NAIC groups that write at least 0.5% of the California workers' compensation market, as determined by written pure premium in the most recent calendar year, are required to submit California medical transaction data to the WCIRB. Once an NAIC Group is required to submit medical transaction data, it will continue to be required to report data even if its California market share declines to less than 0.5%.

No. USL&H, excess coverage, homeowners and self-insured experience should be excluded from the Medical Data Call records. Only claims resulting from direct California insurance coverage (reported with jurisdiction state code 04 for California or 59 for Federal) should be included in the Medical Data Call records.

Inquiries regarding any Medical Data Call issues can be sent to [email protected].

Title 8 of the California Code of Regulations, Section 9789.80 is reserved for a skilled nursing facility fee schedule that is not yet developed. Do not report custodial care facility bills as inpatient hospital bills. Instead, report transactions for these bill types as follows:

• • Report the Revenue Code in the Paid Procedure Code field and do not report a Secondary Procedure Code.
• • A Service From Date and Service To Date range is acceptable. If a date range is reported, the number of days must be reported in the Quantity/Number of Units field.

The following table includes Revenue Code, Place of Service Code, and Provider Taxonomy Code values applicable to transactions for residential treatment facility and nursing & custodial care facility bill types:

For mail order pharmacy transactions, report Place of Service Code 01, ‘Pharmacy.’ Place of Service Code 12, ‘Home’ is not applicable to this type of pharmacy transaction.

Place of Service Code 99, ‘Other Place of Service’ should be reported for transactions for medical expenses when the available codes do not specifically define where the service was performed. For example, Place of Service Code 99 is appropriate to report for medical payments for non-emergency transportation services because there is not currently a code that is specifically defined as ‘automobile’ or ‘bus.’ This value should not be used as a default value when the place of service is missing or a more specific place of service is applicable.  

The WCIRB accepts records via an online application called Compensation Data Exchange (CDX). This is the same online application used for submission of unit statistical report files. Files submitted using CDX must contain the WCIO Universal Electronic Transmittal Record (ETR) as the first record in the WCMED submission. All file submissions must also contain the File Control Record as the last record in the WCMED submission.

CDX evaluates if the file is valid and authorized for submission and sends its standard acknowledgement that the file was accepted by CDX and forwarded to the applicable jurisdiction for processing or sends an acknowledgement indicating the file was rejected. The WCIRB is not directly notified if a file is rejected by CDX. To view the ETR specifications, go to the WCIO Workers Compensation Data Specifications Manual page and click on the "Electronic Transmittal Record Specifications (ETR)" link.

The requirements for California workers' compensation information system (WCIS) reporting are administered by the California Division of Workers' Compensation (DWC) and have a wider scope of data fields reported. The information collected is used to oversee the state's workers' compensation system. WCIS reporting will continue to be administered by the DWC after the WCIRB's Medical Data Call requirement commences.

The requirements for California Medical Data Call reporting are administered by the WCIRB and the data fields that are reported were selected to meet specific needs related to the WCIRB's ratemaking responsibilities. While the requirements of the two systems differ, the Medical Data Call requirements were reviewed in the context of the WCIS requirements to make sure that there are no major inconsistencies in which a particular field has significantly different meanings between the two systems.

The principal differences related to reporting California medical transaction data include the following. Additional California-specific reporting requirements are listed in the California Medical Data Call Reporting Guide (Guide), Appendix 10A, California WCMED Reporting Requirements.

• Medical Liens
  In California, the Paid Procedure Code for a lien must be reported with a California state-specific code. The codes to be used are consistent with the codes used to report liens to the Division of Workers' Compensation (DWC) via the Workers' Compensation Information System (WCIS). The state-specific medical lien code should always be reported in the Paid Procedure Code field. The Amount Charged by Provider reported should represent the amount that is in dispute for the lien and the Paid Amount should represent the settlement amount.

• Medical Legal
  For medical legal services, the Paid Procedure Code must be reported with a California state-specific code along with the applicable modifier for the examiner type (Primary Treating Physician, Agreed Medical Examiner or Panel Qualified Medical Examiner) based on the California Medical Legal Fee Schedule. If an examination designation modifier (psych, toxicology, oncology) is applicable, it is also to be reported. Additionally, the Quantity/Number of Units per Procedure Code must be reported in minutes, not units, for the time-based medical legal codes and with 0000001 for medical legal codes for non-time based codes. Quantity Number of Units for additional records per code MLPRR shall be the number of additional pages beyond those included in the base examination code.

• Copy Services
  Copy Services payable as medical must be reported with a California state-specific code. The Place of Service code reported should be the location of the medical records subpoenaed. In the event the record location is either the WCAB or another insurance company, Place of Service 99 should be reported.

For more detail with examples for each of the above requirements, refer to the Guide, Section 5, Paid Procedure Code.

Capitated Medical Case Management

For large or catastrophic claims, an insurer may negotiate with a medical case management vendor to pay a flat fee or lump sum for complete medical care of a claimant for a specified time frame. The vendor manages the care and issues all payments for medical costs directly to the medical providers. In this situation, the insurer or authorized Submitter must report the medical bill detail as a separate medical data call record as outlined in the California Medical Data Call Reporting Guide.

Capitated Physical Medicine Treatment

For long term physical medicine treatment, an insurer may negotiate with a physical medicine provider to pay a flat fee/lump sum for all physical medicine treatments of a claimant for a specified time frame. If the physical medicine provider does not provide the medical bill detail for each individual treatment, the insurer or authorized Submitter may report the lump sum payment as a single medical transaction data record. The Service Dates should define the entire length of treatment for the claimant and should use CPT Code '97799' ("unlisted physical medicine service or procedure") as the Paid Procedure Code. However, if the physical medicine provider does provide the treatment detail, the detail of each treatment must be submitted as a separate medical data call record.

Because lien settlements often encompass multiple medical services, Submitters are encouraged to report whatever line detail is available on a lien settlement transaction. Valid values for the six key fields (Carrier Code, Policy Number ID, Policy Effective Date, Claim Number ID, Bill ID Number and Line ID Number) must be reported on all submitted records to avoid the record being rejected and returned to the Submitter. Additionally, if the amount of a lien settlement covers multiple claims, the amount of the lien settlement must be allocated to individual claims.

Certain fields such as Primary Diagnosis Code may not always be applicable in cases of lien settlements. Failure to report these fields may result in Informational edit failures, but these edit failures will not result in record rejection.

The WCIRB does not anticipate any changes to the content or requirement for submission of the annual Aggregate Indemnity and Medical Costs Call at this time. The WCIRB may consider modifications to the annual Aggregate Indemnity and Medical Costs Call content once the volume of medical transaction data collected via the Medical Data Call grows. It is unlikely that the Aggregate Indemnity and Medical Costs Call requirement will be eliminated completely.

If a submitted file is deemed so erroneous that the entire data submission should be deleted, a File Type R Replacement containing a Record Total = ‘0’ can be submitted. By retaining the ability to submit this type of Replacement File, Submitters are able to delete all of the records in the Original File submission and then re-report the information correctly.

The six key fields plus the Transaction Code and Transaction Date are required for the record to be accepted. Certain other fields, such as Paid Procedure Code must also be populated for the transaction to successfully process and be consumed into the WCIRB’s database. For any other field, if the information is not available for a particular record, the field should not be reported with a default value. 

For example, a pharmacy billing submitted to the payor on the NCPDP form does not have a field for the Diagnosis Code; therefore, the WCIRB would not expect and does not require this value to be reported. 

The Claim Number Identifier and Policy Number Identifier reported for the Medical Data Call must match the claim number and policy number used for unit statistical reporting. The ability to match these values allows the WCIRB to use the statistical claim information along with the medical transaction data in actuarial analysis.

If these are services paid as medical benefits, and they can be captured at the bill line detail level, they should be reported for the Medical Data Call. It is expected that an appropriate Procedure Code that best describes the medical treatment, good or service be reported since the Paid Procedure Code field must be populated for the transaction to be consumed into the WCIRB’s database. Insurers may only utilize a unique custom procedure code if there is no standard procedure code applicable to the medical service, provided that code is used consistently for all subsequent transactions for the same medical service.

Yes, if a service was provided by a medical service provider and a bill was submitted, whether paid by the claimant or insurer, the line item for the service should be reported.

Yes, the WCIRB will accept this transaction type (04) using the WCIO WCMED Key Field Change record layout. The data submitter may also choose to continue to make key field changes using the Cancellation (02) and new Original (01) methodology. 

It is important to note that when using the Key Field Change record, only the historical data currently present in the database will reflect the key field changes. Any subsequently submitted transactions where the old/original key fields are reported will not be changed until such time as a new Key Field Change record is submitted.