California Medical Data Call Edit Matrix November 2016

Transcription

1 Workers Compensation Insurance Rating Bureau of California California Medical Data Call Matrix November 26

2 Notice The California Medical Data Call Matrix was developed by the Workers Compensation Insurance Rating Bureau of California for the convenience and guidance of its members. It does not bear the official approval of the California Department of Insurance and is not a regulation. 26 Workers Compensation Insurance Rating Bureau of California. All rights reserved. Includes material of the National Council on Compensation Insurance Inc., National Council on Compensation Insurance, Inc. All rights reserved. Used by permission. No part of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including, without limitation, photocopying and recording, or by any information storage or retrieval system without the prior written permission of the Workers Compensation Insurance Rating Bureau of California (WCIRB), unless such copying is expressly permitted in this copyright notice or by federal copyright law. No copyright is claimed in the text of statutes and regulations quoted within this work. Each WCIRB member company, including any registered third-party entities, (Company) is authorized to reproduce any part of this work solely in connection with the transaction of workers compensation insurance and to the extent reasonably necessary for the training of Company personnel. This reproduction right does not include the right to make any part of this work available on any website or on any form of social media. Workers Compensation Insurance Rating Bureau of California, WCIRB, WCIRB California, WCIRB Connect, WCIRB Inquiry, X- Mod Direct, escad and the WCIRB California logo (WCIRB Marks) are registered trademarks or service marks of the WCIRB. WCIRB Marks may not be displayed or used in any manner without the WCIRB s prior written permission. Any permitted copying of this work must maintain any and all trademarks and/or service marks on all copies. To seek permission to use any of the WCIRB Marks or any copyrighted material, please contact the WCIRB at customerservice@wcirb.com.

3 00- Accident Date Accident Date is missing, or not a valid date. 08- Carrier Carrier is missing or not a valid carrier code. 08- Carrier Medical Data Provider is not certified for Carrier Carrier Carrier is not associated with the Carrier Group in the submission. Claim Number Identifier Jurisdiction State 08- Jurisdiction State 08- Policy Effective 53- Date Policy Effective 53- Date 56- Policy Number Identifier Claim Number Identifier is invalid, missing, or all zeros. Jurisdiction State is missing. Jurisdiction State is not valid Birth Year Birth Year is missing. Policy Effective Date is missing or not a valid date. Policy Effective Date is after Accident Date. Policy Number Identifier is invalid, missing or all zeros Birth Year Birth Year is not a valid year Birth Year Birth Year must not be after the Accident Date Birth Year Birth Year is more than 125 years before Accident Date. Claimant Gender Claimant Gender is missing. Stage of ing 03 F File Acceptance Reject file 03 S File Acceptance Reject File 03 S File Acceptance Reject file 03 F File Acceptance Reject file 03 F File Acceptance Reject file 03 F File Acceptance Reject file Note: Please refer to the last page of this document for the Matrix Legend. Page 1

4 Claimant Gender Amount Charged 05- by Provider 05- Bill Identification Number Line Identification Number Network Service Network Service Claimant Gender is not valid per the table. Amount Charged by Provider is not numeric. Bill Identification Number is missing. Line Identification Number is missing. Network Service is missing. Network Service is not valid per the table Paid Amount Paid Amount is not numeric Paid Amount Paid Amount equals Amount Charged by Provider Paid Amount Paid Amount is greater than Amount Charged by Provider. Paid Procedure Paid Procedure is missing. Paid Procedure Paid Procedure is not a valid procedure code. Paid Procedure Paid Procedure is missing and Secondary Procedure is valid. Stage of ing 03 F File Acceptance 03 F File Acceptance Reject file Reject file Paid Procedure First Paid Procedure Modifier First Paid Procedure Modifier Value(s) expected for Procedure Group derived from Paid Procedure were not supplied. First Paid Procedure Modifier is missing. First Paid Procedure Modifier is not a valid modifier. Note: Please refer to the last page of this document for the Matrix Legend. Page 2

5 First Paid Procedure Modifier First Paid Procedure Modifier Place of Service Place of Service Value(s) expected for First Paid Procedure Modifier were not supplied. First Paid Procedure Modifier is missing and Second Paid Procedure Modifier is valid. Place of Service is missing. Place of Service is not valid per the table. Stage of ing Place of Service Primary ICD Diagnostic Primary ICD Diagnostic Primary ICD Diagnostic Value(s) expected for Place of Service were not supplied. Primary ICD Diagnostic is missing and Place of Service is not (Pharmacy). Primary ICD Diagnostic is not a valid ICD code. Primary ICD Diagnostic is missing and Secondary ICD Diagnostic is valid. Primary ICD Diagnostic Primary ICD Diagnostic Provider Identification Number Provider Postal (Zip) Provider Postal (Zip) Provider Taxonomy Provider Taxonomy Value(s) expected for Diagnosis Group derived from Primary ICD-9 Diagnostic were not supplied. Primary and Secondary ICD Diagnostic fields are reported inconsistently with an ICD-9 in one field and ICD-10 in the other. Provider Identification Number is missing. Zip is missing. Zip is not valid. Provider Taxonomy is missing. Provider Taxonomy is not valid. Note: Please refer to the last page of this document for the Matrix Legend. Page 3

6 Stage of ing Provider Taxonomy Value(s) expected for Provider Taxonomy Group were not supplied. Quantity/Number of Units Per Procedure Quantity/Number of Units Per Procedure is not numeric. Quantity/Number of Units per Procedure Value(s) expected for Quantity/Number of Units per Procedure for drug/medication-related records were not supplied. Secondary ICD Diagnostic Secondary ICD Diagnostic is not a valid ICD code and Place of Service is not (Pharmacy). Secondary ICD Diagnostic Secondary ICD Diagnostic is equal to the Primary ICD Diagnostic. Secondary ICD Diagnostic Secondary ICD Diagnostic is missing. Secondary Procedure Secondary Procedure is not a valid procedure code. Secondary Procedure Secondary Procedure is equal to the Paid Procedure. Secondary Procedure Secondary Procedure is missing action action is not valid. F File Acceptance Reject file action Cancellation record does not match a previously reported record. R File Acceptance Return Record action Record is not the latest reported as compared to the database. File Acceptance Return Record action Replacement record does not match a previously reported record. Quality Tracking Replacement record contains the same action Date as record to be action replaced. Quality Tracking Cancellation record contains the same action Date as record to be action deleted. R Quality Tracking action Original record already exists. R Quality Tracking Note: Please refer to the last page of this document for the Matrix Legend. Page 4

7 0520- action Date action Date is not a valid date action Date action Date is outside the current submission period. Second Paid Procedure Modifier Second Paid Procedure Modifier is not a valid modifier. Second Paid Procedure Second Paid Procedure Modifier is equal to the First Paid Procedure Modifier Modifier. All Service Dates are missing; Service Date is required unless both Service Service Date(s) From Date and Service To Date are provided. Service Date along with Service From Date and/or Service To Date have been provided Service Date(s) Service Date(s) Service Date(s) Service Date(s) Please supply only the Service Date or both the Service From Date and Service To Date. One or more of the Service Date(s) fields (Service Date, Service From Date, Service To Date) is not a valid date. One or more of the Service Date(s) fields (Service Date, Service From Date, Service To Date) is before Accident Date. Service From Date or Service To Date is missing. Service From Date and Service To Date are required unless Service Date is provided Service Date(s) Service From Date equals Service To Date Service Date(s) Service To Date is before Service From Date. A valid Service Date or valid Service From Date and Service To Date have Service Date(s) not been provided. Your data file was rejected because of an invalid file name. Stage of ing 03 F File Acceptance 03 F File Acceptance Reject file Reject file Please review your procedures and resubmit the corrected file. S Pre-processor Reject File Note: Please refer to the last page of this document for the Matrix Legend. Page 5

8 Your data file has been rejected because you have not been authorized and certified to send in this specific data type. Stage of ing Please contact customer service to initiate the certification and approval process. S Pre-processor Reject File Your file was rejected because the record length was invalid and/or there were Null characters in the file Please review your procedures and resubmit the corrected file. S Pre-processor Reject File File must contain a File Control Record. S Pre-processor Reject File File must not contain more than one File Control Record. S Pre-processor Reject File Submission File Submission File is not valid per the table. S File Acceptance Reject File Carrier Group Account is not authorized to submit for Carrier Group. S File Acceptance Reject File Reporting Quarter Reporting Quarter is not valid per the table. S File Acceptance Reject File Reporting Quarter Reporting Quarter is after the current quarter. S File Acceptance Reject File Reporting Year must be within the last two years and less than or equal to Reporting Year the current year. S File Acceptance Reject File Submission Date Submission Date is not a valid date. S File Acceptance Reject File Submission Time Submission Time is not a valid time. S File Acceptance Reject File Submission File Identifier Submission File Identifier is not populated. S File Acceptance Reject File Record Total Record Total does not match actual record count. S File Acceptance Reject File File control Record is a duplicate with a prior submission. S File Acceptance Reject File Submission File Identifier for Account Number was previously submitted. Submission File "R" (Replacement) must be reported if the purpose of this file is to replace the previous file submitted. S File Acceptance Reject File Submission File Identifier reported on replacement file does not match a previously reported submission for Account Number. S File Acceptance Reject File Replacement file has a Submission Date and Time prior to the file it is intended to replace. S File Acceptance Reject File Replacement file was rejected because it was submitted after the allowable replacement period. S File Acceptance Reject File The current certification file is less than the required number of records for certification. S File Acceptance Reject File Note: Please refer to the last page of this document for the Matrix Legend. Page 6

9 Stage of ing Submission File = "R" (Replacement) is not a deletion file submission. S File Acceptance Reject File MATRIX LEGEND : F = Field, L = Logical, R = Relational, S = Submission #: made up of the Data Element Number (e.g., 79) followed by the Sequence Number (e.g., ) Message: Unless otherwise indicated, if present means the field is not blank. Note: Please refer to the last page of this document for the Matrix Legend. Page 7

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