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Workers' Compensation Division (WCD)

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Carrie Van Handel    503-947-7742    EDI Medical Bill Reporting: Frequently asked questions Printer friendly version   New-Questions Filing-Related Questions - updated Data-Related Questions - updated Structure-Related Questions Form-Related Questions Pharmacy Reporting Questions - updated     New Questions: What kinds of structural errors have you seen in submitted files? [Answer]     Will Oregon accept medical bill filings from multiple reporting partners for a single carrier? [Answer]     Which bills are required to be reported to Oregon? [Answer]     I dropped off some files on your SFTP server that have not been picked up yet. What's wrong? [Answer]     I got a "TA1" file back from you; what does that mean? [Answer]     How often can we submit medical bill files during the testing period? Do we have to submit them only on the day of the week we indicated in our Transmission Profile? [Answer]     Will Oregon require a Trading Partner Agreement? [Answer]     What is Oregon's Receiver ID? [Answer]     Could you clarify how reconsiderations must be submitted? [Answer]         Filing-Related Questions: Where can I find the list of insurers that are required to report medical bill data to Oregon? [Answer]     We report ANSI 837 medical data for Oregon insurers that are not required to report Bulletin 220 data. Should we report their medical bills along with the rest of our ANSI 837 required reporters? [Answer]     We currently report Bulletin 220 data on a quarterly basis. How frequently will we report ANSI medical bills? [Answer]     Who do we contact to set up a Secure FTP mailbox to report ANSI 837 medical bill data? [Answer]     How soon can we expect to receive the 997 and 824 acknowledgements after we submit an 837 file to Oregon? [Answer]     Will we be able to submit for multiple parties in a single Interchange (as opposed to having to do a separate run for each)? [Answer]     For the 837 Filename, the FEIN is required as part of the name. Our business supports two different lines and we have two different FEINS. Do you want separate files for each LOB, or can we just use one of the FEINS for all of our transactions? [Answer]     When will we actually start reporting to Oregon? We need the start date in order for our programmers to extract the correct transactions for reporting, and not to pull old ones. [Answer]     Updated - Will Oregon require a Trading Partner Agreement for ANSI 837 medical bill filing? [Answer]     Where can I find out when my implementation date is, so that I can plan my IT resources? [Answer]     What rules govern EDI filing of medical bills for Oregon? [Answer]     Do you have a File Naming Convention that you are using for inbound EDI files? [Answer]         Data-Related Questions: I was comparing the date elements for the 837 between California and Oregon. There are some data elements that California requires, but Oregon does not. If those CA fields are written to the 837, will you ignore those elements, or must we leave that information out completely? [Answer]     The structural fields (such as the ISA header fields) are not listed in your data requirements. Are they mandatory? [Answer]     Regarding the Insurer FEIN (DN6): The data edit matrix indicates that it is a required field and it must "match on database" (code 039). What database is this and how does it get populated? Will you be sending back a reject code in the 824 response file for invalid FEINs? NOTE: See correction of error code in answer, below. [Answer]     Batch Control Number is listed as 'optional'. Do we have to include a Batch Control Number in our submissions? [Answer]     Will Oregon perform validation of the provider license prefix? [Answer]     Does Oregon require reporting of denied bills? [Answer]     How are reconsiderations handled by Oregon? [Answer]         Structure-Related Questions: For California reporting, if we sent an IAIABC expectable segment when there were no elements in that segment that California had identified as reportable, they indicated that we could expect a structural error. How does your translator handle valid but unexpected segments? [Answer]         Form-Related Questions: We have questions on the form fields for some of your data requirements; where can we find out more information? [Answer]         Pharmacy Reporting Questions: What do you expect to get when a Pharmacy Benefit Manager (PBM) reports pharmacy payments? Which amount and which received date do you want? [Answer]     Is there a generic NDC code for over-the-counter drugs? [Answer]     Will a pharmacy or pharmacist have a state license number? [Answer]     Updated - The rendering bill provider is mandatory. On a pharmacy bill, if we do not have the rendering bill provider NPI, the rendering bill provider FEIN and license number are required. Will a pharmacy or pharmacist have a state license number? [Answer]     For pharmacy bills, how should we report DN647, Rendering Bill Provider's NPI, and DN592, Rendering Line Provider's NPI? [Answer]     When we receive pharmacy bills, they often contain a different number than the NPI or state license number, e.g. the NCPDP number or DEA number. What number should we do when reporting pharmacy bills? [Answer]   What do we report for DN639, rendering bill provider's first name for a pharmacy bill when the pharmacy is not a "person's" name? [Answer]                                     ---------------Below are the questions and answers---------------     New Questions What kinds of structural errors have you seen in submitted files? We are finding quite a few loop segment problem. Even if WCD has not specified required data fields in a segment which begins the loop containing the required data, the (loop-starting) segment itself must be present, or else a structural error will be triggered. For example, NM1 indicates that a new loop is starting and should be used, with asterisks showing the presence of the fields/absence of data, before the group of REF segments indicating a provider's license number, NPI, etc. [top]       Will Oregon accept medical bill filings from multiple reporting partners for a single carrier? Yes, multiple reporter filings will be accepted. [top]       Which bills are required to be reported to Oregon? Insurers are required to report medical bill payment data on all payments made during each quarter (for quarterly Bulletin 220 reporting) for medical services as defined in OAR 436-010-0005: "Medical Service" means any medical treatment or any medical, surgical, diagnostic, chiropractic, dental, hospital, nursing, ambulances, and other related services, and drugs, medicine, crutches and prosthetic appliances, braces and supports and where necessary, physical restorative services. (NOTE: For ANSI 837 reporting, the same definition applies, but the reporting is weekly or monthly, not quarterly.) [top]       I dropped off some files on your SFTP server that have not been picked up yet. What's wrong? Please check your file name; that has been the most frequent error to date. See below in this document for our File Naming Convention. Files that are misnamed will not be recognized by our file retrieval program, and can't be processed. Please also note that there should be no extension (.ftp, .txt, .edi, etc.) on your files. They just end with '837'. [top]       I got a "TA1" file back from you; what does that mean? A TA1 acknowledgment means there was an Interchange-Level error that prevented us from creating a 997 acknowledgment. There's a structural error with your file that must be corrected before resubmission. The TA1 file name will be formatted just like all our other file names (see below), but ending in "TA1" instead of "997." [top]       How often can we submit medical bill files during the testing period? Do we have to submit them only on the day of the week we indicated in our Transmission Profile? You can submit files daily during testing, if you like. Or you may submit them on a different day than you indicated. Once we move to production, we'd like to be able to predict and balance processing load, so we'd like our submitters to send files on the day of the week we've agreed to. [top]       Will Oregon require a Trading Partner Agreement? We require a Trading Partner Agreement and Transmission Profile from all data reporters. We do not require an Agreement with each carrier/self-insurer. [top]       What is Oregon's Receiver ID? ID Code Qualifier = FI (FEIN) Receiver FEIN = 930952020 Receiver Postal Code = 97301 [top]       Could you clarify how reconsiderations must be submitted? To clarify, you may send reconsiderations one of two ways. For example, if the original provider bill was for $100, and you paid $50 and then reconsidered and paid an additional $25, you could: 1) Send a replacement (05) transaction, to remove the original payment ($50) and replace it with the total reconsidered amount ($75); or 2) Send a second Original Bill (00) of the added amount ($25) and do not cancel or replace the Original Bill of $50. (The second Original Bill must have its own Unique Bill ID that does not duplicate the Unique Bill ID of the originally submitted bill of $50.) If you submit Option 1) above (replacement transaction), the replacement amount must include the total amount paid to the provider (in this case, $75). You cannot send a replacement that includes only the reconsidered amount ($25), because Oregon data would then be incorrect once the replacement transaction overwrote the Original Bill amount of $50. Reconsiderations must be reported within 30 days of the date you paid an additional amount. If you didn't pay anything else, you do not need to send any additional EDI transactions to Oregon WCD. [top]       Filing-Related Questions & Answers: Where can I find the list of insurers that are required to report medical bill data to Oregon? You can find the list on our Insurers Web page under resources. [top]       We report ANSI 837 medical data for Oregon insurers that are not required to report Bulletin 220 data. Should we report their medical bills along with the rest of our ANSI 837 required reporters? We hope that you will report all Oregon medical bill data to us. In order to encourage reporting for non-required insurers, we will send an additional error message: "DN0006 Insurer FEIN: Error Code 039, No Match on Database" for any bill transactions from non-required insurers that reject for other data errors. That way, the submitter can segregate those errors if they do not wish to correct and resubmit them. [top]       We currently report Bulletin 220 data on a quarterly basis. How frequently will we report ANSI medical bills? Filing for the new ANSI 837 medical bill reporting format will be weekly during the test period (July through your company's successful completion of testing with at least 80% accepted transactions.) Then you may want to move to monthly reporting if you are not reporting a high volume of bills. If your expected volume is high, we'd like you to continue to report on a weekly basis. This will allow us to give you quicker feedback on submissions, and reduce the size of any error reports you may have to process after submission. [top]       Who do we contact to set up a Secure FTP mailbox to report ANSI 837 medical bill data? We are in the process of setting up Secure FTP transmission capabilities for ANSI 837 reporting; we already use this methodology for our EDI proof of coverage filings and Bulletin 220 medical bill reporting. Please contact Carrie Van Handel at 503-947-7742 to provide your company's technical contact for setting up SFTP filing. Carrie will then e-mail or call your technical contact person to get the process started. [top]       How soon can we expect to receive the 997 and 824 acknowledgements after we submit an 837 file to Oregon? We will process files Monday - Friday, after 5:00 p.m. Pacific time. Any files that you drop off before the 5:00 cut-off time will be processed that evening, and both 997 and 824 acknowledgements will be dropped off to your SFTP mailbox overnight. Files submitted after 5:00 pm or on weekends will be processed on the next business day and the acknowledgements will be returned overnight. [top]       Will we be able to submit for multiple parties in a single Interchange (as opposed to having to do a separate run for each)? Yes, you will be able to send multiple carrier info. in a single file. We don't anticipate a limit on file size. [top]       For the 837 Filename, the FEIN is required as part of the name. Our business supports two different lines and we have two different FEINS. Do you want separate files for each LOB, or can we just use one of the FEINS for all of our transactions? You can pick one of your FEINs and use it for all your reporting. Just make sure to let us know that (as part of the Reporter Profile information we're working on) so that we can set up our Reporter FEIN table for matching purposes. [top]       When will we actually start reporting to Oregon? We need the start date in order for our programmers to extract the correct transactions for reporting, and not to pull old ones. If you are in Group One (insurers reporting ANSI 837 in another jurisdiction), you will start reporting bills paid on or after July 1, 2008, no matter when the date of service was. Everyone will be reporting weekly, so your first file would come to us during the week of July 7, and would include payments made from July 1 forward. [top]       Will Oregon require a Trading Partner Agreement for ANSI 837 medical bill filing? Updated - We require a Trading Partner Agreement and Transmission Profile from all data reporters. We do not require an Agreement with each carrier/self-insurer. [top]       Where can I find out when my implementation date is, so that I can plan my IT resources? Our "Implementation Schedule" document is linked from the EDI Web page. [top]       What rules govern EDI filing of medical bills for Oregon? EDI filing in Oregon is governed by the Division 160 Rules. Medical reporting is governed by the Division 009 Rules. Both sets of Rules can be found on our main Rules Web page. [top]       Do you have a File Naming Convention that you are using for inbound EDI files? Yes, we will be using the suggested IAIABC format, which is: The State of Jurisdiction (2 Alpha) The Trading Partner/Sender FEIN (9 numeric) Test/Production Indicator (1 Alpha) Date Stamp of 837 File (8 Date CCYYMMDD) Time Stamp of 837 File (6 Time HHMMSS) File Sequential Counter (3 Numeric) File Layout (837, 997, or 824) (3 Numeric) An example of the 837 File name is as follows: OR_123456789_T_20080101_120100_001_837 The corresponding acknowledgement files would be named: OR_123456789_T_20080101_120100_001_997 OR_123456789_T_20080101_120100_001_824 The Date and Time stamp as well as the sequential counter match those of the original 837 not the date/time the acknowledgement files were created. This is done to assist with file pairing. [top]       Data-Related Questions & Answers: I was comparing the date elements for the 837 between California and Oregon. There are some data elements that California requires, but Oregon does not. If those CA fields are written to the 837, will you ignore those elements, or must we leave that information out completely? If we do not require it, then we will skip it. An optional field will not cause a transaction to reject. [top]       The structural fields (such as the ISA header fields) are not listed in your data requirements. Are they mandatory? Yes, these structural fields are required to build the file, and are mandatory. We did not list them on our business data requirements because we assumed that all reporters building the ANSI 837 file would automatically include them. Your file cannot be processed without all structural components present and in the correct order. [top]       Regarding the Insurer FEIN (DN6): The data edit matrix indicates that it is a required field and it must "match on database" (code 039). What database is this and how does it get populated? Will you be sending back a reject code in the 824 response file for invalid FEINs? NOTE: See correction of error code in answer, below. We match against our internal database that includes FEINs of all insurers authorized to write workers' compensation coverage in Oregon. If we receive a medical bill for an insurer not authorized to write coverage in Oregon, we will reject that bill with a 042 code (not statutorily valid) for DN 6 Insurer FEIN. If you get this reject code, it means that either the bill shouldn't have been sent to us, or the insurer needs to contact the Oregon Insurance Division to correct our records. See above, also, for a reject DN6 Insurer FEIN with 039 error "no match on database" to indicate that the rejected bill is from an insurer that is not legally required to report medical bill data to Oregon. These rejects do not have to be corrected and resubmitted, at the reporter's option. We will be correcting our Edit Matrix to reflect this change. [top]       Batch Control Number is listed as 'optional'. Do we have to include a Batch Control Number in our submissions? Although this is listed as optional, we strongly suggest that reporters include a unique Batch Control Number to help them match acknowledgements to submissions. We will return the reported Batch Control Number in our 824 acknowledgement, even if it is all zeroes. [top]       Will Oregon perform validation of the provider license prefix? No, Oregon will not be validating provider license prefixes. You only need to report the provider license number when you do not report an NPI. We encourage you to collect and report the NPI for all providers. [top]       Does Oregon require reporting of denied bills? No, you do not have to report denied bills at this time. [top]       How are reconsiderations handled by Oregon? If you are reporting a payment made on a previously denied bill, that will be reported as an Original Bill (00). If you are reporting an additional payment made on a previously-reported Original Bill, you would report that additional amount as an additional Original Bill. For example, if you were billed $100 but paid $50, you would report an Original Bill for $50. After reconsideration, if you then paid an additional $25, you would report another Original Bill for $25. We would add the two together to arrive at the total cost for the service of $75, with a billed amount of $100. [top]       Structure-Related Questions & Answers: For California reporting, if we sent an IAIABC expectable segment when there were no elements in that segment that California had identified as reportable, they indicated that we could expect a structural error. How does your translator handle valid but unexpected segments? We do not consider it a structural error if a segment that we do not utilize is reported. However, those unutilized segments must be structurally correct--including proper codes--as defined in the IAIABC manual. [top]       Form-Related Questions & Answers: We have questions on the form fields for some of your data requirements; where can we find out more information? We have completed a Data Elements by Source Table, which is on our main EDI Web page. This table gives information on the various source field(s) for our required data elements. Please note that the national NCPDP form is still under review and has not been finalized. [top]       Pharmacy Reporting Questions: What do you expect to get when a Pharmacy Benefit Manager (PBM) reports pharmacy payments? Which amount and which received date do you want? We think there may be two scenarios: 1) PBM pays the pharmacy and then submits that bill payment to us. Carrier pays PBM and that bill is also submitted to us (2 bills); OR 2) PBM pays the pharmacy and does not submit that bill payment to us. Carrier pays PBM and that bill is submitted to us (1 bill). In the first case, PBM will send us a Replacement Bill (same Unique Bill ID as the one they originally submitted to us) when the carrier/self-insured pays them. Each bill will have its own received and paid dates. In the second case, PBM sends us an Original Bill telling us how much the carrier paid them, along with the received and paid date. We will not know how much the PBM paid the pharmacy, or when that payment was made. [top]       Is there a generic NDC code for over-the-counter drugs? No, there is no generic NDC code. All over-the-counter drugs have their own NDC code associated with them. If you pay for OTC drugs, please indicate their correct NDC code on the line. [top]       Will a pharmacy or pharmacist have a state license number? We want the pharmacy information, not the individual pharmacist's NPI and license number. Pharmacies are licensed in Oregon; their license numbers begin with "IP" for institutional pharmacies and "RP" for retail pharmacies. If you do not report the pharmacy's NPI, you must report their state license number. We believe all pharmacies have NPIs, though, and we would prefer that identifier. [top]       The rendering bill provider is mandatory. On a pharmacy bill, if we do not have the rendering bill provider NPI, the rendering bill provider FEIN and license number are required. Will a pharmacy or pharmacist have a state license number? Updated - We want the pharmacy information, not the individual pharmacist's NPI and license number. Pharmacies are licensed in Oregon; their license numbers begin with "IP" for institutional pharmacies and "RP" for retail pharmacies. If you do not report the pharmacy's NPI, you must report their state license number. We believe all pharmacies have NPIs, though, and we would prefer that identifier.[top]       For pharmacy bills, how should we report DN647, Rendering Bill Provider's NPI, and DN592, Rendering Line Provider's NPI? For pharmacy bills, the only rendering provider NPI required is for the bill provider, e.g., the pharmacy's NPI. There is no rendering line provider for pharmacy bills. The one exception to this is for physician-billed drugs on the CMS 1500 form. In this case only, if the rendering bill provider is different from the rendering line provider, then provide the rendering line provider's NPI on the correct line in box 24J. The rendering bill provider's NPI goes in box 33a/. [top]   When we receive pharmacy bills, they often contain a different number than the NPI or state license number, e.g. the NCPDP number or DEA number. What number should we do when reporting pharmacy bills? Oregon requires either the provider's NPI or state license number. If one of these numbers is not available, then you can use the default of 99999. However, it is imperative that reporters begin collecting and reporting NPIs or state license numbers for all providers. Even though there is only one place on the NCPDP form (or paper UCF form) (required by Oregon's rules when reporting pharmacy bills), for the NPI or state license number, either the NPI or state license must be on the bill. All pharmacies in Oregon must be licensed, so even in those rare instances when there is no NPI, the pharmacy will always have a state license number. We highly recommend you contract those entities who report pharmacy bills to you and alert them that the NPI or state license number should be colleted and reported for all pharmacy bills in Oregon. [top]       What do we report for DN639, rendering bill provider's first name for a pharmacy bill when the pharmacy is not a "person's" name? Use the word "pharmacy" in DN639 for all pharmacy bills when the pharmacy's name is not a "person's" name. For instance, if the pharmacy's name is Joe Smith's Pharmacy, use "Joe" in DN639. In DN638, rendering bill providers last/group name, use Smith's Pharmacy." If, however, the pharmacy's name is "South City Pharmacy", report "pharmacy" in DN639, and in DN638, use "South City Pharmacy." [top]                   If you have questions about this Web page, please contact Carrie Van Handel, 503-947-7742.

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