Medical Data Call 

The record return file is returned via text file (.txt) attachment included in a system-generated email.

Yes. The product type is reported as WCM for medical data call.

Yes. The medical data call files require the standard CDX naming convention. The first two positions will be MC for medical data call and all other parts of the CDX file naming convention follow. We have the ability to accept a limited amount of additional file identification content on the far right of the file name, after the end of the standard CDX naming convention.

Display the submission control record at the end of the file. The file should be structured with the E.T.R. transmittal record at the top of the file, then the medical data transactions, then the submission control record at the end of the file.

Carriers must set up the WCMED product within CDX and establish reporting permissions for this product.

Yes. Monthly submissions are encouraged so that large volumes of data can be successfully transmitted and received.

The claim number identifier is a linking field and must match the unit statistical claim number. Since each carrier’s systems and business partner arrangements are different, each carrier will have to make a business decision to either require it from the vendor, supply it to the vendor, or populate it in their own system prior to submission.

We recognize that the difference in duration of reporting from 11 report levels (unit data) to 30 years (medical data) may pose a problem when reporting older claims. In these cases, we would accept the policy number and claim number that identify the claim in your system today. This policy number and claim number must be consistently used for all future reporting of claim transactions.

If a payment transaction is reported prior to the void or stop pay, the transaction must be cancelled to remove it from the database. If the void or stop pay occurs before a transaction is reported, then the void or stop pay transaction does not need to be reported.

Key fields that change require a cancellation record to first remove the record from the database. After cancelling the previously reported record, submit a new record with all key fields, including those that did not change. Include transaction code 01 (original), with transaction date reported as the date the key field change was made in the source system. All other data elements must be reported according to the specific data element reporting rule. 
Key fields are defined as carrier code, policy number, policy effective date, claim number identifier, bill ID number, line ID number, transaction code, and transaction date. Because the medical data call is transactional, non-key field changes would be corrected through the reporting of future replacement transactions. 

Use the same 12-digit claim number that is reported on the unit statistical report for the same claim. Claim number is required for file acceptance. 

The reporting rules for record replacements and cancellations are found in the medical data call manual. If the records are true replacements, then the entire bill should be reported. Otherwise, the new record would overlay the previously reported record with missing data. On a cancellation record, only data required for linkage (key identifying fields) would be required.

Medical data call is based on transaction date. The transaction date is the date the information was processed by the original source of the data. Do not use submitted or received date. Some carriers choose to report on the date of actual payment, which is permitted.

When key fields change, carriers should cancel a record (transaction code 02) and then submit a new record (transaction code 01). When non-key fields change, carriers should replace the original record with a new record (transaction code 03) and include the new values. The key fields cannot be changed during the replacement transaction so that the data processing system can match the records. 
For non-key field changes, if a change is made for the same bill ID and line ID, the carrier must replace the record. The incremental amount or change is not submitted as a separate transaction. Transactions are reported summarized at the bill ID and line ID level. 
When replacing any data element, all fields in the transaction must be reported regardless of whether the fields are changing. 
Key fields are defined as carrier code, policy number, policy effective date, claim number identifier, bill ID number, line ID number, transaction code, and transaction date.

Reporting requirements are related to transaction dates. Do not use service date to determine which transactions go into the file. 
The only other date that matters for inclusion is accident date. Accident date is important because of the reporting duration requirement, which states that transactions must be reported until medical transactions no longer occur for the claim or 30 years from the accident date, whichever comes first.

If the items are services for which your company pays medical benefits and they can be captured at the detail level, they should be reported. However, medical expenses incurred for the benefit of the carrier and reported as allocated expenses for unit statistical reporting should not be reported.

No. 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, transactions where the paid amount is zero should be reported as long as zero is the final payment amount after processing and the zero is not due to duplicate billing or a denied claim. 
If a claim is denied prior to reporting any transactions, no transactions should be sent. If transactions were reported prior to denial, those transactions should be cancelled.

If the original record reports charged zero, a transaction would not normally be received. However, if the insurer makes a payment even though charges are zero, that transaction should be sent.

If medical transactions were reported and the claim is later denied, those transactions should be cancelled. If the claim is denied prior to reporting any transactions, no transactions should be reported. If the claim is workers compensation and all services on a bill were denied because they were unrelated to the injury, those services should not be reported.

It is not necessary to submit all fields. For a cancellation record, submit all key fields (carrier code, policy number, policy effective date, claim number identifier, bill identification number, line identification number, transaction code, and transaction date). Transaction code must equal 02, and transaction date must be after the original transaction date.

Report the data as an original record. A replacement record that does not match an original record will be rejected.

No.

Yes.

Do not report original or replacement subrogation-related records or medical bill line adjustments related to subrogation.

No. The policy effective date in effect at the time of the accident must be reported. This is a critical field.

Policy number identifier is a critical field and must be populated.

Carriers must ensure that required data elements are provided to any reporting entity. Carrier code, policy number, policy effective date, and claim number must match unit statistical data.

No.

All transactions occurring in the quarter based on transaction date should be reported, whether for existing or new claims. Prior history is not required.

Multiple procedure codes may apply. Report the primary code in the paid procedure code field and the secondary code when applicable.

It represents a circumstance that alters a procedure without changing its definition.

The hierarchy is APC or DRG, state-specific, national or industry, then revenue or in-house.

It is acceptable to leave the field blank. Default code 999.9 is not valid.

Only valid ICD codes. Default or internal codes are not valid.

Report CPT/HCPCS as the paid procedure code and revenue code as the secondary procedure code.

Report the code that reflects the provider’s network association, regardless of whether a discount applies.

PPO, then HMO, then participation agreement.

ICD procedure codes are not accepted. Report CPT/HCPCS and revenue code instead.

Yes. Provider taxonomy code 333600000X and place of service code 01 may be used.

Yes. Provider taxonomy is required and may need to be obtained or built through provider files.

Through billing vendor software or internal processes. No specific product is recommended.

No.

No. It applies to all healthcare settings, including pharmacies.

Use crosswalks based on type of bill as outlined in the medical data call manual.

Blank-fill until the information can be obtained.