Workers Compensation Information System Division of Workers Compensation

Workers’ Compensation Information System Division of Workers’ Compensation 1

California L. C. § 138. 6 Workers' Compensation Information System • The data collected electronically shall be compatible with the Electronic Data Interchange System of the International Association of Industrial Accident Boards and Commissions 2

WWW. IAIABC. ORG 3

California Code of Regulations Chapter 4. 5 Division of Workers' Compensation Subchapter 1 Administrative Director-Administrative Rules Article 1. 1 Workers’ Compensation Information System 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 Medical Bill Payment Records 4

Workers’ Compensation Information System (WCIS) California EDI Implementation Guide for Medical Bill Payment Records Version 1. 0 December 2005 5

L. C. § 138. 6 Goals for WCIS Medical Data • Assist the department to manage the workers' compensation system in an effective and efficient manner. • Facilitate the evaluation of the efficiency and effectiveness of the benefit delivery system. • Assist in measuring how adequately the system indemnifies injured workers and their dependents • Provide statistical data for research into specific aspects of the workers' compensation program. 6

WCIS Electronic Data Collection • First Reports of Injury – March, 2000 • Subsequent Reports of Injury – July, 2000 • Medical/Bill Payment Reports – March, 2006 7

Medical Data Collection Insurance Carriers Injured Worker Electronic Data Interface Medical Providers DWC WCIS 8

The Nationally Accepted EDI Medical Data System Providers Functions Eligibility Verification Pre-Authorization and Referrals Service Billing Claim Submission Claims Status Inquiries Accounts Receivable (AR) E-Billing Regulations Payers Functions Jurisdictions WCIS Function Regulations 270 (Eligibility Inquiry) 271 (Eligibility Information) 278 (Referral Authorization and Certification) Enrollment Pre-Certification & Adjudication 148 (First Report of Injury)* 275 (Claims Attachment)* Claims Acceptance and Reporting Requirements 276 (Claim Status Inquiry) Claims Adjudication 837 (Claims Submission) 837 Health Care Claim. 997 Functional Acknowledgement. 277 (Claim Status Response) 835 (Health. Care Claim Payment Advice) Accounts Payable Maintain a Bona fide database of detailed medical bill payment records which corresponds to the FROI, SROI, UEF, DEU, and WCAB In California 824 Detailed Acknowledgement 9

What is EDI? • Electronic Data Interchange • Standardized electronic exchange of files/data between computers • Standard Set of Codes • Standard Set of Data Elements 10

Standard Electronic File Formats American National Standards Institute (ANSI) • ANSI – 837 Health Care Claim • ANSI – 997 Functional Acknowledgment • ANSI – 824 Detailed Acknowledgment 11

Standard Non-Medical Code Sets • Place of Service Bill/Line Codes – IAIABC • Revenue Billed/Paid Codes – IAIABC • Claim Adjustment Group Codes – IAIABC • Claim Adjustment Reason Codes – IAIABC • California Medical License Numbers – California Department of Consumer Affairs • California Medical Facility License Numbers – California Department of Health Services 12

Standard Medical Code Sets • HCPCS – Centers for Medicare & Medicaid Services • ICD_9 – Centers for Medicare & Medicaid Services • CPT – American Medical Association • NDC – First databank • DRG – US Government printing Office • Medical Provider Codes – American Medical Association 13

Standard Medical Data Elements Standard Paper Medical Bill Types • UB 92/HCFA 1450 • CMS-1500 Form (formerly HCFA 1500) • American Dental Association • Universal Pharmacy Form 14

Other Medical Data Sources • Insurers • Payers • Jurisdictional Licensing Boards • Senders 15

Part II WHY EDI? • Opportunity to modernize the sector • Opportunity to lower per unit costs • Opportunity to lower total medical delivery costs 16

Become fitter, leaner, and ready to meet future challenges • The Challenge: • Over $5. 3 billion in medical costs 2002 • Estimated 15% goes to administration • Lack of e-commerce • The Opportunity: • Retool tired processes • Chance to Reengineer processes 17

Lowering Per Unit Costs • Reduced Accounts Payable/Reporting Cycle • Improved Accuracy (5% data entry errors) • Lower Cost Transactions • Reduce/Eliminate paperwork • Reduce Operational Costs (office supplies, postal costs, and telephone charges) 18

Workgroup for Electronic Data Interchange (WEDI) 19

Part III Nuts & Bolts • Understanding the Transactions Cycle • Trading Partner Agreement • Adopted ANSI Structure • Technical Assistance 20

Transaction Cycle Trading Partners 837 Health Care Transmission Set 824 & 997 Acknowledgments DWC WCIS 21

Trading Partner Agreements Define exactly how to exchange transactions – Communication methods – Submitter/Receiver IDs – Delimiters – Frequency – Turnaround Expectations – Transactions to be exchanged 22

837 Health Care Claim Transmission Line 11 Line 1 Procedure Line 22 Line or Line 333 Line a product 23

What Your Computer Sees During an 837 Transaction ISA*00* **ZZ*003000 *ZZ*WHY INC *020524*1718*U*00401*00001*0*T: ~ GS*HC*0003000*WHY INC*20030114*1615*1*X*004010 X 098~ ST*837*0001~ BHT*0019*00*0001*2003014*1645*CH~ REF*87*004010 X 098~ MN 1*41*2*MARY SMITH CLEARINGHOUSE*****46*0003000~ PER*IC*MARY SMITH*TE*9135551234*FX*6123334567*ED*6125559876~ NM!*40*2*MEDICARE PART B*****46* WHY INC~ HL*1*20*1~ MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24*123456789~ N 3*PO BOX 1234~ N$*SALISBURY*MO*660453565*US~ REF*1 C*09876~ PER*1 C*BILLING PROVIDER CONTACT OFFICE NURSE*TE*9135551234*FX* 6123334567 TE* 6125559876~ HL*2*1*22*0~ HL * SBR*P*18**MEDICARE PART B*****MB~ NM!*IL*1*BENNING*CARRIE****MI*134 -56 -7890 A~ N 3*PO BOX 123~ N 4*NEOMA*MO*67799*US~ DMB*D 8*19330324*M~ MN 1*PR*2*MEDICARE PART B*****PI*00065~ N 3*1000 MAIN ST~ N$*ST LOUIS*MO*66666*US~ CLM*MEDBGOOD-MIS 1*1500***11: : 1*Y*C*Y*Y*B******P~ RE*X 4*32 D 1234567~ NTE*ADD*CLAIM NOTE TEXT~ HI*BK: 3999~ NM 1*DN*1*FOLLARD*BEN*J**M. D. *24 -111223333~ PRV*RF*ZZ*101 Y 00000 N~ RED*1 C*B 11277 NM!*82*1*TREPED*HOWARD****24*88899 -1111~ PRV*PE*ZZ*101 Y 00000 N~ RED*1 C*2327870~ LX*1 SV 1*HC: 99213*15000*UN*1*11**1: : : **N~ DTP*472*DB*81298399~ RE*X 4*32 D 1234567~ SE*36*0001~ GE*1*1~ IEA*1*00001~ 24

Part IV Implications for Payers • Identify points of changeimpact • Develop internal systems • Out sourcing to a vender 26

Points of Impact • Review existing workflows per transaction – Can workflow be improved/automated? – Can information returned be better utilized/automated? – Do you use non-standard codes in these processes? – Is there value in implementing transactions which you do not currently conduct electronically? – Is there value in implementing transactions not currently required by the California DWC? 27

Internal Systems • Do you need to changes your direct data entry systems • Data content (data elements) must meet the data content portion of the California electronic standard • Systems will also need to be capable of receiving data transfers from the DWC • Coming soon-If provider chooses to send data electronically, payer must accept • Do you have a crosswalk from standard code sets to ones used by your internal systems? 28

Questions to ask a software vendor • Will your vendor be DWC compliant by the • mandated deadlines? What are your service level agreements for continued support? – – New versions Training • Will the required code sets be submitted? • How much lead time is required to install and test the • software? What is the minimum hardware requirement for servers and workstations to run the California compliant version? 29

Part V Where are you now? Assigned a “point person” for your office? Completed an Action Plan? Work toward completing your Gap Analysis? Communicated with vendors, billing services, or the DWC concerning 3/18/06? Test Internally? Scheduled External Testing? Staying abreast of upcoming requirements? 30

Where are you? Which of the following has gained influence over strategic decision making? Significant Slight No Increase Change Boards 60% 33% 7% Investors 44% 42% 14% Government 34% 46% 20% Rating Agencies 26% 49% 25% Regulators 57% 34% 9% 31

Where are you? What Investment in new governance-related activities will you make in the coming year? Decrease Investment 1% No change in Investment 25% 0 -5% increase 30% 5 -10% increase 25% 10 -15% increase 9% 15 -25% increase More then 25% increase 5% 5% 32

Where are you? What governance-related business activities will you increase investment in the coming year? The Compliance function IT Spending Internal communications 64% 38% 26% Instilling a culture of compliance though out the organization 42% Interaction with key stakeholders (regulators, government, lobby groups) 31% 33

DWCWCIS Help • WCIS web site (www. dir. ca. gov) • WCIS Trading Partner Liaisons • WCIS e-mail (wcis@dir. ca. gov) • WCIS Medical EDI Training 34

WCIS Trading Partner Liaisons Damon Chen 510 -286 -6753 dchen@dir. ca. gov Johnny Lee 510 -286 -6772 jlee@dir. ca. gov Elisema Cantu 510 -286 -6763 ecantu@dir. ca. gov 35

WCIS Medical EDI Training • Training Conference in Los Angels Area • Training Conference in Oakland Area • Web Based step by step training • Help Desk by telephone or email 36