Free Inpatient Data Reporting Rules & Instructions (PDF) - New Mexico


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Date: September 12, 2006
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State: New Mexico
Category: Workers Compensation
Author: MFarley
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http://workerscomp.state.nm.us/pdf/hospital.pdf

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New Mexico Workers' Compensation

Inpatient Data Collection Instructions

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION INPATIENT DATA COLLECTION INSTRUCTIONS

Table of Contents 1. 2. 3. 4. 5. 6. 7. Reporting Requirements..............................Page (2) When and How to file.................................Page (2) Technical Requirements..............................Page(3) Data Definitions....................................... Page (4) Electronic Layout.......................................Page(6) Excel & Paper Reporting...............................Page (7) APPENDIX...............................................Page (8) AUGUST 15, 2006

(August 15, 2006)

Page (1)

New Mexico Workers' Compensation DATA REPORTING REQUIREMENTS:

Inpatient Data Collection Instructions

Rule 11.4.7.11 requires all worker compensation payers to report inpatient hospital services data from information collected on the UB-92 form (changes to the data collection guide due to the new UB04 will become effective March 2007). The schedule for reporting is determined by the date of payment of the services provided. All information requested as being mandatory must be provided to the WCA. Conditional field requirements are also outlined in these instructions. Information provided must be complete and accurate. Inpatient hospital services are those services provided to injured or ill workers under state workers' compensation coverage that has a service period of greater than 24 hours. Additionally, the inpatient worker has been admitted to a general hospital or an acute hospital and is provide a room and meals. WHEN TO FILE: The insurer must report an inpatient hospital bill to the WCA within 10 to 90 days of payment of the bill. Reports may be submitted by mail, fax or electronic media in batches daily, weekly or monthly from the insurer or insurer's representative. In any event, the insurer must report the inpatient bill not later than the 92nd day from the date of payment. Note for the first data sets, inpatient bills paid from July 1, 2005 through December 31, 2005 must be reported in the first quarter of 2006 (January 1, 2006 through April 1, 2006). HOW TO FILE: The insurer or insurer representative has three methods to file inpatient bills to the WCA: Paper (UB-92 and Supplement), Electronic CD, or Email (Excel file). Under the paper process the insurer must complete the information on a supplemental form (E10-1, see Appendix) for each inpatient billing that is being submitted to the WCA. The paper billing information may be faxed or mailed using the following: · · To fax the information the phone number to use is (505) 841-6883. The Mailing address: NM Workers' Compensation Adm. P.O. Box 27198 Albuquerque, NM 87125-7198 Attention: Statistics

To submit an electronic format to the WCA, a profile of the sender must be established. To do this, the sender of the information must contact the Economic Research Bureau at (505) 841-6044 and provide the following using the Inpatient Data Provider Partner form (E9) (See Appendix): 1. Sender Name and Address 2. Sender FEIN 3. The Payers the sender is sending for and their FEINs 4. Contact person 5. Phone number of Contact person 6. The email address of contact person 7. Method of reporting, CD, Excel-email, 8. Frequency of reporting

(August 15, 2006)

Page (2)

New Mexico Workers' Compensation REPORT RECORD FORMATS

Inpatient Data Collection Instructions

The sender of the inpatient data should have a clear understanding of the report record format for the UB-92 information. Table B (in Appendix) shows the data element (Field-Name), UB-92 location block, the data type, New Mexico's requirements, length of the field, Column beginning and ending points, and format notes. The data element definitions are also explained in Table (A). Note, for paper submission a supplemental form needs to accompany each inpatient bill. This information is provided in the Appendix. The reporting organization must be aware that the record lengths remain constant for all records. Each data field within the record has a WCA technical requirement designation (i.e. M = Mandatory, C = Conditional, O = Optional). Data elements that are not available or have no values will have a blank entry in that field except for the following technical requirements designated under the NM Req. column (see Table B in Appendix): · M = Mandatory field. A data element having this designation must be included in every transmission of a record. If a mandatory field element is not contained in the UB-92 transmission, a critical error will result and a statistical staff member will contact the sender party. · C = Conditional field. A non-null data element having this designation must be transmitted with every UB-92 record. This information is often time sensitive and is not provided at every stage of the claim process. Once the information is known it must be provided to the WCA at all of the reporting events. · O = Optional field. A non-null data element having this designation may be transmitted.

TECHNICAL FILING REQUIREMENTS (FOR ELECTRONIC) The following rules apply for submission of the inpatient UB-92 billing information. A diagram in the appendix shows the transaction flow for the billing information: · Billing Type = 111: This bill establishes a new inpatient bill for the injured worker for the admission's date provided on the UB-92. There must be one billing type of 111 for a general acute hospital inpatient bill per injured worker for a specific admission date. Duplicate billing type 111 or subsequent billing types of 121 and 851 will not be accepted for the specific SSN and Admissions date. Billing Type = 115: This bill establishes additional charges based on the original billing information provided under billing-type 111. There must be a Billing Type = 111 established in the database prior to the filing and acceptance of a billing type = 115. This billing type is used only for general acute hospitals for inpatient services. More than one billing type 115 may be filed for the same SSN and admissions date. Billing Type = 117: This billing type is used to correct a previously submitted bill. The sender uses this billing type to replace the billing information previously submitted under billing type 111 for a particular injured worker (SSN) and specific admission's date. Note a previous Bill must have been established for the worker and admission's date prior to sending this billing type. This billing type is only used for general acute hospital inpatient services. Once this billing type has been sent, only subsequent billing type =117 will be processed for the same SSN and Admissions date. Billing Type = 121: This bill establishes a new inpatient bill for the injured worker for the admission's date provided on the UB-92. This Billing type is used for inpatient services that are special in nature and are not covered under the billing type of 111. One example might be dialysis services (long-term). There Page (3)

·

·

·

(August 15, 2006)

New Mexico Workers' Compensation Inpatient Data Collection Instructions must be one billing type of 121 for special services under general acute hospital inpatient bill per injured worker for a specific admission date. Duplicate billing type 121 or subsequent billing type of 111 and 851 will not be accepted for the specific SSN and admission's date. · Billing Type = 125: This bill establishes additional charges based on the original billing information provided under billing-type 121. There must be a Billing Type = 121 established in the database prior to the filing and acceptance of a billing type = 125. This billing type is used only for general acute hospitals for inpatient (special) services. More than one billing type 125 may be filed for the same SSN and admissions date. Billing Type = 127: This billing type is used to correct a previously submitted bill. The sender uses this billing type to replace the billing information previously submitted under billing type 121 for a particular injured worker (SSN) and specific admission's date. Note a previous Bill must have been established for the worker and admission's date prior to sending this billing type. This billing type is only used for special services under general hospital inpatient services. Once this billing type has been sent, only subsequent billing type =127 will be processed for the same SSN and Admissions date. Billing Type = 851: This bill establishes a new inpatient bill for the injured worker for the admission's date provided on the UB-92 (For Critical Access Hospitals, CAH only). Under this billing type, a room charge must be indicated on the UB92 for it to be considered an inpatient bill. There must be one billing type of 851 for a Critical Access hospital inpatient bill per injured worker for a specific admission date. Duplicate billing type 851 or subsequent billing types 111 and 121 will not be accepted for the specific SSN and admission's date. Billing Type = 855: This bill establishes additional charges based on the original billing information provided under billing-type 851. Under billing type 851 and 855, a room charge must be indicated on the UB92 for it to be considered an inpatient bill. There must be a Billing Type = 851 established in the database prior to the filing and acceptance of a billing type = 855. This billing type is used only for critical access hospitals (CAH) for inpatient services. More than one billing type 855 may be filed for the same SSN and admissions date. Billing Type = 857: This billing type is used to correct a previously submitted bill. Under billing type 857, a room charge must be indicated on the UB92 for it to be considered an inpatient bill. The sender uses this billing type to replace the billing information previously submitted under billing type 851 for a particular injured worker (SSN) and specific admission's date. Note a previous Bill must have been established for the worker and admission's date prior to sending this billing type. This billing type is only used for Critical Access Hospitals (CAH) for inpatient services. Once this billing type has been sent, only subsequent billing type =857 will be processed for the same SSN and Admissions date.

·

·

·

·

DATA DEFINITIONS The following table outlines the definitions of the data requested. The source of the data provide to the database is outlined under column UB-92 of Table A. TABLE A Screen Name
Admin-Clm-No

Table Field
Admin_Claim-No.

Definition
Claim Number assigned by insurer's claim administrator. Inpatient bill is not filed with the WCA until a claim number has been established and payment has been made.

UB-92
Insurer

REQ
M

(August 15, 2006)

Page (4)

New Mexico Workers' Compensation Screen Name Table Field
Worker Last Name Worker_last_name

Definition

Inpatient Data Collection Instructions UB-92 REQ
12 C

SSN Birth Date of Admin Type of Bill

SSN Date_of_Birth Date of Admission Bill_Type

The last name of the injured worker off of the UB-92 paper form. For the electronic or CD records, the SSN is compared with the WCA database under the insurer's claim number. Social Security Number of the injured worker. Date of birth of the injured worker. Date of injured worker admitted into the hospital for services extending beyond 24 hours. Bill Type describing how the bill is generated from the hospital or payer. Valid Codes for WCA are 111= Admission through Discharge Claim 115= Additional Charges of Claim 117 = Replacement of Claim Others: 121, 125, 127: For Special Services 851 = Admission through Discharge of CAH 855 =Additional Charges of Claims 857 = Replacement of Claim Describes under what conditions the injured worker was admitted as inpatient status to the hospital. Valid codes: 1= Emergency, 2= Urgent, 3= Elective, 5 =Trauma Center, 9 = unavailable Defines where the admission of the injured worker originated. Valid codes: 1= Physician Referral, 2 = Clinic Referral 3= HMO Referral, 4 = Transfer from Hospital 5= Transfer from Skilled Nursing Facility 6= Transfer from another HCF 7= Emergency Room 8= Law Enforcement 9 = Information unavailable A = Transfer from a Critical Access Hospital Date that the injured worker is discharged or inpatient services have ended at the hospital. Indicator describing the state or status of the injured worker at the time of the hospital discharge. Valid codes (01 ­76) (see UB92 Definitions, Medicare) Hospital `s Medical -Record Number of Patient. Name of the insurer from UB-92. Federal Tax-id number of insurer. Federal Tax-id number of employer. Name of the Medical Review Co. or Sender of Medical Data to WCA Total amount of billed charges of medical services designated by revenue code (001).

60 14 17 4

M M M M

Type of Admin

Admission_type

19

M

Source of Admin

Admission_source

20

M

Date of Discharge Discharge Status

Discharge_dt Discharge_Status

6 22

C C

Medical Record Number Insurer Name FEIN Employer FEIN Sender Total Charges

Medical Record No Payer Insurer_fein Emplyer_fein Sender_Name Total Gross Charges

23 50 Insurer Insurer Sender 47

C M M M Paper M

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Page (5)

New Mexico Workers' Compensation Screen Name Table Field

Definition

Inpatient Data Collection Instructions UB-92 REQ

Total Paid

Total Paid Amount

Date Paid PDC 2nd-9th Diag. DRG PPC Date 2nd ­ 6th Proc. REV-CD(X)

Date_paid Principle Diagnosis Code 2nd-9th diagnosis codes Diagnosis Related Group (DRG) Principle Procedure Code PPC Date 2nd-6th Procedure Codes Revenue Code (XX)

REV-CD Rate REV-CD Amt

Revenue Code (XX) Rate RC-XX Total Charges

HOSP ID Dt-Occurrence

Hospital _FEIN Date of Occurrence

When reporting use both dollars and cents in the format without the decimal point and zero fill before first digit. The amount paid by the payer for the inpatient services. When reporting use both dollars and cents in the format without the decimal point and zero fill before first digit. The date the bill was paid by the payer The ICD-9-CM code indicating the principal or major diagnosis of the injured worker injuries or illness. Secondary and additional ICD-9-CM code describing the diagnosis of the injury or illness of the injured worker. The group code describing the overall diagnosis of the injury or illness of the injured worker. The ICD-9-CM code describing the procedures used to treat the injured worker. The date of the principle procedure used to treat the injured worker. Secondary and additional ICD-9-CM codes to describe to procedures used to treat the injured worker. The description of the medical services provided under inpatient status (code is 4 digit): Note the first revenue code must be mandatory. The cost per services based on Revenue Code. (This is the Accommodation Rate for revenue codes 100 through 219) The amount of the medical services provided under the specific revenue code. Note, for the first revenue code, total charges are mandatory. Numerical format without decimal point and zero fill before first digit.. The Federal Identification number of the Hospital (9-digit Field) The date of the occurrence for the injury or illness of the patient.

Insurer

M

Insurer 67 68-75 56 80 80 81 A-E 42

M M C M M M C C

44 47

C C

5 32

M M

ELECTRONIC LAYOUT FOR MAILED DATA SUBMISSIONS
Table B (in appendix) record layout should be used when data is submitted by mail in electronic form (on CD or diskette). The UB-92 form locators are printed in the table below as a guide to reporting the required data. A Header and Trailer record (see Table C, appendix) is used for each submission. Each file should be separated by insurer billed data information. Note, the order of the billing type is critical to the success of the acceptance of the transmission. All billing types = 111, 121, 851 should be processed first. Media: CD or diskette File Format: ASCII TEXT: with a header record first, then the data records followed by the trailer record. File Length:--- 823 Header and Trailer record not included in file length

(August 15, 2006)

Page (6)

New Mexico Workers' Compensation EXCEL EMAIL SPECIFICATIONS

Inpatient Data Collection Instructions

Other Instructions: Submit data as a fixed column input text file where each row represents the data from one discharge. All data fields should be left justified. Leave unused spaces blank - do not fill.

Table B record layout should be used when data is submitted by email. Three worksheets in excel should be established: (1) the first is the Header Worksheet, which has the header information. (2) The second worksheet has the inpatient data records by row based on the column headings. (3) The third worksheet outlines the trailer information. Note: for excel files, the first row has column headers as defined by the first column in Table B. Data submissions that are mailed (in an Excel format) must also use this record layout. The UB-92 form locators are printed in the Table B as a guide to reporting the required data and data required by the insurer or sender is also outlined. File Format: Microsoft Excel spreadsheet (version 1997 or more recent) File Name (required for all emailed data submissions): Please contact the WCA for the file naming convention. File Password (required for all emailed data submissions): Please contact the WCA for a file password. Other Instructions: Put the names of the column headers in order in the first row of the Excel worksheet. Each row following the first row will represent the data for one hospital billing type for a particular SSN and admission date. Leave unused cells blank - do not fill.

PAPER REQUIREMENTS
The Sender must provide a clear copy of the UB-92 for each inpatient hospital bill submitted for a workers' compensation case (See Rule 11.4.7.11). The bill must be submitted no later than 90 days from the date of payment of the bill to the WCA. Each UB-92 submitted must have a supplemental form (E10-1) shown in the Appendix. The supplemental form is used to collect that information that is not on the UB-92 and is in Table B outlined as "insurer" under the UB-92 column. Note all of the mandatory fields outlined in Table B must be present on the UB-92 when submitted to the WCA.

SPECIAL PROCESSING INSTRUCTIONS (Paper Only): If partial payment is made to an original bill (X11) and is previously filed with the WCA and an additional payment is made for the same bill at a later date, then a new E10 -1 is filed with the original bill (X11) with both the previous payment and new payment noted in the total paid field.

(August 15, 2006)

Page (7)

New Mexico Workers' Compensation

Inpatient Data Collection Instructions

APPENDIX

CONTENTS 1. 2. 3. 4. 5. 6. Table B (Inpatient Data Record).................Page (9) Table C (Header, and Trailer Record)..........Page (11) Inpatient Billing Diagram........................Page (12) Data Partner Profile (E9).........................Page(13) UB92 Supplemental Form (E10-1)..............Page(14) Acknowledgement & Error Matrix..............Page (15-20)

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Page (8)

New Mexico Workers' Compensation Inpatient Data Collection Instructions INPATIENT RECORD FORMAT TABLE B Field Name UB-92 Type NM Length Begin End Notes Loc. Req.
Admissions_dt Discharge_dt Principle Diagnosis Code (PDC) 2nd Diagnosis code 3rd Diagnosis code 4th Diagnosis code 5th Diagnosis code 6th Diagnosis code 7th Diagnosis code 8th Diagnosis code 9th Diagnosis code Diagnosis Related Group code (DRG) Revenue Code 1 (RC-1) RC-1 HCPCS Rate RC-1 Total Charge Revenue Code 2 (RC-2) RC-2 HCPCS Rate RC-2 Total Charge Revenue Code 3 (RC-3) RC-3 HCPCS Rate RC-3 Total Charge Revenue Code 4 (RC-4) RC-4 HCPCS Rate RC-4 Total Charges Revenue Code 5 (RC-5) RC-5 HCPCS Rate RC-5 Total Charges Revenue Code 6 (RC-6) RC-6 HCPCS Rate RC-6 Total Charges Revenue Code 7 (RC-7) RC-7 HCPCS Rate RC-7 Total Charges Revenue Code 8 (RC-8) RC-8 HCPCS Rate RC-8 Total Charges Revenue Code 9 (RC-9) RC-9 HCPCS Rate RC-9 Total Charges Revenue Code 10 (RC-10) RC-10 HCPCS Rate RC-10 Total Charges Revenue Code 11 (RC-11) RC-11 HCPCS Rate RC-11 Total Charges Revenue Code 12 (RC-12) RC-12 HCPCS Rate RC-12 Total Charges Revenue Code 13 (RC-13) RC-13 HCPCS Rate RC-13 Total Charges Revenue Code 14 (RC-14) 17,{6} 6, Bl-2 67 68 69 70 71 72 73 74 75 **56 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 Date Date A-N A-N A-N A-N A-N A-N A-N A-N A-N A-N A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N M C M C C C C C C C C M M C M C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C C 8 8 6 6 6 6 6 6 6 6 6 3 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 1 9 17 23 29 35 41 47 53 59 65 71 74 78 88 98 102 112 122 126 136 146 150 160 170 174 184 194 198 208 218 222 232 242 246 256 266 270 280 290 294 304 314 318 328 338 342 352 362 366 376 386 8 16 22 28 34 40 46 52 58 64 70 73 77 87 97 101 111 121 125 135 145 149 159 169 173 183 193 197 207 217 221 231 241 245 255 265 269 279 289 293 303 313 317 327 337 341 351 361 365 375 385 389 mmddccyy mmddccyy No periods No Periods No Periods No Periods No Periods No Periods No Periods No Periods No Periods 3 ­digit code

Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999

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New Mexico Workers' Compensation Field Name UB-92 Type Loc.
RC-14 HCPCS Rate RC-14 Total Charges Revenue Code 15 (RC-15) RC-15 HCPCS Rate RC-15 Total Charges Revenue Code 16 (RC-16) RC-16 HCPCS Rate RC-16 Total Charges Revenue Code 17 (RC-17) RC-17 HCPCS Rate RC-17 Total Charges Revenue Code 18 (RC-18) RC-18 HCPCS Rate RC-18 Total Charges Revenue Code 19 (RC-19) RC-19 HCPCS Rate RC-19 Total Charges Revenue Code 20 (RC-20) RC-20 HCPCS Rate RC-20 Total Charges Revenue Code 21 (RC-21) RC-21 HCPCS Rate RC-21 Total Charges Revenue Code 22 (RC-22) RC-22 HCPCS Rate RC-22 Total Charges Revenue Code 23 (RC-23) RC-23 HCPCS Rate RC-23 Total Charges TOTAL GROSS CHARGES Total Paid Amount Principle Procedure Code (PPC) PPC Date 2nd Procedure Code 3rd Procedure Code 4th Procedure Code 5th Procedure Code 6th Procedure Code Clm-Admin Claim Number Birth_dt , Injured Worker SSN, Injured Worker Employer_id (FEIN) Insurer_fein Payer Bill-type Discharge Status Admission_type Admission_Source Date_paid Medical Record No Hospital_FEIN 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 42 44 47 47 Insurer 80 80 81, A 81, B 81, C 81, D 81, E Insurer 14 60 Insurer Insurer 50 4 22 19 20 Insurer 23 5 A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. A-N A-N Num. Num. Num. A-N Date A-N A-N A-N A-N A-N A-N Date A-N A-N A-N A-N A-N A-N A-N A-N Date A-N A_N

NM Req.
C C C C C C C C C C C C C C C C C C C C C C C C C C C C C M M M M C C C C C M M M M M M M C M M M C M

Inpatient Data Collection Instructions Length Begin End Notes
10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 4 10 10 10 10 6 8 6 6 6 6 6 25 8 9 9 9 30 3 2 1 1 8 20 9 390 400 410 414 424 434 438 448 458 462 472 482 486 496 506 510 520 530 534 544 554 558 568 578 582 592 602 606 616 626 636 646 652 660 666 672 678 684 690 715 723 732 741 750 780 783 785 786 787 795 815 399 409 413 423 433 437 447 457 461 471 481 485 495 505 509 519 529 533 543 553 557 567 577 581 591 601 605 615 625 635 645 651 659 665 671 677 683 689 714 722 731 740 749 779 782 784 785 786 794 814 823 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 Format: 9999999999 No Periods Format MMDDCCYY No Periods No Periods No Periods No Periods No Periods Claim Number of E1, E6 Format: MMDDCCYY Format 999999999 Format: 999999999 Format: 999999999 Valid Code =111,115,117 121,125,127 851,855,857 Codes: 01,02,04,05,06, 07,08,20, 30, 40,41,42 43,50,51,62, 63, 65, Codes: 1,2,3,4,5,9 Codes: 1-9, A Format: MMDDCCYY Format: 999999999

(August 15 2006)

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Page (10)

New Mexico Workers' Compensation Field Name UB-92 Type Loc.
Date of Occurrence 32 Date

NM Req.
M

Inpatient Data Collection Instructions Length Begin End Notes
8 824 831 Format: MMDDCCYY

**56: State Requirement on UB-92 TABLE C HEADER RECORD Field Name Values Req. Length Format Column Position Begin End 1 3 4 28 29 37 38 45 46 46

Header ID HIP M 3 Text Sender Name M 25 Text Sender FEIN 999999999 M 9 Text Date Transmission MMDDCCYY M 8 Date Test File Indicator P, T M 1 Text P = Production, T = Test. For Test Files Data will be discarded after test. TRAILER RECORD Field Name Trailer ID Detail Record Count Values TRP 99999 Req. M M Length 3 5 Format Text Num

Column Position Begin End 1 3 4 8

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New Mexico Workers' Compensation Inpatient Data Collection Instructions INPATIENT DATA TRANSACTIONS

Worker Admit. IP ?

General Acute Hospital?

N

Critical Access Hospital?

N

Special Services ?

NO

Initial Bill Paid?

Yes General Acute Hosp. Bill-Type = 111 Cov Days > 1 Critical Access Hospital Bill-type = 851 Cov. Days > 1 (Room Charge) Special Hospital Services (Inpatient) for GAH. Bill-type = 121 Cov. Days > 1

Additional Charges? yes

NO

General Acute Hosp. Bill Type = 115 Prior bill type 111

Critical Access Hospital Bill Type = 855 Prior bill type 851

Special Services? Bill Type = 125 Prior bill type 121

No

Correct Total Bill Information ?

Yes

General Acute Hosp Bill Type = 117 Prior bill type 111 on file

Critical Access Hospital Bill Type = 857 Prior bill type 111

Special Services Bill Type = 127 Prior bill type 121 on file.

STOP

NEW
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New Mexico Workers' Compensation

Inpatient Data Collection Instructions

MEXICO WORKERS' COMPENSATION ADMINISTRATION

Inpatient Medical Data Provider Partner Profile
ATTN: STATISTICS PO BOX 27198 ALBUQUERQUE, NM 87125-7198
PLEASE PRINT IN BLACK INK OR TYPE

Email Address: [email protected] Phone Number: (505) 841-6044

Reporting Purpose Code

PARTNER TYPE:

TPA Employer

Carrier Other

Medical Bill Review Company



Sender Administrator

Name: Mail/Address: City: Postal Code: Contact Person: Fax #:
FILE TRANSMISSION: Medical Hosp.

DATA PROVIDER PARTNER: (SENDER) FEIN: State: Phone: Email Address:

FREQUENCY OF REPORTING: Weekly Monthly Semi-Annually Daily Bi-weekly Quarterly Annually
Other

Medical Opt

FILE TYPE:

ANSI
EXCEL



Flat File (ASCII) UB-92 (Paper)

DAY OF WEEK:

Sat. Sun. Mon. Tue. Wed. Thur. Fri.

NETWORK: MAIL BOX ACCT. USER ID: MESSAGE CLASS: Production Start Date Test Start Date_______________ Email File
ORGANIZATIONS REPORTING UNDER SENDER ADMINISTRATOR:

Insurer Name

FEIN

Type (Carrier or Self-Insured) Postal Code, Phone Number

Agreement Person

Title

Signature

Date

E9 (11/18/2005)

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Page (13)

New Mexico Workers' Compensation New Mexico Workers' Compensation Administration Inpatient Data UB-92 Supplement Mail: UB-92 with Supplement to NM Workers' Compensation Adm. P.O. Box 27198 Albuquerque, NM 87125-7198 Attention: Statistics Unit Please Print
(1)Injured Worker's Last Name: (4)Insurer's Name: (2) Sender's Name

Inpatient Data Collection Instructions Attach to UB-92 FAX: UB-92 with supplement to (505) 841-6883 Questions: call (505)-841-6000, ask for Statistics Unit
(3) Sender's FEIN

OR

(5) Insurer's FEIN: (7) Employer's FEIN: (9) Date of Payment of Billed Amt.:
(11) Number of Attached Pages: (14) TPA FEIN (12) Total Amount Paid on Bill

(6) Employer's Name: (8) Insurer's Claim Number:
(10) Date of Submission:

(13) DRG if not in Block 56

(15) TPA Name

INSTRUCTIONS: Please provide the supplemental form for each inpatient bill (UB-92) submitted to the WCA through the mail or by FAX. Insurers or insurer representatives must file a UB-92 with the supplemental form (E10-1) within 10 to 90 days from the date of payment. DEFINITIONS: (1) Injured Worker's Last Name: This block of information is required by the supplemental form to insure that the information corresponds to the UB-92 in case that the form and Billing information gets separated. (2) Sender's Name: Name of the company representing the insurer submitting the UB-92 information to the WCA. (3) Sender FEIN: Federal Tax Identification Number of the company representing the insurer submitting UB-92 data. (4) Insurer Name: Name of the company financially responsible for Workers' Compensation claim. (5) Insurer FEIN: Federal Tax Id number of insurer. (6) Employers' Name: Name of the company employing injured worker. (7) Employer FEIN: Federal Tax Id number of employer. (8) Insurer's Claim Number: The Claim Administrator's Claim Number associated with the E1.2 and E6.1 filed with the WCA. (9) Date of Payment: Date of the payment of the inpatient bill submitted to the insurer for this claim. (10) Date of Submission: The date the UB-92 is faxed or mailed to the WCA. (11) Number of Attached Pages: The number of pages faxed or mailed to the WCA for this Bill. (12) Total Amount Paid: The total amount paid to the hospital for the billed charges submitted on the UB-92 (13) DRG Code: The Diagnosis-Related Group code is based on the patient's primary and secondary diagnosis and the procedures performed during an inpatient stay. FOR INTERNAL USE SSN DOI WCA# Date Received

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E10-1/18-2006 Page (14)

New Mexico Workers' Compensation Inpatient Data Collection Instructions DETAIL ACKNOWLEDGMENT Table D
POSITION GROUP TRANSACTION SET ID ACKNOWLEDGEMENT DETAIL RECORD RECORD SEQUENCE NBR DATE PROCESSED TIME PROCESSED CLAIM ADMINISTRATOR CODE CLAIM ADMINISTRATOR POSTAL CODE INDEPENDENT ADJUSTOR CODE ACKNOWLEDGEMENT TRANSACTION SET ID AK1 M M M M M C M 9 9 9 3 9 N DATE TIME A/N A/N A/N A/N 4 13 21 27 36 45 54 12 20 26 35 44 53 56 DATA ELEMENT NAME TECH REQ LENGTH FORMAT VALUES NM F_TYPE BEG M 3 A/N 1 END 3

Inpatient Billing Report UB First Report of Injury or Illness
SUBSEQUENT REPORT APPLICATION ACKNOWLEDGEMENT CODE TRANSACTION ACCEPTED TRANSACTION REJECTED TRANSACTION ACCEPTED WITH ERRORS INSURED REPORT NUMBER CLAIM ADJUSTOR CLAIM NUMBER AGENCY CLAIM NUMBER TRANSACTION SET PURPOSE CODE (FROM ORIGINGAL TRANS) TRANSACTION SET DATE REQUEST CODE (PURPOSE) NONE CONTACT SENDER FREE FORM NUMBER OF ERRORS ERROR CODE ELEMENT NUMBER ELEMENT ERROR NUMBER VARIABLE SEGMENT NUMBER

INP 148 A49 M TA TR TE C C C M M 0 0 1 0 M 60 2 A/N N 147 207 206 208 3 25 25 25 2 A/N A/N A/N A/N DATE A/N 59 84 109 134 136 144 83 108 133 135 143 146 2 A/N 57 58

(NOT USED )

4 3 2

N N N

209 213 216

212 215 217

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New Mexico Workers' Compensation Error Matrix Table #1
Message Number 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 Edit Description Bill number out of sequence or wrong billing number Invalid or missing Admissions Type code Invalid or missing Source Code Missing Principle Diagnosis code Missing Diagnosis Related Group code Missing Revenue Code Missing Mandatory Date Missing or invalid total charge data Missing Mandatory Field Invalid or missing Insurer FEIN Missing Principle Procedure code Invalid Discharge Status Admissions date < Date of Occurrence Admissions date > Discharge Date Discharge date < Date of Occurrence PPC Date < Admissions date Duplicate (111) for same admin & SSN Admissions date < Birthdate Date Occurrence < Birthdate PPC date > date paid Invalid or missing Sender FEIN Dn 4 X DN 6

Inpatient Data Collection Instructions
DN 14 DN 17 DN 19 DN 20 DN 22 DN 32 DN 42.01

X X

X X X X X X X

X X X X X X X X X X X

X

Table #2
Edit Description Bill number out of sequence or wrong billing number Invalid or missing Admissions Type code Invalid or missing Source Code Missing Principle Diagnosis code Missing Diagnosis Related Group code Missing Revenue Code Missing Mandatory Date Missing or invalid total charge data Missing Mandatory Field Invalid or missing Insurer FEIN Missing Principle Procedure code Invalid Discharge Status Admissions date < Date of Occurrence Admissions date > Discharge Date Discharge date < Date of Occurrence PPC Date < Admissions date DN 47.00 DN 47.01 DN 42.XX DN 47.xx DN 50 DN 55.01 DN 55.02 DN 56 DN 60

X X X X X X X X

(August 15, 2006)

Page (16)

New Mexico Workers' Compensation
Edit Description Bill number out of sequence or wrong billing number Duplicate (111) for same admin & SSN Admissions date < Birth-date Date Occurrence < Birth-date PPC date > date paid Invalid or missing Sender FEIN DN 47.00 DN 47.01 DN 42.XX

Inpatient Data Collection Instructions
DN 47.xx DN 50 DN 55.01 DN 55.02 DN 56 DN 60

X

Table #3
Edit Description Bill number out of sequence or wrong billing number Invalid or missing Admissions Type code Invalid or missing Source Code Missing Principle Diagnosis code Missing Diagnosis Related Group code Missing Revenue Code Missing Mandatory Date Missing or invalid total charge data Missing Mandatory Field Invalid or missing Insurer FEIN Missing Principle Procedure code Invalid Discharge Status Admissions date < Date of Occurrence Admissions date > Discharge Date Discharge date < Date of Occurrence PPC Date < Admissions date Duplicate (111) for same admin & SSN Admissions date < Birthdate Date Occurrence < Birthdate PPC date > date paid Invalid or missing Sender FEIN DN 61 DN 62 DN 65 DN 67 DN 80.1 DN 80.2 DN 100

X

X X X X X

X

X X

(August 15, 2006)

Page (17)

New Mexico Workers' Compensation Field Name
Bill-type

Inpatient Data Collection Instructions
Data Num 44.01 Data Num 47.10

UB-92 Data #
4

Field Name RC-1 HCPCS Rate RC-2 HCPCS Rate RC-3 HCPCS Rate RC-4 HCPCS Rate RC-5 HCPCS Rate RC-6 HCPCS Rate RC-7 HCPCS Rate RC-8 HCPCS Rate RC-9 HCPCS Rate RC-10 HCPCS Rate RC-11 HCPCS Rate RC-12 HCPCS Rate RC-13 HCPCS Rate RC-14 HCPCS Rate RC-15 HCPCS Rate

Field Name RC-10 Total Charges RC-11 Total Charges RC-12 Total Charges RC-13 Total Charges RC-14 Total Charges RC-15 Total Charges RC-16 Total Charges RC-17 Total Charges RC-18 Total Charges RC-19 Total Charges RC-20 Total Charges RC-21 Total Charges RC-22 Total Charges RC-23 Total Charges Payer

Field Name 2nd Procedure Code 3rd Procedure Code 4th Procedure Code 5th Procedure Code 6th Procedure Code Sender FEIN

Data Num 81.01

Hospital_FEIN

5

44.02

47.11

81.02

Discharge_dt

6

44.03

47.12

81.03

Birth_dt , Injured Worker Admissions_dt

14

44.04

47.13

81.04

17

44.05

47.14

81.05

Admission_type

19

44.06

47.15

100 44.07 47.16

Admission_Source

20

Discharge Status

22

44.08

47.17

Medical Record No Date of Occurrence Revenue Code 1 (RC-1) Revenue Code 2 (RC-2) Revenue Code 3 (RC-3) Revenue Code 4 (RC-4) Revenue Code 5 (RC-5)

23

44.09

47.18

32

44.10

47.19

42.01

44.11

47.20

42.02

44.12

47.21

42.03

44.13

47.22

42.04

44.14

47.23

42.05

44.15

50

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Page (18)

New Mexico Workers' Compensation Field Name UB-92 Field Data Data #
Revenue Code 6 (RC-6) Revenue Code 7 (RC-7) Revenue Code 8 (RC-8) 42.06 Name RC-16 HCPCS Rate RC-17 HCPCS Rate RC-18 HCPCS Rate

Inpatient Data Collection Instructions
Field Name Total Paid Amount Date_paid Data Num 55.01 Field Name Data Num

Num 44.16

42.07

44.17

55.02

42.08

44.18

Diagnosis Related Group code (DRG)

56

Revenue Code 9 (RC-9) Revenue Code 10 (RC-10)

42.09

RC-19 HCPCS Rate RC-20 HCPCS Rate RC-21 HCPCS Rate RC-22 HCPCS Rate RC-23 HCPCS Rate TOTAL GROSS CHARGE S RC-1 Total Charge RC-2 Total Charge RC-3 Total Charge RC-4 Total Charges RC-5 Total Charges

44.19

SSN, Injured Worker Clm-Admin Claim Number

60

42.10

44.20

61

Revenue Code 11 (RC-11) Revenue Code 12 (RC-12) Revenue Code 13 (RC-13)

42.11

44.21

Insurer_fein

62

42.12

44.22

Employer_id (FEIN) Principle Diagnosis Code (PDC) 2nd Diagnosis code 3rd Diagnosis code 4th Diagnosis code 5th Diagnosis code 6th Diagnosis code 7th Diagnosis code

65

42.13

44.23

67

Revenue Code 14 (RC-14) Revenue Code 15 (RC-15) Revenue Code 16 (RC-16) Revenue Code 17 (RC-17) Revenue Code 18 (RC-18) Revenue Code 19 (RC-19)

42.14

47.00

68

42.15

47.01

69

42.16

47.02

70

42.17

47.03

71

42.18

47.04

72

42.19

47.05

73

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New Mexico Workers' Compensation Field Name UB-92 Field Data Data #
Revenue Code 20 (RC-20) Revenue Code 21 (RC-21) Revenue Code 22 (RC-22) 42.20 Name RC-6 Total Charges RC-7 Total Charges RC-8 Total Charges RC-9 Total Charges

Inpatient Data Collection Instructions
Field Name 8th Diagnosis code 9th Diagnosis code Principle Procedure Code (PPC) PPC Date Data Num 74 Field Name Data Num

Num 47.06

42.21

47.07

75

42.22

47.08

80.01

Revenue Code 23 (RC-23)

42.23

47.09

80.02

NOTES: The following are our latest changes to the manual since January 18th 2006: (1) Header record does not include insurer FEIN number. We are allowing multiple FEIN for insurers to be filed per sender file. (2) We are adding the field Date of Occurrence to the data record. We are noticing that a number of records are not comparable to the 148 or A49 record submitted for the worker and the date of injury is not the same. (3) Several typographical errors were corrected. April 13, 2006 A change in special processing for Paper was added to the instructions to deal with partial payments. See page 7 August 15, 2006 · Formatting Clarification for no decimals in money amounts. Addition to Error Matrix and acknowledgement record

(August 15, 2006)

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