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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.0. RULES For Medical Treatment Billing and Payment on or After October 15, 2011

New query

§9792.5.1. Medical Billing and Payment Guide; Electronic Medical Billing and Payment Companion Guide; Various Implementation Guides.

(a) The California Division of Workers' Compensation Medical Billing and Payment Guide, version 1.1, which sets forth billing, payment and coding rules for paper and electronic medical treatment bill submissions, is incorporated by reference. It may be downloaded from the Division of Workers' Compensation through the Department of Industrial Relations' website at www.dir.ca.gov or may be obtained by writing to:

DIVISION OF WORKERS' COMPENSATION
MEDICAL UNIT
ATTN: MEDICAL BILLING AND PAYMENT GUIDE
P.O. BOX 71010
OAKLAND, CA 94612

(b) The California Division of Workers' Compensation Electronic Medical Billing and Payment Companion Guide, version 1.1, which sets forth billing, payment and coding rules and technical information for electronic medical treatment bill submissions, is incorporated by reference. It may be downloaded from the Division of Workers' Compensation website at www.dir.ca.gov or may be obtained by writing to:

DIVISION OF WORKERS' COMPENSATION
MEDICAL UNIT
ATTN: MEDICAL BILLING AND PAYMENT COMPANION GUIDE
P.O. BOX 71010
OAKLAND, CA 94612

(c) The HIPAA-approved Technical Reports Type 3 for billing listed in subdivision (c)(1) through (3) are incorporated by reference. They may be obtained for a fee from the ASC X12's Secretariat, the Data Interchange Standards Association (DISA):

Data Interchange Standards Association (DISA) at http://store.x12.org

(1)(A) ASC X12N/005010X222
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Professional (837)
MAY 2006
(B) ASC X12N/005010X222E1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Professional (837)
Errata
January 2009
(C) ASC X12N/005010X222A1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Professional (837)
Errata
June 2010
(2)(A) ASC X12N/005010X223
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Institutional (837)
MAY 2006
(B) ASC X12N/005010X223A1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Institutional (837)
Errata Type 1
OCTOBER 2007
(C) ASC X12N/005010X223E1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Institutional (837)
Errata
JANUARY 2009
(D) ASC X12N/005010X223A2
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Institutional (837)
Type 1 Errata
June 2010
(3)(A) ASC X12N/005010X224
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Dental (837)
MAY 2006
(B) ASC X12N/005010X224A1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Dental (837)
Errata Type 1
OCTOBER 2007
(C) ASC X12N/005010X224E1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Dental (837)
Errata
JANUARY 2009
(D) ASC X12N/005010X224A2
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim: Dental (837)
Errata
June 2010

(d) The HIPAA-approved implementation guides for pharmacy billing listed in subdivision (d)(1) and (2) are incorporated by reference. They may be obtained for a fee from the National Council for Prescription Drug Programs (NCPDP), 9240 E. Raintree Drive, Scottsdale, AZ 85260; Telephone (480) 477-1000; and FAX (480) 767-1042. They may also be obtained through the Internet at http://www.ncpdp.org.

(1) Telecommunication Standard Implementation Guide Version D.0, August 2007, National Council for Prescription Drug Programs.

(2) The Batch Standard Implementation Guide, Version 1.2, 2006, National Council for Prescription Drug Programs.

(e) The following HIPAA-approved Technical Report Type 3 and errata, for acknowledgment and remittance are incorporated by reference:

(1)(A) ASC X12C/005010X231
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Implementation Acknowledgment for Health Care Insurance (999)
June 2007
(B) ASC X12C/005010X231A1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Implementation Acknowledgment for Health Care Insurance (999)
June 2010
(2)(A) ASC X12N/005010X214
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Acknowledgment (277)
January 2007
(B) ASC X12N/005010X214E1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Acknowledgment (277)
April 2008
(C) ASC X12N/005010X214E2
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Acknowledgment (277)
January 2009
(3)(A) ASC X12N/005010X221
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Payment/Advice (835)
APRIL 2006
(B) ASC X12N/005010X221E1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Payment/Advice (835)
Errata
JANUARY 2009
(C) ASC X12N/005010X221A1
Based on Version 5, Release 1
ASC X12 Standards for Electronic Data Interchange
Technical Report Type 3
Health Care Claim Payment/Advice (835)
Errata
June 2010

They may be obtained for a fee from the Data Interchange Standards Association (DISA) at: http://store.x12.org

(f) The National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version, Version 6.0 07/10, and the 1500 Form (revised 08-05) are incorporated by reference. The manual can be obtained directly from the National Uniform Claim Committee at: http://www.nucc.org/index.php?option=com_content&task= view&id=33&Itemid=42.

(g) The National Uniform Billing Committee Official UB-04 Data Specifications Manual 2011, Version 5.0, July 2010, including the UB-04 form, is incorporated by reference. The manual can be obtained from the National Uniform Billing Committee at http://www.nubc.org/become.html by becoming a UB-04 committee paid subscriber.

(h) The Manual Claim Forms Reference Implementation Guide Version 1.0, October 2008, National Council of Prescription Drug Programs (NCPDP) Data Specifications Manual including the NCPDP paper WC/PC Universal Claim Form Version 1.1 - 05/2009, except pages 13-36, is incorporated by reference. The manual can be obtained from the NCPCP's vendor at: www.communiform.com/ncpdp.

(i) The CDT 2011-2012: ADA Practical Guide to Dental Procedure Codes, including the ADA 2006 Dental Claim Form, is incorporated by reference. The manual can be obtained from the American Dental Association at:

AMERICAN DENTAL ASSOCIATION
HTTP://WWW.ADA.ORG/
211 EAST CHICAGO AVE.
CHICAGO, IL 60611-2678

Or on the web at:

HTTP://WWW.ADA.ORG/

Note: Authority cited: Sections 133, 4603.4, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 4603.4, Labor Code.

HISTORY

1. New section filed 4-18-2011; operative 4-18-2011 pursuant to Government Code section 11343.4 (Register 2011, No. 16).

2. Amendment of subsections (a), (b) and (h) filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.