Section V - Reporting Rules

The Medical Data Call is the detailed line information of a bill, also referred to as a medical transaction, reported to the PCRB as an individual record. The Original report is the first reporting of the medical transaction, identified by Transaction Code 01-Original in the record layout (Positions 44-45). For record reporting details, refer to the Medical Data Call Record section and the Data Dictionary section of this manual.

All medical transactions (existing claims and new claims) that occur within a specific quarter, based on Transaction Date (Positions 61-68), must be reported in that quarter’s submission. Historical data for existing claims is not to be reported.

Quarterly submissions are due to the PCRB at the end of the following quarter. For example, medical transactions that occur in September are reported in the 3rd quarter submission due to the PCRB by December 31 of the reporting year. For details on quarterly and monthly reporting options, refer to Reporting Frequency in the General Rules section of this manual.

Medical data providers may delete or change previously reported records (whether the records were reported in earlier submissions or as a prior record in the current submission). Since Medical Data Call reporting is done at the individual line level of a bill, it is not necessary to resubmit every line of a bill if only one line must be deleted or changed.

Transaction Code (Positions 44-45) is used to identify these changes as follows:

Transaction Code 02 – Cancellation – Deletes a record
Transaction Code 03 – Replacement – Changes a record
Transaction Code 04 – Key Field Change – Revise Key Field Values

Note: An Original (01) must be in the same submission or on the PCRB’s database before a Cancellation (02) or a Replacement (03) can be submitted.

For additional information, refer to Transaction Code in the Data Dictionary section of this manual.

1. Record Deletions

A record or multiple records that have been previously reported can be deleted from the PCRB’s database via a cancellation record. The Cancellation transaction (Transaction Code 02) deletes all records, whether one or multiple, for a given key field combination (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number).

To delete a previously submitted record, submit a cancellation record with the following:

(a) All key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number) populated. The key fields must match those reported on the previous record to which the cancellation applies.
(b) Transaction Code 02-Cancellation (Positions 44-45).
(c) Transaction Date (Positions 61-68) reported as the date the cancellation is performed. This date must be after the transaction date on the previous record to which the cancellation applies.

Example: Deleting a single record
Carrier 99990 submits an erroneous record (A). To remove it from the database, the carrier submits a cancellation record (B) with the same key fields and Transaction Code 02. The Transaction Date of the cancellation record is the date when the cancellation is performed.

Not all data elements are shown. For each record of this example, the corresponding data for the elements not shown is identical.

2. Key Field Changes

a. Bill Line Process

In order to change a key field on a single previously submitted record, a Cancellation record must first be submitted to remove the record from the database. This process changes only one Transactional record at a time. Refer to Deleting a Record in this section of the manual for details.

After deleting the previously reported record, submit a new record with the following:

(a) All key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number) populated with the corrected information and the previously reported information for any key fields that are not being changed.
(b) Transaction Code 01-Original (Positions 44-45).
(c) Transaction Date (Positions 61-68) reported as the date the key field change was made.

Example:  Key field change using bill line process
Carrier 99990 submits an original record (A) with an erroneous Claim Number Identifier of 1000. To change the claim number identifier, the carrier first submits a cancellation record (B) with all the key fields as previously reported (including Claim Number Identifier 1000), Transaction Code 02, and Transaction Date as the date the cancellation was performed. After submitting the cancellation, the carrier submits a new record (C) with the corrected Claim Number Identifier and all the other key fields as previously reported, Transaction Code 01, and Transaction Date as the date the change was performed.

Not all data elements are shown. For each record of this example, the corresponding data for the elements not shown is identical.

b. Key Field Change File Process

When using this option of changing key fields on all previously reported and impacted records through the Key Field Change file, the process below must be followed to allow PCRB to apply the key field changes to all affected records in the Medical Data Call database. This process is provided to carriers and group access level providers to make Key Field Changes to previously reported Medical Data Call records at the claim level.

Submit a Key Field Change file including only Key Field Change record(s):

• Create a Medical Data Call .txt file.  Use a file naming convention starting with MK, instead of MC, so that PCRB can identify key field change files separately from standard medical data submission files.  For example: MKEP_SSSSC_RRRRR_CCYYMMDDHHMM
• The Key Field Change file must only contain Key Field Change records.
• Add a File Control Record. Refer to Part 4—Record Layouts for the File Control Record layout.
• The File Control Record should be reported as an Original (Submission File Type Code “O”).
• The Reporting Quarter Code and Reporting Year should reflect the current reporting quarter and year.
• The Submission File Identifier is a unique identifier that is used to distinguish the file being submitted from previously submitted files.

Each Key Field Change record—Transaction Code 04 (refer to Part 4—Record Layouts for the Key Field Change record)—should contain:

• All four of the previous key fields (Previous Carrier Code, Previous Policy Number Identifier, Previous Policy Effective Date, and Previous Claim Number Identifier), as they were reported, for a given claim
• Transaction Code 04—Key Field Change
  • All four Key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, and Claim Number Identifier) as they should be reported going forward

Once the Key Field Change file has been submitted to PCRB, all future Medical Data Call bill line transaction records must be submitted with the new key fields. These will then link the records with the previously submitted records that changed because of the Key Field Change file.

If a Key Field Change file is submitted on the same day as other Medical Data Call bill line transaction files, the Key Field Change file should be submitted first, and all subsequent files should have the corrected key fields.

If the Key Field Change file was submitted in error, a new Key Field Change file can be submitted reflecting the correct data. The File Replacement option (using Submission File Type Code “R” for Replacement on the File Control Record) will not be allowed for the Key Field Change file type.

Example: Key Field Change File Process
In the example below, key fields were initially reported inconsistently across data types. A different carrier code and a claim number, including three leading zeros, were reported on the Unit Statistical data. This is a prime example of how a Key Field Change transaction can correct this problem across the medical database.

3. Non-Key Field Record Changes

A record or multiple records that have been previously reported can be changed via a replacement record. The replacement record shows the current cumulative values for all data elements rather than the change in value.

Medical Data Manager will reject replacement records if the transaction date of the replacement record is 24 months or more from prior record (original or replacement record) intended to be replaced.

Medical Data Manager expects the latest version of a record to have the latest transaction date.  The transaction date of a new original record must be later than the transaction date of the prior cancellation record.  The transaction date of a replacement record or cancellation record must be later than the original or replacement record intended to be replaced or cancelled.

Changes via a replacement record can only be made to non-key fields. To change key fields, refer to Key Field Changes section above.

To change a non-key field for a previously reported record (original or replacement), submit a replacement record with the following:

(a) All key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number) populated. The key fields must match those reported on the previous record to which the change applies.
(b) Transaction Code 03-Replacement (Positions 44-45).
(c) Transaction Date (Positions 61-68) reported as the date the information was changed in the system of the administering entity.
(d) The current cumulative values for all non-key fields (not the change in value).

Note: The replacement record must include all data elements even if they do not change.

Example: Changing an amount field due to an additional reimbursement
Carrier 99990 submits a record (A) for a medical transaction. One week later, the carrier makes an additional reimbursement of $1,000. To change the transaction, the carrier submits a replacement record (B) with the same key fields as the record being changed, Transaction Code 03, and the current cumulative value (not the change in value) for all non-key fields including the Paid Amount, which reflects the total after reimbursement. The Transaction Date of the replacement record is the date the additional reimbursement was made in the system of the administering entity.

Not all data elements are shown.  For each record of this example, the corresponding data for the elements not shown is identical.

Example:  Changing a quantity field due to a previously reported error
Carrier 99990 submits a record with an error in the Quantity/Number of Units field (A). To correct the error, the carrier submits a replacement record (B) with the same key fields as the record being corrected, Transaction Code 03, and the current cumulative value (not the change in value) for all non-key fields including Quantity/# of Units, which reflects the corrected value. The Transaction Date of the replacement record is the date the change was made in the system of the administering entity.

Not all data elements are shown.  For each record of this example, the corresponding data for the elements not shown is identical.

4. Multiple Field Changes

Changes may be made to multiple fields in a record by submitting a single replacement record that includes the following:

(a) All key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number) populated. The key fields must match those reported on the previously reported original or replacement record to which the changes apply.
(b) Transaction Code 03-Replacement (Positions 44-45).
(c) Transaction Date (Positions 61-68) reported as the date the information was changed in the system of the administering entity.
(d) The current cumulative values for all non-key fields (not the change in value).

Note: The replacement record must include all data elements even if they do not change.

Example: Changing multiple fields
Carrier 99990 must change the Service Date, Amount Charged by Provider, and Paid Amount (A). The carrier submits a replacement record (B) with the same key fields as the record being changed, Transaction Code 03, and the current cumulative value (not the change in values) for all non-key fields including Service Date, Amount Charged by Provider, Paid Amount, and Quantity/#of Units. The Transaction Date of the replacement record is the date the change was made in the system of the administering entity.

Not all data elements are shown.  For each record of this example, the corresponding data for the elements not shown is identical.

Medical data providers may delete or replace an entire file that was previously submitted by using Submission File Type Code “R” (Replacement) on the File Control Record (Record Type – SUBCTRLREC).  The File Replacement option (using Submission File Type Code “R” for Replacement on the File Control Record) will not be allowed for the Key Field Change file type.  For record layout and data element details, refer to File Control Record in the Record Layouts section of this manual.

Note: A Replacement (R) file received by the PCRB more than 24 months or more from the first day of the reporting quarter will be rejected.

Example:  A data submitter wants to replace a file reported in 1st quarter 2013. The first day of the quarter is 01/01/2013.  PCRB will not accept a replacement file submitted on or after 01/01/2015.

1. Deleting Files

To delete an entire file from the PCRB’s database, submit a File Control Record with no other records in the file.  The File Control Record for the file is completed as follows:

*Record Total = 1 will be accepted for carriers counting the Electronic Transmittal Record.

2. Replacing Files

To replace an entire file that was previously submitted in error, submit a new file with a File Control Record and all the records to be replaced.

Example: Replacing a file submitted in error
A file is submitted on February 21, 2013 and contains 5,000 records for 4th quarter 2012. On February 23, 2013, the data provider realizes that 500 of the transactions for which records were submitted were reported with Transaction Date 20121209 (12/09/2012) but actually occurred on 01/09/2013 (1st quarter). To replace the entire file, the data provider submits a new file with the 4,500 records for 4th quarter 2012. The File Control Record for the replacement file is completed as follows:

The 500 records reported in error must be submitted with 1st quarter 2013 data with the corrected Transaction Date.

Note: A Replacement (R) file received by the PCRB 24 months or more from the first day of the reporting quarter will be rejected.

Example: A data submitter wants to replace a file reported in 1st quarter 2013. The first day of the quarter is 01/01/2013.  PCRB will not accept a replacement file submitted on or after 01/01/2015.

Medical Data Manger will reject files for duplicate file names if the file names have the same data provider code (NCCI carrier code) and either the file name or Submission File Identifier are identical.

Duplicate records are two or more records that refer to a single service that was performed by a medical provider. Duplicates can affect medical analysis by overstating utilization. Therefore, data submitters are responsible for filtering out duplicates before sending data to the PCRB.

The PCRB will review submissions for records with the same key fields (Carrier Code, Policy Number Identifier, Policy Effective Date, Claim Number Identifier, Bill Identification Number, and Line Identification Number) and the same Transaction Code. If the key fields and Transaction Code are the same, the PCRB will keep the record with the latest Transaction Date. If the Transaction Date is also the same, the PCRB will keep the latest record submitted.

1. True Duplicates (Repeating a Single Bill or Line)

It is possible to have records that are truly duplicates but do not share all key fields. This can occur if a service provider sends a second bill (notice) for a service that was not paid. The payer’s system might create two records with different Bill Identification Numbers although they are for a single service. In this situation, the data submitter must filter out the duplicate records. Do not submit both records since it will overstate utilization.

There are three options to accomplish this:

Option # 1 – Do not submit the second record to the PCRB. The original record will be considered the current record on the database.
Option # 2 – If both records are created in the same quarter and the first has not yet been reported, do not submit the first record to the PCRB. The second record, once submitted, will be considered the current record on the database.
Option # 3 – Cancel the original record and submit a new original record. The second record will be considered the current record on the database. For details, refer to Record Replacements and Cancellations above.

Note: It is possible that the duplicate bill includes additional lines (e.g., follow-up visits, prescriptions). Report the additional lines in accordance with standard reporting procedures.

Example: Reporting options for true duplicates
A claimant received durable medical equipment. The service provider bills payer (Bill ID 101) but does not get paid immediately. The following month, the service provider sends another bill to the payer with the charge for the original durable medical equipment, and the payer’s system assigns Bill ID 201 to the second notice.

Incorrect reporting:
If both records are submitted, the PCRB’s database will show two durable medical equipment bills for a total charge of $150, double the amount of what actually occurred:

Correct reporting (3 options):
Option #1-Submitting only the first record provides an accurate picture of what occurred and minimizes the number of records stored on the database:

Option #2 – Submitting only the second record provides an accurate picture of what occurred and minimizes the number of records stored on the database (this option may not be used if the first record is already on the PCRB’s database):

Option #3 – Submitting a cancellation record (Transaction Code 02) cancels the first record. Submitting a new record (Transaction Code 01) then provides an accurate picture of what occurred.

Note: If Bill 201 includes additional lines (e.g., follow-up visits, prescriptions), report the additional lines in accordance with standard reporting procedures.

2. Multiples of a Procedure Code

It is possible to have a situation where a service provider performs the same service multiple times. These instances are not considered true duplicates (single service billed multiple times) and must be reported to the PCRB. For example, a claimant receives an X-ray, and the service provider requests a second X-ray that repeats the first. Both procedures would be reported.

Dispensing fees are charges assessed when providers issue drugs or supplies to claimants. These dispensing fees include overhead, supplies, and labor, etc., to fill a prescription.  Dispensing fees are not reimbursed by the Pennsylvania Workers’ Compensation Fee Schedule.

Retail pharmacies, fee for service providers or Part B providers (physicians) are reimbursed at 110% of the AWP and there is no dispensing fee.

Inpatient hospital bills contain many services over multiple days.  When reporting inpatient hospital bills to the PCRB, only one transaction is required.

The Pennsylvania Workers’ Compensation Fee Schedule uses Diagnostic Related Group (DRG) codes to determine reimbursement of inpatient hospital bills.  Report the DRG code for the Paid Procedure Code.  Do not report NCCI’s proprietary code “PER-DIEM” in the Paid Procedure Code field, but data submitters may report supporting codes, if any, in the Secondary Procedure Code field.  Refer to Part IV – Data Dictionary for reporting specifications.  “PER-DIEM” may be reported on bills from acute care provided in a trauma center or a burn facility.

Medical billings can contain procedure codes billed by the medical provider that are not directly involved in the reimbursement calculation for the services rendered. For the Medical Data Call, the Paid Procedure Code (Positions 153–177) identifies the procedure associated with the reimbursement paid on a line item or bill. The Secondary Procedure Code (Positions 290–314) field identifies the related procedures billed by the medical provider.

For example, for an inpatient hospital bill, the billed services are often coded using Hospital Revenue Codes, and yet, according to the state fee schedule, the reimbursement is based on a Diagnosis-Related Group (DRG).  In these cases, the DRG should be reported as the Paid Procedure Code for every line to which the DRG reimbursement applies.  The Secondary Procedure Code field should reflect the underlying CPT®/HCPCS or Revenue Code billed by the hospital.

The examples in this section illustrate the reporting of Paid Procedure Codes and Secondary Procedure Codes.

1. DRG Reimbursement (Multiple Dates of Service) Example

A billing for inpatient shoulder surgery shows charges at the Revenue Code level.  For this example,  assume that applicable state regulations indicate that the appropriate reimbursement is based on a DRG code.  The DRG may have been supplied in the PPS code field (FL 71) on the UB-04 form or it is derived by the billing review software.

When reporting the bill transactions on the Medical Data Call, every record should report the DRG as the Paid Procedure Code when applicable.   Each record reports a single Revenue Code as the Secondary Procedure Code along with the associated billed charges as the Amount Charged by Provider (Positions 186-196).  The DRG reimbursement applies to the entire bill.  The Paid Amount (Positions 197-207) may be reported on one transaction (reflecting a bill level reimbursement), and all other transactions for the bill are reported as $0.

The following is an example of correct reporting when multiple dates of services are audited separately:

Example: Correct Reporting – Services Audited Separately

Alternatively, when one cannot proportion this reimbursement among the entire billed lines, one can report the total DRG reimbursement as the Paid Amount on a single transaction.

The following is an example of correct reporting when multiple dates of services are bundled together:

Example: Correct Reporting – Bundled Billing

The following is an example of incorrect reporting when multiple services are audited separately – in this case, Hospital Revenue Codes were used as the Paid Procedure Codes instead of the correct DRG codes:

Example: Incorrect Reporting – Services Audited Separately

2. DRG Reimbursement (Single Service Date) Example

Alternatively, inpatient hospital transactions reimbursed under a DRG can be reported on a per-day basis.  Because the DRG determined the reimbursement, report the DRG as the Paid Procedure Code.  When submitting transactions for individual service dates of an inpatient stay, report the daily reimbursement amount on one of the bill lines for the day as the Paid Amount.  The Paid Amount on all other transactions with the same Service Date (Positions 129-136) is reported as $0 because the daily reimbursement amount was already included on another bill line.  Note that the sum of the Paid Amounts will equal the total reimbursement for the entire bill.

The following is an example of correct reporting for a single service date when services are audited separately:

Example: Correct Reporting – Single Service Date

The following is an example of incorrect reporting for a single service date when services are audited separately:

Example: Incorrect Reporting – Single Service Date

3. DRG Reimbursement With Implant Example

The standard DRG reimbursement does not always cover the entire bill, especially bills charging for services or equipment that are expected to vary greatly in cost.  Implants and prosthetics are one category of devices that often are not subject to the DRG calculation and, instead, are reimbursed separately.

When reporting the bill line transactions reimbursed according to the DRG, report the applicable DRG in the Paid Procedure Code.  For bill line transactions that are not reimbursed under the DRG, report the procedure code (typically a Hospital Revenue Code) used to determine the reimbursement for that bill line in the Paid Procedure Code field and the associated reimbursement in the Paid Amount field.

The following is an example of correct reporting when an implant was billed and reimbursed separately:

Example: Correct Reporting – DRG Reimbursement With Implant

*Line ID Number 6 with Paid Procedure Code 0278 in the Implant Revenue code.

The following is an example of incorrect reporting when an implant was billed and reimbursed separately:

Example: Incorrect Reporting – DRG Reimbursement With Implant

*Line ID Number 6 with Paid Procedure Code 0278 in the Implant Revenue code.

For reporting medical marijuana payments, report the following Paid Procedure Codes:

• MM001 Medical Marijuana—Reimbursement to injured worker (claimant)
• MM002 Medical Marijuana—Reimbursement directly to dispensary

When reporting reimbursement for medical marijuana, this existing Taxonomy Code 175F00000X—Naturopath value is recommended as the closest Taxonomy Code for a dispensary.

In order to specify a dispensary as a new Place of Service Code, the following code is to be reported.

• Place of Service DS—Dispensary (Centers for Medicare & Medicaid Services (CMS) does not currently have a code for dispensary)

If applicable state or nationally recognized code values are created for medical marijuana reporting, those code values should be reported in lieu of MM001 and MM002.

Medical Marijuana – Reimbursement to Claimant

When an injured worker is provided with a prescription for medical marijuana that is reimbursed to the injured worker, it is reported with Paid Procedure Code MM001, Naturopath as the Taxonomy Code, and Dispensary as the Place of Service Code; and the Date of Service should be reported as a single Service Date.  The Quantity Number of Units field should be populated with the number of grams dispensed.

Example: Correct Reporting – Medical Marijuana – Reimbursement to Claimant

Medical Marijuana – Reimbursement to Dispensary

When an injured worker is provided with a prescription for medical marijuana that is reimbursed to a dispensary, it is reported with Paid Procedure Code MM002, Naturopath as the Taxonomy Code, and Dispensary as the Place of Service Code; and the Date of Service should be reported as a single Service Date.  The Quantity Number of Units field should be populated with the number of grams dispensed.

Example: Correct Reporting – Medical Marijuana – Reimbursement to Dispensary

This information identifies the provider that was paid and the location where the services were provided.

Fields associated with provider information include:

• Provider Identification Number
• Provider Taxonomy Code
• Provider ZIP (Postal) Code
• Provider Postal (ZIP+4) Code

The Provider Identification Number and Taxonomy Code should be reported for the dispensing pharmacy or DME supplier, the individual provider billing for services they perform, or the facility billing for the services.   The ZIP Code fields should be reported for the dispensing pharmacy, DME supplier, or service facility.

Billing house information that may be geographically remote from the service facility that is being paid should not be reported.

The examples in this section illustrate reporting provider information for various scenarios.

1.  Pharmacy and DME

A local pharmacy dispenses prescription drugs to a claimant and the transaction involves a PBM (Pharmacy Benefits Management) company.  Report the dispensing provider information.  The PBM company is considered a billing house and may be geographically remote from the location where the drugs are dispensed and the rules under which payment is made.

   2. Professional Services

A physician bills for services provided in an office setting.  Since the billing and service information all relate to the same location and provider, report the physician provider information.

  3.  Facility Bills

A claimant is treated by a physical therapist employed by a hospital that bills from a centralized billing location in another state.  Because the individual providing services is not reimbursed directly, report the provider information of the service facility where the services were performed.