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


§9702. Electronic Data Reporting.
Workers' compensation information systems Web site

 (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.

(1) The Administrative Director, upon written request, may grant a claims administrator either a partial or total variance in reporting all or part of the data elements required pursuant to subdivision (e) of this section. Any variance granted by the Administrative Director under this subdivision shall be set forth in writing.

(A) A partial variance requested on the basis that the claims administrator is unable to transmit some of the required data elements to the WCIS shall be granted for a six month period only if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that any medical data elements currently being transmitted by the claims administrator or the claims administrator's agent to public or private research or statistical entities shall be reported by the claims administrator to the WCIS; and

3. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within six months from the request.

(B) A partial variance requested on the basis that the claims administrator is unable to report some of the required data elements to the WCIS because the data elements are not available to the claims administrator or the claims administrator's agent shall be granted for a six month period only if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that any medical data elements currently being transmitted by the claims administrator or the claims administrator's agent to public or private research or statistical entities shall be reported by the claims administrator to the WCIS;

3. a documented showing that the claims administrator will submit to the WCIS the medical data elements available to the claims administrator or the claims administrator's agents; and

4. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within six months from the request.

(C) A total variance shall be granted for a twelve month period if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that the claims administrator has not contracted with a bill review company to review medical bills submitted by providers in its workers' compensation claims;

3. a documented showing that the claims administrator is unable to transmit medical data to public or private research or statistical entities; and

4. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within twelve months from the request.

(2) "Undue hardship" shall be determined based upon a review of the documentation submitted by the claims administrator. The documentation shall include: the claims administrator's total required expenses; the reporting cost per claim if transmitted in house; and the total cost per claim if reported by a vendor. The costs and expenses shall be itemized to reflect costs and expenses related to reporting the data elements listed in subdivision (e) only.

(3) The variance period for reporting data elements under subdivisions (a)(1)(A) and (B) shall not be extended. The variance period for reporting data elements under subdivision (a)(1)(C) may be extended for additional twelve month periods if the claims administrator resubmits a written request for a variance. A claims administrator granted a variance shall submit to the WCIS all data elements that were required to be submitted under subdivision (e) 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.

(b) Each claims administrator shall submit to the WCIS on each claim, within five (5) 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 2 11
CLAIM ADMINISTRATOR ADDRESS LINE 1 10
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
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
POSTAL CODE OF INJURY SITE 33
SALARY CONTINUED INDICATOR 67
SELF INSURED INDICATOR 24
SOCIAL SECURITY NUMBER (1) 42
THIRD PARTY ADMINISTRATOR FEIN 8
THIRD PARTY ADMINISTRATOR NAME 9
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.

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 (b), (d), (e), (f), or (g) of this section shall also include the following elements for data linkage:


Data Element Name DN
CLAIM ADMINISTRATOR CLAIM NUMBER (2) (3) (4) 15
DATE OF INJURY (2) 31
INSURER FEIN (4) 6
JURISDICTION CLAIM NUMBER (2) (3) (4) 5
MAINTENANCE TYPE CODE (1) 2
MAINTENANCE TYPE CODE DATE (1) 3
SOCIAL SECURITY NUMBER (2) (3) 42
THIRD PARTY ADMINISTRATOR FEIN (4) 8

(1) Maintenance Type Code (DN 2) and Maintenance Type Code Date (DN 3) are required for transmissions under Subsections (b), (d), (f), and (g).

(2) This number will be provided by WCIS upon receipt of the first report. The 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), Employee SSN (DN 42), and Claim Administrator Claim Number (DN 15) need not be submitted if the Jurisdiction Claim Number (DN 5) accompanies the transmission, except for transmissions required under Subsection (f).

(4) If the 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
CLAIM STATUS 73
DATE DISABILITY BEGAN 56
DATE OF MAXIMUM MEDICAL IMPROVEMENT 70
DATE OF REPRESENTATION 76
DATE OF RETURN TO WORK 68
DATE OF RETURN TO WORK/RELEASE TO WORK 72
EMPLOYMENT STATUS CODE 58
LATE REASON CODE 77
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 PAIDTO 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
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 s 11750, et seq.

(e) 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 California EDI Implementation Guide for Medical Bill Payment Records sets forth the specific California reporting requirements. The data elements required in this subdivision are taken from California EDI Implementation Guide for Medical Bill Payment Records and the IAIABC EDI Implementation Guide for Medical Bill Payment Records. The claims administrator shall submit the data within ninety (90) calendar days of the medical bill payment. Each claims administrator shall transmit the data elements by electronic data interchange in the manner set forth in the California EDI Implementation Guide for Medical Bill Payment Records.


Data Element Name DN
ACKNOWLEDGMENT TRANSACTION SET ID 110
ADMISSION DATE 513
ADMITTING DIAGNOSIS CODE 535
APPLICATION ACKNOWLEDGMENT CODE 111
BASIS OF COST DETERMINATION CODE 564
BATCH CONTROL NUMBER 532
BILL ADJUSTMENT AMOUNT 545
BILL ADJUSTMENT GROUP CODE (5) 543
BILL ADJUSTMENT REASON CODE 544
BILL ADJUSTMENT UNITS 546
BILL SUBMISSION REASON CODE 508
BILLING FORMAT CODE 503
BILLING PROVIDER FEIN 629
BILLING PROVIDER LAST/GROUP NAME 528
BILLING PROVIDER POSTAL CODE 542
BILLING PROVIDER PRIMARY SPECIALTY CODE (4) 537
BILLING PROVIDER STATE LICENSE NUMBER (4) 630
BILLING PROVIDER UNIQUE BILL IDENTIFICATION
NUMBER 523
BILLING TYPE CODE 502
CLAIM ADMINISTRATOR CLAIM NUMBER 15
CLAIM ADMINISTRATOR FEIN 187
CLAIM ADMINISTRATOR NAME 188
CONTRACT TYPE CODE 515
DATE INSURER PAID BILL 512
DATE INSURER RECEIVED BILL 511
DATE OF BILL 510
DATE OF INJURY 31
DATE PROCESSED 108
DATE TRANSMISSION SENT 100
DAYS/UNITS BILLED 554
DAYS/UNITS CODE 553
DIAGNOSIS POINTER 557
DISCHARGE DATE 514
DISPENSE AS WRITTEN CODE 562
DME BILLING FREQUENCY CODE 567
DRG CODE 518
DRUG NAME 563
DRUGS/SUPPLIES BILLED AMOUNT 572
DRUGS/SUPPLIES DISPENSING FEE 579
DRUGS/SUPPLIES NUMBER OF DAYS 571
DRUGS/SUPPLIES QUANTITY DISPENSED 570
ELEMENT ERROR NUMBER 116
ELEMENT NUMBER 115
EMPLOYEE FIRST NAME 44
EMPLOYEE LAST NAME 43
EMPLOYEE MIDDLE NAME/INITIAL 45
EMPLOYEE EMPLOYMENT VISA 152
EMPLOYEE GREEN CARD 153
EMPLOYEE PASSPORT NUMBER 156
EMPLOYEE SOCIAL SECURITY NUMBER 42
FACILITY CODE 504
FACILITY FEIN 679
FACILITY MEDICARE NUMBER 681
FACILITY NAME 678
FACILITY POSTAL CODE 688
FACILITY STATE LICENSE NUMBER 680
HCPCS BILL PROCEDURE CODE 737
HCPCS LINE PROCEDURE BILLED CODE 714
HCPCS LINE PROCEDURE PAID CODE 726
HCPCS MODIFIER BILLED CODE 717
HCPCS MODIFIER PAID CODE 727
HCPCS PRINCIPLE PROCEDURE BILLED CODE 626
ICD-9 CM DIAGNOSIS CODE 522
ICD-9 CM PRINCIPAL PROCEDURE CODE 525
ICD-9 CM PROCEDURE CODE 736
INSURER FEIN 6
INSURER NAME 7
INTERCHANGE VERSION ID 105
JURISDICTION CLAIM NUMBER 5
JURISDICTION MODIFIER BILLED CODE (8)(10) 718
JURISDICTION MODIFIER PAID CODE (8) 730
JURISDICTION PROCEDURE BILLED CODE (8) 715
JURISDICTION PROCEDURE PAID CODE (8)(9) 729
LINE NUMBER 547
MANAGED CARE ORGANIZATION FEIN (1) 704
MANAGED CARE ORGANIZATION IDENTIFICATION
NUMBER 208
MANAGED CARE ORGANIZATION NAME 209
MANAGED CARE ORGANIZATION POSTAL CODE 712
NDC BILLED CODE 721
NDC PAID CODE 728
ORIGINAL TRANSMISSION DATE 102
ORIGINAL TRANSMISSION TIME 103
PLACE OF SERVICE BILL CODE 555
PLACE OF SERVICE LINE CODE 600
PRESCRIPTION BILL DATE 527
PRESCRIPTION LINE DATE 604
PRESCRIPTION LINE NUMBER 561
PRINCIPLE DIAGNOSIS CODE 521
PRINCIPLE PROCEDURE DATE 550
PROCEDURE DATE 524
PROVIDER AGREEMENT CODE (3) 507
RECEIVER ID 99
RELEASE OF INFORMATION CODE 526
RENDERING BILL PROVIDER FEIN 642
RENDERING BILL PROVIDER LAST/GROUP NAME 638
RENDERING BILL PROVIDER POSTAL CODE 656
RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE 651
RENDERING BILL PROVIDER SPECIALTY LICENSE
NUMBER 649
RENDERING BILL PROVIDER STATE LICENSE NUMBER 643
RENDERING LINE PROVIDER NATIONAL ID (7) 592
RENDERING LINE PROVIDER FEIN 586
RENDERING LINE PROVIDER LAST/GROUP NAME (6) 589
RENDERING LINE PROVIDER POSTAL CODE 593
RENDERING LINE PROVIDER PRIMARY SPECIALTY
CODE (6) 595
RENDERING LINE PROVIDER STATE LICENSE NUMBER (6) 599
REPORTING PERIOD 615
REVENUE BILLED CODE 559
REVENUE PAID CODE 576
SENDER ID 98
SERVICE ADJUSTMENT AMOUNT 733
SERVICE ADJUSTMENT GROUP CODE (5) 731
SERVICE ADJUSTMENT REASON CODE (5) 732
SERVICE BILL DATE(S) RANGE 509
SERVICE LINE DATE(S) RANGE 605
TEST/PRODUCTION INDICATOR 104
TIME PROCESSED 109
TIME TRANSMISSION SENT 101
TOTAL AMOUNT PAID PER BILL (2) 516
TOTAL AMOUNT PAID PER LINE (2) 574
TOTAL CHARGE PER BILL 501
TOTAL CHARGE PER LINE - PURCHASE 566
TOTAL CHARGE PER LINE - RENTAL 565
TOTAL CHARGE PER LINE 552
TRANSACTION TRACKING NUMBER 266
UNIQUE BILL ID NUMBER 500

(1) For HCO claims use the FEIN of the sponsoring organization in DN 704.

(2) Not required on non-denied bills if amount paid equals amount charged.

(3) For MPN claims use code P "Participation Agreement"

(4) Does not apply if billing provider is an organization.

(5) Required if charged and paid amounts differ.

(6) Optional if rendering provider equals billing provider.

(7) To be provided following the assignment of a National Provider Identifier by the United States Department of Health and Human Services, Centers for Medicare & Medicaid Services ( "CMS").

(8) The codes for this data element are the codes that are set forth in the California Official Medical Fee Schedule, a publication of the State of California, Department of Industrial Relations (adopted pursuant to Labor Code s 5307.1 and Title 8, California Code of Regulations s 9790 et seq.).

(9) Optional if procedure billed equals procedure paid.

(10) Use when a modifier has been provided.

(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, commencing in 2001, claims administrators shall, for each claim with a date of injury on or after July 1, 2000 and with any payment in any benefit category in the previous calendar year, report the total paid in each payment category through 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 Subsection (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 Title 8, California Code of Regulations, 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 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.


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).



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