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The Oregon Administrative Rules contain OARs filed through September 15, 2014
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
WORKERS' COMPENSATION DIVISION

 

GENERAL PROVISIONS

Electronic Data Interchange; Medical Bill Data

436-160-0001

Authority, Applicability, Purpose, and Administration of these Rules

(1) These rules are promulgated under the director's authority contained in ORS 656.726(4).

(2) These rules apply to workers’ compensation related transactions filed with the director by electronic data interchange (EDI) on or after Oct. 1, 2014.

(3) The purpose of these rules is to require workers’ compensation medical bill data reporting by electronic data interchange.

(4) Orders issued by the division in carrying out the director's authority to enforce ORS chapter 656 are considered orders of the director.

(5) The director may waive procedural rules as justice requires, unless otherwise obligated by statute.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS Ch. 84 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

Electronic Data Interchange

436-160-0004

Adoption of Standards

(1)(a) The director adopts, by reference, IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb 1, 2014.

(b) The director adopts, by reference, the ASC X12 Implementation Acknowledgment for Health Care Insurance (999), dated February 2011.

(2) The form, format, and delivery of data elements reported and definitions will conform to the standards adopted under section (1), unless otherwise provided in these rules.

(3) Copies of the guides in section (1) are available for review during regular business hours at the Workers’ Compensation Division, Operations Section, 350 Winter Street NE, Salem OR 97301, 503-947-7717.

(a) IAIABC members may view a copy of the Release 2.0 guide, or non-members may purchase a copy at the IAIABC website: http://www.iaiabc.org.

(b) The ASC X12 999 guide is available for purchase at the X12 online store: http://store.x12.org/store/healthcare-5010-consolidated-guides.

Stat. Auth.: ORS 656.264
Stats. Implemented: ORS 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0005

General Definitions

For the purpose of these rules, unless it conflicts with statute or rule:

(1) “ANSI” means the American National Standards Institute.

(2) “ASC X12” means the Accredited Standards Committee chartered by the American National Standards Institute (http://www.x12.org/x12org/index.cfm).

(3) “Director” means the Director of the Department of Consumer and Business Services or the director's designee for the matter.

(4) “Division” means the Workers' Compensation Division of the Department of Consumer and Business Services.

(5) “Electronic data interchange” or “EDI” means a computer to computer exchange of information in a standardized electronic format.

(6) “Electronic record” means information created, generated, sent, communicated, received, or stored by electronic means.

(7) “Exclude (not applicable to the transaction)” means the data element must not be sent or cannot be sent.

(8) “Fatal Technical” means the transaction set or item structurally requires the data element.

(9) “FEIN” means the federal employer identification number or other federal reporting number used by the insurer, insured, or employer for federal tax reporting purposes.

(10) “Header record” means the record that precedes each transmission for the purpose of identifying a sender, the date and time of the transmission, and the transaction set within the transmission.

(11) “Health Care Provider” has the same meaning as “medical provider,” under OAR 436-010-0005(28).

(12) “IAIABC” means the International Association of Industrial Accident Boards and Commissions, a professional trade association comprised of state workers' compensation regulators and insurance representatives (www.iaiabc.org).

(13) “If Applicable/Available with Item Accept if Invalid” means the data element must be sent if appropriate for the item record. Even if the item record has an invalid value, the transaction set or item record will not be rejected.

(14) “If Applicable/Available with Item Reject if Invalid” means the data element must be sent if appropriate for the item record. If the item record has an invalid value, then the transaction set or item record will be rejected.

(15) “Information” means data, text, images, sounds, codes, computer programs, software, databases, or the like.

(16) “Insurer” means the State Accident Insurance Fund Corporation, an insurer authorized under ORS chapter 731 to transact workers' compensation insurance in Oregon, an assigned claims agent selected by the director under ORS 656.054, or a self-insured employer.

(17) “Mandatory data element” means an element that will cause a rejection of a transaction if the data element is omitted or submitted in an invalid format, or with an improper value.

(18) “Mandatory Conditional” means the data element is required when certain conditions are present.

(19) “Medical Bill” means a statement of charges for medical services, specified as “compensable medical services,” under ORS 656.245.

(20) “Not Applicable” means the data element is not relevant, appropriate, or doesn't apply, although if present with an improper value will not cause a rejection of a transaction.

(21) “Record” means electronic record.

(22) “Trading partner” means the entity sending electronic data interchange (EDI) transactions to the division. Trading partners may include vendors or insurers.

(23) “Trailer record” means the record that designates the end of a transmission and provides a count of transactions contained within the transmission, not including the header and trailer records.

(24) “Transaction” means a set of EDI records, defined according to standards in OAR 436-160-0004.

(25) “Transmission” means a defined set of transactions, including both header and trailer records to be sent to the division or sender by EDI.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 84.004 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

436-160-0040

Recognized Received Date

An electronic record is received when:

(1) The record enters the division’s designated information processing system;

(2) All the required data elements and electronic records are in the form and format specified in these rules in the proper sequence; and

(3) The record can be fully processed by the division's information processing system.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 84.043 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

436-160-0060

Testing Procedures and Requirements

Testing and transition to production:

(1) Before testing can begin, or the division can accept medical billing data, the trading partner must submit a completed Medical Billing Data EDI Trading Partner Profile (Form 4015) to the division’s EDI Coordinator. Form 4015 is available on the division’s website: http://wcd.oregon.gov/operations/edi/ediindex.html#bill.

(2) For test purposes each transmission must conform to the standards specified in OAR 436-160-0004.

(3) Test files will be evaluated in terms of whether the data sent was received in the correct standardized format and fully processed by the division's information processing system.

(4) The EDI Coordinator will determine the number of required transactions per test submission based on the anticipated volume of production transactions.

(5) To be approved to send production transmissions, the sender must:

(a) Accomplish secure file transfer protocol (SFTP) uploads and downloads;

(b) Demonstrate the ability to send transmissions to the division that are in the correct format and can be processed through the division's information processing system;

(c) Resolve any consistently recurring errors, and demonstrate the ability to correct and resubmit corrections to errors identified by the division;

(d) Send transmissions to the division that do not result in a 999 acknowledgment indicating a rejection;

(e) Send transmissions to the division without transaction level technical errors;

(f) Demonstrate the ability to receive and process acknowledgement transactions; and

(g) Achieve an acceptance rate of at least 90 percent.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 84.013 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

Insurers’ Obligation to Report Medical Bill Data

436-160-0405

Insurers’ Reporting Responsibilities

(1) Insurers with an average of at least 100 accepted disabling claims per year, based on the average accepted disabling claim volume for the previous three calendar years, are required to electronically submit detailed medical bill payment data to the Department of Consumer and Business Services under OAR 436-160-0415.

(2) The director will notify an insurer when the insurer has reached a three-year average accepted disabling claim count of at least 100. The insurer is required to report medical bill payment data beginning with the date specified in the notice and must continue to report in subsequent years.

(3) If the insurer’s claim count drops below an average of 50 accepted disabling claims, based on the average accepted disabling claim volume for the previous three calendar years, insurers may apply to the director for an exemption from the reporting requirement.

(4) The list of insurers required to report medical bill data is published in Bulletin 359.

(5) Insurers that do not meet the requirement to submit medical data under (1) of this rule may voluntarily submit medical billing data.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

436-160-0410

Electronic Medical Bill Data Transmission and Format Requirements

(1) The transmission data and format requirements are included in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0 (Feb 1, 2014), and Appendices A and B of these rules. Oregon-specific information can be found on the division’s Electronic Data EDI webpage: http://www.cbs.state.or.us/wcd/operations/edi/ediindex.html.

(2) Data elements are listed in Appendices A and B:

(a) Appendix A shows all medical bill data elements accepted by EDI in Oregon, and whether the data element is “Fatal Technical” (F), “Mandatory” (M), “Mandatory Conditional” (MC), “If Applicable/Available with Item Reject if Invalid” (AR), or “If Applicable/Available with Item Accept if Invalid” (AA) for each transaction type.

(b) Appendix B lists mandatory conditional data elements that are mandatory under specific conditions.

(3) Unless otherwise provided in these rules, the data elements must have the meaning provided in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb. 1, 2014, Section 2; Health Care Claim (837).

(4) Transactions will be rejected if “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements are omitted, or include invalid values.

(5) Transactions will be rejected if “If Applicable/Available with Item Reject if Invalid” data elements include invalid values.

(6) Invalid “If Applicable/Available with Item Accept if Invalid” data elements will be ignored if they are included in a transaction.

[ED. NOTE: Appendices referenced are not included in rule text. Click here for PDF copy of appendicies.]

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 1-2014, f. 2-14-14, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0415

Oregon ASC X12 837 Medical Bill Data Reporting Requirements

(1) Event reporting requirements:

(a) Medical bills, including interpreter bills under OAR 436-009, must be reported within 60 days of the date paid.

(b) Denied medical bills for accepted claims must be reported within 60 days of date of denial. Denied bills are defined as any bills in which there is a non-zero charge and a zero payment.

(c) Transactions must be received and accepted by the division within 60 days of either the date paid or the date denied to be considered timely reported. If a transaction is initially rejected it must be corrected, resubmitted, and accepted within the original 60 day time period to be considered timely reported.

(d) Cancellations must be reported as soon as the payer knows that a medical bill was sent in error.

(e) Corrections/Replacements must be reported within 60 days of changes to any of the “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements in Appendices A and B.

(f) Bills received by the insurer before Oct. 1, 2014, may be reported to the Division using the IAIABC reporting standard version 1.1.

(2) Data reporting requirements are described in Appendices A and B.

(3) Technical requirements are described on the division’s Electronic Data EDI webpage for specifications on the Secure File Transfer Protocol (SFTP) requirements.

(4) Data Quality: The director will conduct electronic edits for blank or invalid data. Affected insurers are responsible for pre-screening the data they submit to check that all the required information is reported and is formatted correctly. OAR 436-160-0420 describes the acceptance or rejection protocol for all reported medical bills. The insurer is responsible for timely correcting and resubmitting all rejected transactions for which law or rule require filing, reporting, or notice to the director.

(5) An insurer must request and receive authorization from the director to stop submitting a previously rejected transaction when the division determines the transaction is uncorrectable.

(6) The director will periodically review reported bill data to monitor insurer performance. If the director finds repeated or egregious violations of the reporting requirements of these rules the director may issue civil penalties under OAR 436-160-0445 and ORS 656.745.

(a) Medical bills must be reported timely. “Timely” means that an insurer reports medical bills as required by OAR 436-160-0415(1).

(b) Medical bills must be reported accurately. “Accurately” means that the reported medical bill data accepted by the division conforms to the reporting requirements of the Appendices A and B.

(c) The insurer may be subject to penalties for any reported medical bills that have not been accepted by the division or designated as uncorrectable under OAR 436-160-0415(5) within 180 days of the date of bill payment or denial.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0420

Medical Bill Acknowledgement

(1)(a) The sender is expected to retrieve both TA1 and 999 interchange and functional acknowledgements (as defined by ASC X12) for each medical bill file submitted, unless technical errors in the file prevent 999 processing. In addition, the sender is expected to retrieve the 824 detailed acknowledgement, as defined by IAIABC Release 2.0 (Feb.1, 2014) for each medical bill file submitted, if at least one transaction has successfully passed the 999 edits.

(b) The detailed acknowledgement will indicate either an item accepted (IA) or an item rejected (IR) acknowledgement for each individual transaction.

(2) A TA1, 999 or 824 acknowledgement will be available for all transactions the division is unable to process, including but not limited to:

(a) An omitted mandatory data element;

(b) An improperly populated data element field, e.g., numeric data element field is populated with alpha or alphanumeric data, or is not a valid value according to the standards adopted in 436-160-0004;

(c) Transactions or electronic records within the transaction that require matching, and cannot be matched to the division's database, e.g., cancellation of an original bill that does not match the Unique Bill ID;

(d) Illogical data in mandatory or required conditional field, e.g., payment date is after reporting date;

(e) Duplicate transmission or duplicate transaction within the transmission;

(f) Invalid bill submission reason code; or

(g) Illogical event sequence relationship between transactions, e.g., cancellation transaction submitted before an original bill is accepted.

(3) A transaction accepted acknowledgement will be available for all transactions that are in a format capable of being processed by the division's information processing system and that are not rejected under section (2) of this rule.

(4) An insurer’s obligation to report medical bill data for the purposes of this rule is not satisfied unless the division acknowledges acceptance of the transaction.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0430

Medical Bill Data Changes

(1) Changes to medical bill information must be submitted according to the standards referenced in OAR 436-160-0004.

(2) The Unique Bill ID will be used to match cancellations, corrections, and replacements to the original bill. Failure to match on this data element will result in a rejected transaction.

(3) The insurer must correct and resubmit any transactions rejected for which law or rule requires filing, reporting, or notice to the director.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

436-160-0440

Monitoring and Auditing Insurers

(1) The director may monitor and conduct periodic audits of medical bill data to ensure compliance with ORS chapter 656 and these rules.

(2) All records maintained or required to be maintained must be disclosed upon request by the director.

Stat. Authority: ORS 656.726(4)
Stat. Implemented: ORS 656.252, 656.254, 656.264, 656.455 & 656.726
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

436-160-0445

Assessment of Civil Penalties

(1) Under ORS 656.745, the director may assess a civil penalty against an insurer that fails to comply with ORS Chapter 656 or the director’s rules and orders.

(2) The insurer is responsible for its own actions as well as the actions of others acting on the insurer’s behalf. If an insurer or someone acting on the insurer’s behalf violates any provisions of these rules, the director may impose a civil penalty against the insurer.

Stat. Auth. ORS 656.726(4)
Stats. Implemented: ORS 656.254 & 656.745
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14; Administrative correction, 9-24-14

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