REPRESENTATION
76
DATE OF RETURN/RELEASE TO WORK
72
EMPLOYEE DATE OF DEATH
57
INSURED REPORT NUMBER
26
LATE REASON CODE
77
NUMBER OF BENEFIT ADJUSTMENTS
80
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS
82
NUMBER OF DEPENDENTS
55
NUMBER OF PAID TO DATE/REDUCED EARNINGS/
RECOVERIES
81
NUMBER OF PAYMENTS/ADJUSTMENTS
79
NUMBER OF PERMANENT IMPAIRMENTS
78
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES
AMOUNT
96
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES
CODE
95
PAYMENT/ADJUSTMENT CODE
85
PAYMENT/ADJUSTMENT DAYS PAID
91
PAYMENT/ADJUSTMENT END DATE
89
PAYMENT/ADJUSTMENT PAID TO DATE
86
PAYMENT/ADJUSTMENT START DATE
88
PAYMENT/ADJUSTMENT WEEKLY AMOUNT
87
PAYMENT/ADJUSTMENT WEEKS PAID
90
PERMANENT IMPAIRMENT BODY PART CODE (1) (2)
83
PERMANENT IMPAIRMENT PERCENTAGE (2)
84
RETURN TO WORK QUALIFIER
71
SALARY CONTINUED INDICATOR
67
WAGE
62
WAGE PERIOD
63
_________________
(1) May use Code 90 (Multiple Body Parts) to reflect combined rating for any/all impairments.
(2) Use actual permanent disability rating at the time of initial payment of permanent disability benefits. For compromise and release cases and stipulated settlements, use permanent disability estimate as reported to the appropriate rating organization established under Insurance Code § 11750, et seq.
(e) Claims administrators handling one hundred and fifty (150) or more total claims per year shall submit to the WCIS on each claim 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 California EDI Implementation Guide for Medical Bill Payment Records sets forth the specific California reporting requirements.
Data Element Name
DN
ACKNOWLEDGMENT TRANSACTION SET ID
0110
ADA PROCEDURE BILLED CODE
0719
ADA PROCEDURE PAID CODE
0722
ADMISSION DATE
0513
ADMISSION HOUR
0622
ADMISSION TYPE CODE
0577
ADMITTING DIAGNOSIS CODE
0535
APPLICATION ACKNOWLEDGMENT CODE
0111
BILL ADJUSTMENT AMOUNT
0545
BILL ADJUSTMENT GROUP CODE
0543
BILL ADJUSTMENT REASON CODE
0544
BILL ADJUSTMENT UNITS
0546
BILL FREQUENCY TYPE CODE
0505
BILL SUBMISSION REASON CODE
0508
BILLED DRG CODE
0548
BILLING FORMAT CODE
0503
BILLING PROVIDER CITY
0540
BILLING PROVIDER COUNTRY CODE
0569
BILLING PROVIDER FEIN
0629
BILLING PROVIDER FIRST NAME
0529
BILLING PROVIDER LAST/GROUP NAME
0528
BILLING PROVIDER NATIONAL PROVIDER ID
0634
BILLING PROVIDER POSTAL CODE
0542
BILLING PROVIDER PRIMARY ADDRESS
0538
BILLING PROVIDER PRIMARY SPECIALTY CODE
0537
BILLING PROVIDER SECONDARY ADDRESS
0539
BILLING PROVIDER STATE CODE
0541
BILLING PROVIDER STATE LICENSE NUMBER
0630
BILLING PROVIDER UNIQUE BILL IDENTIFICATION
NUMBER
0523
BILLING TYPE CODE
0502
CLAIM ADMINISTRATOR CLAIM NUMBER
0015
CLAIM ADMINISTRATOR FEIN
0187
CLAIM ADMINISTRATOR MAILING POSTAL CODE
0014
CLAIM ADMINISTRATOR NAME
0188
COMPOUND DRUG INDICATOR
0762
CONDITION CODE
0556
CONTRACT LINE TYPE CODE
0741
CONTRACT TYPE CODE
0515
DATE INSURER PAID BILL
0512
DATE INSURER RECEIVED BILL
0511
DATE OF BILL
0510
DATE OF INJURY
0031
DATE PROCESSED
0108
DATE TRANSMISSION SENT
0100
DAYS/UNITS BILLED
0554
DAYS/UNITS CODE
0553
DAY(S)/UNIT(S) PAID
0580
DIAGNOSIS CODE
0522
DIAGNOSIS POINTER
0557
DISCHARGE DATE
0514
DISCHARGE HOUR
0623
DISPENSE AS WRITTEN CODE
0562
DRUG NAME
0563
DRUGS/SUPPLIES BILLED AMOUNT
0572
DRUGS/SUPPLIES DISPENSING FEE
0579
DRUGS/SUPPLIES NUMBER OF DAYS
0571
DRUGS/SUPPLIES QUANTITY DISPENSED
0570
ELEMENT ERROR NUMBER
0116
ELEMENT NUMBER
0115
EMPLOYEE FIRST NAME
0044
EMPLOYEE LAST NAME
0043
EMPLOYEE MIDDLE NAME/INITIAL
0045
EMPLOYEE SOCIAL SECURITY NUMBER
0042
EMPLOYER FEIN
0016
EMPLOYER NAME
0018
FACILITY CITY
0686
FACILITY CODE
0504
FACILITY COUNTRY CODE
0689
FACILITY NAME
0678
FACILITY NATIONAL PROVIDER ID
0682
FACILITY POSTAL CODE
0688
FACILITY PRIMARY ADDRESS
0684
FACILITY SECONDARY ADDRESS
0685
FACILITY STATE CODE
0687
FACILITY STATE LICENSE NUMBER
0680
HCPCS LINE PROCEDURE BILLED CODE
0714
HCPCS LINE PROCEDURE PAID CODE
0726
HCPCS MODIFIER BILLED CODE
0717
HCPCS MODIFIER PAID CODE
0727
HIPPS RATE CODE
0625
INSURER FEIN
0006
INSURER NAME
0007
INSURER POSTAL CODE
0616
JURISDICTION CLAIM NUMBER
0005
JURISDICTION MODIFIER BILLED CODE
0718
JURISDICTION MODIFIER PAID CODE
0730
JURISDICTION PROCEDURE BILLED CODE
0715
JURISDICTION PROCEDURE PAID CODE
0729
JURISDICTION TRACKING NUMBER
0743
LINE ITEM PRIOR ACTUAL AMOUNT PAID
0761
LINE NUMBER
0547
LUMP SUM PAYMENT SETTLEMENT CODE
0293
MANAGED CARE ORGANIZATION FEIN
0704
MANAGED CARE ORGANIZATION IDENTIFICATION
NUMBER
0208
MANAGED CARE ORGANIZATION NAME
0209
NDC BILLED CODE
0721
NDC PAID CODE
0728
ORIGINATOR TRANSACTION IDENTIFICATION
BATCH CONTROL NUMBER
0532
ORIGINAL TRANSMISSION DATE
0102
ORIGINAL TRANSMISSION TIME
0103
OTHER PROCEDURE CODE
0736
OUTPATIENT REASON FOR VISIT CODE
0520
PAID DRG CODE
0549
PLACE OF SERVICE BILL CODE
0555
PLACE OF SERVICE LINE CODE
0600
PRESCRIPTION DATE(S) RANGE
0527
PRESCRIPTION LINE DATE
0604
PRESCRIPTION LINE NUMBER
0561
PRESENT ON ADMISSION INDICATOR
0533
PRINCIPAL DIAGNOSIS CODE
0521
PRINCIPAL PROCEDURE CODE
0525
PRINCIPLE PROCEDURE DATE
0550
PRIOR ACTUAL AMOUNT PAID
0760
PROCEDURE DATE
0524
PROCEDURE DESCRIPTION
0551
PROVIDER AGREEMENT CODE
0507
PROVIDER AGREEMENT LINE CODE
0742
RECEIVER ID
0099
REFERRING PROVIDER FIRST NAME
0691
REFERRING PROVIDER LAST/GROUP NAME
0690
REFERRING PROVIDER NATIONAL PROVIDER ID
0699
RENDERING BILL PROVIDER FIRST NAME
0639
RENDERING BILL PROVIDER LAST/GROUP NAME
0638
RENDERING BILL PROVIDER NATIONAL PROVIDER
ID
0647
RENDERING BILL PROVIDER PRIMARY SPECIALTY
CODE
0651
RENDERING BILL PROVIDER STATE LICENSE
NUMBER
0643
RENDERING LINE PROVIDER NATIONAL PROVIDER
ID
0592
RENDERING LINE PROVIDER FEIN
0586
RENDERING LINE PROVIDER FIRST NAME
0587
RENDERING LINE PROVIDER LAST/GROUP NAME
0589
RENDERING LINE PROVIDER PRIMARY SPECIALTY
CODE
0595
RENDERING LINE PROVIDER STATE LICENSE
NUMBER
0599
REPORTING PERIOD
0615
REVENUE BILLED CODE
0559
REVENUE PAID CODE
0576
SENDER ID
0098
SERVICE ADJUSTMENT AMOUNT
0733
SERVICE ADJUSTMENT GROUP CODE
0731
SERVICE ADJUSTMENT REASON CODE
0732
SERVICE ADJUSTMENT UNITS
0734
SERVICE BILL DATE(S) RANGE
0509
SERVICE LINE DATE(S) RANGE
0605
SUPERVISING PROVIDER FIRST NAME
0659
SUPERVISING PROVIDER LAST/GROUP NAME
0658
SUPERVISING PROVIDER NATIONAL PROVIDER ID
0667
SUPERVISING PROVIDER PRIMARY SPECIALTY CODE
0671
TEST/PRODUCTION INDICATOR
0104
TIME PROCESSED
0109
TIME TRANSMISSION SENT
0101
TOTAL AMOUNT PAID PER BILL
0516
TOTAL AMOUNT PAID PER LINE
0574
TOTAL CHARGE PER BILL
0501
TOTAL CHARGE PER LINE
0552
TRANSACTION TRACKING NUMBER
0266
UNIQUE BILL ID NUMBER
0500
(1) Each claims administrator shall submit all medical bills data including interpreter bills within ninety (90) calendar days of the medical bill payment or the date of the final determination that payment for billed medical services will be denied.
(2) Each claims administrator shall submit all medical lien lump sum payments or settlements following the filing of a lien claim for the payment of such medical services pursuant to Labor Code sections 4903 and 4903.1 within ninety (90) calendar days of the medical lien lump sum payment or settlement.
(3) Data transmission shall follow the requirements set forth in IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0 dated February 1, 2014. California Specific requirements are included in the California EDI Implementation Guide for Medical Bill payment Records Version 2.0, dated the designated effective date (see Section 9701(c)(2)).
(f) Notwithstanding the requirement in Subsection (b) to submit data elements omitted from the first report within 60 days from the date of transmission of the first report, when a claims administrator becomes aware of an error or need to update data elements previously transmitted, or learns of information that was previously omitted, the claims administrator shall transmit the corrected, updated or omitted data to WCIS no later than the next submission of data for the affected claim.
(g) No later than January 31 of every year, claims administrators shall report for each claim the total paid in any payment category in the previous calendar year by submitting the following data elements:
Data Element Name
DN
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT
96
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE
95
PAYMENT/ADJUSTMENT CODE
85
PAYMENT/ADJUSTMENT END DATE
89
PAYMENT/ADJUSTMENT PAID TO DATE
86
PAYMENT/ADJUSTMENT START DATE
88
(h) Final reports (MTC = FN) are required only for claims where indemnity benefits are paid. For medical-only claims, the final report may be reported under this section or on the annual report (MTC = AN) with claim status = “closed.”
(i)(1) A claims administrator's obligation to submit copies of benefit notices to the Administrative Director pursuant to Labor Code section 138.4 is satisfied upon written determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under subdivision (d) and continued compliance with that subsection.
(2) Reserved.
(3) On and after September 22, 2006, a claims administrator's obligation to submit an Annual Report of Inventory pursuant to California Code of Regulations, title 8, section 10104 is satisfied upon determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under subdivisions (b), (d), (e), and (g), and continued compliance with those subsections.
(j) The data submitted pursuant to this section shall not have any application to, nor be considered in, nor be admissible into, evidence in any personal injury or wrongful death action, except as between an employee and the employee's employer. Nothing in this subdivision shall be construed to expand access to information held in the WCIS beyond that authorized in California Code of Regulations, title 8, section 9703 and Labor Code section 138.7.
(k) Each claims administrator required to submit data under this section shall submit to the Administrative Director an EDI Trading Partner Profile at least thirty days prior to its first transmission of EDI data. Each claims administrator shall advise the Administrative Director of any subsequent changes and/or corrections made to the information provided in the EDI Trading Partner Profile by filing a corrected copy of the EDI Trading Partner Profile with the Administrative Director.
(l)(1) The Administrative Director may grant a claims administrator either a partial or total variance in reporting all or part of the data elements required under this section upon a documented showing that compliance with the reporting deadlines would cause undue hardship to the claims administrator.
(2) “Undue hardship” shall be determined based upon a review of the documentation submitted by the claims administrator. The documentation shall include:
(A) A statement explaining why the claims administrator is unable to transmit required data elements to the WCIS.
(B) The claims administrator's estimated expenses necessary to meet the reporting requirements of this section.
(C) The reporting cost per claim if transmitted directly by the claims administrator and the total cost per claim if reported by a vendor.
(D) Submission of a plan documenting the means by which the claims administrator will ensure full compliance with the data reporting within six months from the date of the request.
(3) Any variance granted by the Administrative Director under this subdivision shall be set forth in writing and shall be for a period of six (6) months.
(4) The variance period for reporting data elements under this subdivision may be extended for additional six (6) month period if the claims administrator resubmits a written request for an extension of the variance.
(5) Upon expiration of the variance period, a claims administrator granted a variance shall submit to the WCIS all data elements that were required to be submitted under this section during the variance period except for data elements that were not known to the claims administrator, the claims administrator's agents, or not captured on the claims administrator's electronic data systems. The data shall be submitted in an electronic format acceptable to the Division.
Note: Authority cited: Sections 133, 138.4, 138.6 and 138.7, Labor Code. Reference: Sections 138.4, 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 subsections (a)(1)-(3), amendment of subsection (e) and new subsections (e)(1)-(3) and (l)(1)-(5) filed 4-6-2015; operative 4-6-2016 (Register 2015, No. 15).


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