Cal. Code Regs. tit. 8 § 9702

Current through Register 2024 Notice Reg. No. 41, October 11, 2024
Section 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 NameDN
ACCIDENT DESCRIPTION /CAUSE38
CAUSE OF INJURY CODE37
CLAIM ADMINISTRATOR ADDRESS LINE 110
CLAIM ADMINISTRATOR ADDRESS LINE 211
CLAIM ADMINISTRATOR CITY12
CLAIM ADMINISTRATOR CLAIM NUMBER15
CLAIM ADMINISTRATOR FEIN8
CLAIM ADMINISTRATOR NAME9
CLAIM ADMINISTRATOR POSTAL CODE14
CLAIM ADMINISTRATOR STATE13
CLASS CODE(3)59
DATE DISABILITY BEGAN56
DATE LAST DAY WORKED65
DATE OF HIRE(1)61
DATE OF INJURY31
DATE OF RETURN TO WORK68
DATE REPORTED TO CLAIM ADMINISTRATOR41
DATE REPORTED TO EMPLOYER40
EMPLOYEE ADDRESS LINE 1(1)46
EMPLOYEE ADDRESS LINE 2(1)47
EMPLOYEE CITY(1)48
EMPLOYEE DATE OF BIRTH52
EMPLOYEE DATE OF DEATH57
EMPLOYEE FIRST NAME44
EMPLOYEE LAST NAME43
EMPLOYEE MIDDLE INITIAL(1)45
EMPLOYEE PHONE(1)51
EMPLOYEE POSTAL CODE(1)50
EMPLOYEE STATE(1)49
EMPLOYER ADDRESS LINE 119
EMPLOYER ADDRESS LINE 220
EMPLOYER CITY21
EMPLOYER FEIN16
EMPLOYER NAME18
EMPLOYER POSTAL CODE23
EMPLOYER STATE22
EMPLOYMENT STATUS CODE(1)58
GENDER CODE53
INDUSTRY CODE25
INITIAL TREATMENT CODE39
INSURED REPORT NUMBER26
INSURER FEIN6
INSURER NAME7
JURISDICTION4
MAINTENANCE TYPE CODE2
MAINTENANCE TYPE CODE DATE3
MARITAL STATUS CODE(2)54
NATURE OF INJURY CODE35
NUMBER OF DEPENDENTS(2)55
OCCUPATION DESCRIPTION60
PART OF BODY INJURED CODE36
POLICY EFFECTIVE DATE29
POLICY EXPIRATION DATE30
POLICY NUMBER28
POSTAL CODE OF INJURY SITE33
SALARY CONTINUED INDICATOR67
SELF INSURED INDICATOR24
SOCIAL SECURITY NUMBER(4)42
TIME OF INJURY32
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 NameDN
AGENCY/JURISDICTION CLAIM NUMBER(2)(3)5
CLAIM ADMINISTRATOR CLAIM NUMBER(4)15
CLAIM ADMINISTRATOR FEIN(8)8
DATE OF INJURY(5)31
EMPLOYEE DATE OF BIRTH(6)52
EMPLOYEE FIRST NAME(7)44
EMPLOYEE FEIN(7)16
INSURER FEIN(4)6
JURISDICTION(1)4
MAINTENANCE TYPE CODE(1)2
MAINTENANCE TYPE CODE DATE(1)3
TIME OF INJURY(9)32
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 acceptance of the first report under subdivision (b).
(3) The Agency/Jurisdiction Claim Number (DN 5) is required on all transmissions under subdivision (b), except for original, denied and acquired reports. The Agency/Jurisdiction Claim Number (DN 5) is required on all transmissions under subdivisions (d), (e), (f) and (g).
(4) The Insurer FEIN (DN 6) and Claim Administrator Claim Number (DN 15) are required on all transmissions under subdivisions (b), (d), (e), (f) and (g).
(5) The Date of Injury (DN 31) is required on all transmissions under subdivisions (b), (d) and (g), except acquired and cancel first report transmissions under subdivision (b).
(6) The Employee Date of Birth (DN 52) is required on all first report transmissions under subdivision (b), except cancel first report transmissions under subdivision (b).
(7) The Employer FEIN (DN 16) and Employee First Name (DN 44) are required on all first report transmissions under subdivision (b) except for transmissions to cancel a first report.
(8) The Claims Administrator FEIN (DN 8) is required on all transmissions under subdivisions (b), (d), (e), (f) and (g).
(9) The Time of Injury (DN 32) is required on all non-cumulative trauma first report transmissions except acquired transmissions and denied, changed and corrected transmissions for claims that have been previously submitted as acquired under subdivision (b) with a Date of Injury (DN 31) on or after the implementation date of the California EDI Implementation Guide for First and Subsequent Reports of Injury, Version 3.1.
(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 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 NameDN
BENEFIT ADJUSTMENT CODE92
BENEFIT ADJUSTMENT START DATE94
BENEFIT ADJUSTMENT WEEKLY AMOUNT93
CLAIM ADMINISTRATOR POSTAL CODE14
CLAIM STATUS73
CLAIM TYPE74
DATE DISABILITY BEGAN56
DATE OF MAXIMUM MEDICAL IMPROVEMENT70
DATE OF REPRESENTATION76
DATE OF RETURN/RELEASE TO WORK72
EMPLOYEE DATE OF DEATH57
INSURED REPORT NUMBER26
LATE REASON CODE77
NUMBER OF BENEFIT ADJUSTMENTS80
NUMBER OF DEATH DEPENDENT/PAYEE RELATIONSHIPS82
NUMBER OF DEPENDENTS55
NUMBER OF PAID TO DATE/REDUCED EARNINGS/RECOVERIES81
NUMBER OF PAYMENTS/ADJUSTMENTS79
NUMBER OF PERMANENT IMPAIRMENTS78
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES AMOUNT96
PAID TO DATE/ REDUCED EARNINGS/RECOVERIES CODE95
PAYMENT/ADJUSTMENT CODE85
PAYMENT/ADJUSTMENT DAYS PAID91
PAYMENT/ADJUSTMENT END DATE89
PAYMENT/ADJUSTMENT PAID TO DATE86
PAYMENT/ADJUSTMENT START DATE88
PAYMENT/ADJUSTMENT WEEKLY AMOUNT87
PAYMENT/ADJUSTMENT WEEKS PAID90
PERMANENT IMPAIRMENT BODY PART CODE(1)(2)83
PERMANENT IMPAIRMENT PERCENTAGE(2)84
RETURN TO WORK QUALIFIER71
SALARY CONTINUED INDICATOR67
WAGE62
WAGE PERIOD63
____________________
(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 NameDN
ACKNOWLEDGMENT TRANSACTION SET ID0110
ADA PROCEDURE BILLED CODE0719
ADA PROCEDURE PAID CODE0722
ADMISSION DATE0513
ADMISSION HOUR0622
ADMISSION TYPE CODE0577
ADMITTING DIAGNOSIS CODE0535
APPLICATION ACKNOWLEDGMENT CODE0111
BILL ADJUSTMENT AMOUNT0545
BILL ADJUSTMENT GROUP CODE0543
BILL ADJUSTMENT REASON CODE0544
BILL ADJUSTMENT UNITS0546
BILL FREQUENCY TYPE CODE0505
BILL SUBMISSION REASON CODE0508
BILLED DRG CODE0548
BILLING FORMAT CODE0503
BILLING PROVIDER CITY0540
BILLING PROVIDER COUNTRY CODE0569
BILLING PROVIDER FEIN0629
BILLING PROVIDER FIRST NAME0529
BILLING PROVIDER LAST/GROUP NAME0528
BILLING PROVIDER NATIONAL PROVIDER ID0634
BILLING PROVIDER POSTAL CODE0542
BILLING PROVIDER PRIMARY ADDRESS0538
BILLING PROVIDER PRIMARY SPECIALTY CODE0537
BILLING PROVIDER SECONDARY ADDRESS0539
BILLING PROVIDER STATE CODE0541
BILLING PROVIDER STATE LICENSE NUMBER0630
BILLING PROVIDER UNIQUE BILL IDENTIFICATION NUMBER0523
BILLING TYPE CODE0502
CLAIM ADMINISTRATOR CLAIM NUMBER0015
CLAIM ADMINISTRATOR FEIN0187
CLAIM ADMINISTRATOR MAILING POSTAL CODE0014
CLAIM ADMINISTRATOR NAME0188
COMPOUND DRUG INDICATOR0762
CONDITION CODE0556
CONTRACT LINE TYPE CODE0741
CONTRACT TYPE CODE0515
DATE INSURER PAID BILL0512
DATE INSURER RECEIVED BILL0511
DATE OF BILL0510
DATE OF INJURY0031
DATE PROCESSED0108
DATE TRANSMISSION SENT0100
DAYS/UNITS BILLED0554
DAYS/UNITS CODE0553
DAY(S)/UNIT(S) PAID0580
DIAGNOSIS CODE0522
DIAGNOSIS POINTER0557
DISCHARGE DATE0514
DISCHARGE HOUR0623
DISPENSE AS WRITTEN CODE0562
DRUG NAME0563
DRUGS/SUPPLIES BILLED AMOUNT0572
DRUGS/SUPPLIES DISPENSING FEE0579
DRUGS/SUPPLIES NUMBER OF DAYS0571
DRUGS/SUPPLIES QUANTITY DISPENSED0570
ELEMENT ERROR NUMBER0116
ELEMENT NUMBER0115
EMPLOYEE FIRST NAME0044
EMPLOYEE LAST NAME0043
EMPLOYEE MAILING CITY0048
EMPLOYEE MAILING POSTAL CODE0050
EMPLOYEE MIDDLE NAME/INITIAL0045
EMPLOYEE SOCIAL SECURITY NUMBER0042
EMPLOYER FEIN0016
EMPLOYER NAME0018
FACILITY CITY0686
FACILITY CODE0504
FACILITY COUNTRY CODE0689
FACILITY NAME0678
FACILITY NATIONAL PROVIDER ID0682
FACILITY POSTAL CODE0688
FACILITY PRIMARY ADDRESS0684
FACILITY SECONDARY ADDRESS0685
FACILITY STATE CODE0687
FACILITY STATE LICENSE NUMBER0680
HCPCS LINE PROCEDURE BILLED CODE0714
HCPCS LINE PROCEDURE PAID CODE0726
HCPCS MODIFIER BILLED CODE0717
HCPCS MODIFIER PAID CODE0727
HIPPS RATE CODE0625
INSURER FEIN0006
INSURER NAME0007
INSURER POSTAL CODE0616
JURISDICTION CLAIM NUMBER0005
JURISDICTION MODIFIER BILLED CODE0718
JURISDICTION MODIFIER PAID CODE0730
JURISDICTION PROCEDURE BILLED CODE0715
JURISDICTION PROCEDURE PAID CODE0729
JURISDICTION TRACKING NUMBER0743
LINE ITEM PRIOR ACTUAL AMOUNT PAID0761
LINE NUMBER0547
LUMP SUM PAYMENT SETTLEMENT CODE0293
MANAGED CARE ORGANIZATION FEIN0704
MANAGED CARE ORGANIZATION IDENTIFICATION NUMBER0208
MANAGED CARE ORGANIZATION NAME0209
NDC BILLED CODE0721
NDC PAID CODE0728
ORIGINATOR TRANSACTION IDENTIFICATION BATCH CONTROL NUMBER0532
ORIGINAL TRANSMISSION DATE0102
ORIGINAL TRANSMISSION TIME0103
OTHER PROCEDURE CODE0736
OUTPATIENT REASON FOR VISIT CODE0520
PAID DRG CODE0549
PLACE OF SERVICE BILL CODE0555
PLACE OF SERVICE LINE CODE0600
PRESCRIPTION DATE(S) RANGE0527
PRESCRIPTION LINE DATE0604
PRESCRIPTION LINE NUMBER0561
PRESENT ON ADMISSION INDICATOR0533
PRINCIPAL DIAGNOSIS CODE0521
PRINCIPAL PROCEDURE CODE0525
PRINCIPLE PROCEDURE DATE0550
PRIOR ACTUAL AMOUNT PAID0760
PROCEDURE DATE0524
PROCEDURE DESCRIPTION0551
PROVIDER AGREEMENT CODE0507
PROVIDER AGREEMENT LINE CODE0742
RECEIVER ID0099
REFERRING PROVIDER FIRST NAME0691
REFERRING PROVIDER LAST/GROUP NAME0690
REFERRING PROVIDER NATIONAL PROVIDER ID0699
RENDERING BILL PROVIDER FIRST NAME0639
RENDERING BILL PROVIDER LAST/GROUP NAME0638
RENDERING BILL PROVIDER NATIONAL PROVIDER ID0647
RENDERING BILL PROVIDER PRIMARY SPECIALTY CODE0651
RENDERING BILL PROVIDER STATE LICENSE NUMBER0643
RENDERING LINE PROVIDER NATIONAL PROVIDER ID0592
RENDERING LINE PROVIDER FIRST NAME0587
RENDERING LINE PROVIDER LAST/GROUP NAME0589
RENDERING LINE PROVIDER PRIMARY SPECIALTY CODE0595
RENDERING LINE PROVIDER STATE LICENSE NUMBER0599
REPORTING PERIOD0615
REVENUE BILLED CODE0559
REVENUE PAID CODE0576
SENDER ID0098
SERVICE ADJUSTMENT AMOUNT0733
SERVICE ADJUSTMENT GROUP CODE0731
SERVICE ADJUSTMENT REASON CODE0732
SERVICE ADJUSTMENT UNITS0734
SERVICE BILL DATE(S) RANGE0509
SERVICE LINE DATE(S) RANGE0605
SUPERVISING PROVIDER FIRST NAME0659
SUPERVISING PROVIDER LAST/GROUP NAME0658
SUPERVISING PROVIDER NATIONAL PROVIDER ID0667
SUPERVISING PROVIDER PRIMARY SPECIALTY CODE0671
TEST/PRODUCTION INDICATOR0104
TIME PROCESSED0109
TIME TRANSMISSION SENT0101
TOTAL AMOUNT PAID PER BILL0516
TOTAL AMOUNT PAID PER LINE0574
TOTAL CHARGE PER BILL0501
TOTAL CHARGE PER LINE0552
TRANSACTION TRACKING NUMBER0266
UNIQUE BILL ID NUMBER0500

(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 Workers' Compensation Medical Bill Data Reporting Implementation Guide, Release 2.0, February 1, 2015 Publication. 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)
(1) 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, the claims administrator shall transmit the corrected data to WCIS within 60 calendar days from the date of transmission of the error acknowledgment.
(2) 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 a need to update data elements previously transmitted, or learns of information that was previously omitted, the claims administrator shall transmit the 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 NameDN
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT96
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE95
PAYMENT/ADJUSTMENT CODE85
PAYMENT/ADJUSTMENT END DATE89
PAYMENT/ADJUSTMENT DAYS PAID91
PAYMENT/ADJUSTMENT PAID TO DATE86
PAYMENT/ADJUSTMENT START DATE88
PAYMENT/ADJUSTMENT WEEKLY AMOUNT87
PAYMENT/ADJUSTMENT WEEKS PAID90

(h) Final reports (MTC = FN) are required only for claims where indemnity benefits are paid or claims where no benefits are paid. For medical-only claims or claims with only non-indemnity benefit payments, the final report may be reported under this section or on the annual report (MTC = AN) with Claim Status (DN0073) = "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.

Cal. Code Regs. Tit. 8, § 9702

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).
5. Amendment of subsections (b)-(e) and (e)(3), redesignation and amendment of subsection (f) as new subsection (f)(1), new subsection (f)(2) and amendment of subsections (g)-(h) filed 3-27-2017; operative 9-27-2017 (Register 2017, No. 13).

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.

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).
5. Amendment of subsections (b)-(e) and (e)(3), redesignation and amendment of subsection (f) as new subsection (f)(1), new subsection (f)(2) and amendment of subsections (g)-(h) filed 3-27-2017; operative 9/27/2017 (Register 2017, No. 13).