The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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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 appendices.]
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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