Please select from the following topics for more information:
Business Partner Arrangements
Question 1: In arrangements where a service provider is reimbursed by the TPA, and then the carrier reimburses the TPA, will the carrier need to have the TPA pass the service provider details to them for reporting?
Answer: NCCI requires that all service provider data be reported at the line item detail level. The Provider ID Number should reflect the Service Provider’s ID and the Provider Type (taxonomy code), and Place of Service should reflect that of the Service Provider.
If the carrier will be providing the data to NCCI, the TPA will need to pass the service provider details to the carrier. However, the TPA can also provide the data directly to NCCI.
Question 2: Will a vendor reporting on behalf of a carrier be required to report all of the data elements in the record layout?
Answer: Regardless of who submits the Call to NCCI, the data submitter must report the standard record layout in its entirety with all data elements populated according to their specific reporting requirements. It would be the carrier’s decision to require the entire record layout from the vendor or populate it itself prior to submission.
< Top
Editing
Question 1: How will the editing, rejection, and correction process work?
Answer: Although NCCI will validate each data element, a record will not be rejected based on a single error on a single data element, nor will we request that a correction be made to a single data element in order to load the record into production. The exception to this will be the data elements required on the Submission Control record. Without these elements, we cannot even begin to process the file. So, the submission will be rejected and returned to the data provider exactly as received.
What we will initially be doing is Quality Tracking—a process that uses tolerance levels based on the criticality of the data element.
Question 2: If NCCI will not be editing the Medical Data against the Unit Statistical data, why do the Claim Number Identifier and Policy Number Identifier have to match that which was reported on the Unit?
Answer: The ability to match the Claim Number Identifier and Policy Number Identifier with the Unit Statistical data claim number allows NCCI to use the statistical claim information along with the medical call data in our actuarial analysis. Additionally, future medical data validation processes may utilize the Unit Statistical data.
< Top
Industry Codes
Question 1: Will NCCI require the use of industry standard codes for data elements such as Provider Type Code, Place of Service Code, Paid Procedure Code, Paid Procedure Modifier Code, and ICD-9 Diagnostic Code, or will the carrier be allowed to use internal codes from its system or the vendor’s system?
Answer: NCCI will be comparing the codes reported by the data provider against the standard codes defined and maintained by the various industry organizations. Refer to the specific data element in Part 5—Data Dictionary of the Medical Data Call Reporting Guidebook for the code source.
Although we will not reject individual records for invalid or missing codes, we will consider the correct reporting of the field an overall factor in the quality of the quarterly data.
Question 2: The instructions for the CMS-1500 Health Insurance Claim form indicate that the Provider Taxonomy number is optional for completing the Provider of Service or Supplier Information fields. Is the Provider Type Code only to be reported to NCCI if it is included with the claim form?
Answer: Provider Type is a required field for the NCCI Medical Data Call. As noted in the source column of the Record Layout, this information may be obtained from either the provider or payer. Since the CMS-1500 form does not require the Provider Taxonomy, it may be necessary for the data reporting entity to “build” a provider file. Many bill review software packages include a provider file that “links” the provider name, address, ID (tax ID or NPI), and provider type.
< Top
Participation
Question 1: How did NCCI verify market share for the Medical Data Call participation?
Answer: For the participation, market share was determined using the three most recent years (2004–2006) of Net Direct Written Premium taken from either the NAIC data or Call #1 on file at NCCI.
Question 2: When will NCCI conduct its next participation evaluation and what will the lead time be to get our systems ready?
Answer: The next participation will occur in January 2011 and new participants will have 12 months lead time to comply. Any carrier that thinks it will be identified at that time due to expanding its book of business should consider using the lead time it has now to, at a minimum, plan its medical reporting project.
< Top
Reporting Requirements
Question 1: What if the Claim Number Identifier supplied by our vendor does not exist or does not match the Unit Statistical Claim Number Identifier?
Answer: Claim Number Identifier is a linking field and is required to match the unit statistical claim number. Because each carrier's systems and business partner arrangements are different, each carrier will have to make a business decision to supply the claim number to the vendor, or populate the claim number in its own system prior to submission.
Question 2: If we need to report the Policy Number and Claim Number that were reported for units, what would we report if this information is not available for older claims?
Answer: We understand that the difference in duration of reporting from 11 report levels (unit data) to 30 years (medical data) may pose a problem with this requirement 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 must, however, be consistently used for all future reporting of the claim transactions.
Question 3: Payments such as mileage charges, transportation charges, hotel expenses, and nurse case management expenses are coded as medical payments in our system. Are these types of payments to be reported on the Medical Data Call?
Answer: Only if the payment is a line item on a medical service provider’s bill. Otherwise, these payments should not be reported on the Medical Data Call.
Question 4: Are reimbursements to the claimant or employer for a bill that it has paid excluded from the Medical Data Call?
Answer: 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.
Question 5: Why is there a Secondary Procedure Code Field when each record is based on a transaction at the line level of a bill; wouldn't there only be one Paid Procedure Code?
Answer: Although, generally, only one Procedure Code is listed on the medical form, multiple codes may apply. Secondary Procedure Code should be reported when it is identified and will be required in some unique situations such as Ambulatory Payment Classification and Ambulatory Surgical Center (facility fees).
Report the procedure code associated with the reimbursement in the Paid Procedure Code field, and auxiliary codes in the Secondary Procedure Code field.
Question 6: What is meant by Paid Procedure Code Modifier?
Answer: The Paid Procedure Code Modifier (as defined by state fee schedules or AMA guidelines) represents a service or procedure that has been altered by a specific circumstance without changing the definition of the service or procedure.
For example: CPT Code 73070 reports radiologic examination of the elbow, with two views taken. There is no code for one view. If the service was reduced by one view, modifier 52, which is the modifier that indicates reduced services, it would need to be appended to the report.
Question 7: How do I know which Network Service Code to report?
Answer: If the claimant received a medical service from an HMO, PPO, or other network provider, then report the code that appropriately reflects the network that the provider is associated with. There does not need to be a network reduction. That's important to note because if, for example, the provider is an “in network” PPO provider but there is no PPO discount or other reduction, it is still a PPO record because the provider was still part of a PPO network.
< Top
Transactional Reporting
Question 1: Should the quarterly report include existing claims with medical transactions that occurred in that quarter or new claims only?
Answer: All transactions that occurred in the quarter based on transaction date, whether existing claims (up to 30 years) or new claims, should be reported. We do not expect historical data for any existing claims that are reported.
Question 2: How should payment transactions that are voided or stop-paid be handled?
Answer: If a payment transaction was reported to NCCI prior to the void or stop pay, the transaction will have to be cancelled in order to remove it from NCCI's database. If the void or stop pay occurred before a transaction was reported, then the void or stop pay transaction should not be reported. Refer to Part 6 of the Medical Data Call Reporting Guidebook for instructions on reporting cancellations.
Question 3: How do we report changes to a previously reported medical transaction?
Answer: Key field changes (Carrier Code, Claim Number Identifier, Bill Identification Number, and Line Identification Number) 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. Transaction Code 01-original, Transaction Date reported as the date the key field change was made in the source system, and all other data elements must be reported according to the specific data element reporting rule.
Because the medical data call is transactional, “non-key” field changes would be corrected through the reporting of future transactions.
< Top
Resources and Tools
Question 1: Is a password required to access the Medical Data Call Reporting Guidebook on ncci.com?
Answer: No. We have made the Medical Data Call Reporting Guidebook as well as our Medical Data Call Web articles and circulars available on the public section of ncci.com. Access them through the Medical Data Call link on the right navigation bar.
Question 2: Will an online tool be available for tracking our Medical Data Call data?
Answer: NCCI is currently developing a Data Manager Dashboard-type tool for managing the Carrier’s data that will provide statistics on file acceptance, quality tracking, and quarter-end validation.
< Top
Use of Data
Question 1: Will NCCI share the medical data with the other research organizations such as the Workers Compensation Research Institute (WCRI)?
Answer: NCCI will not share the medical data we collect with outside research organizations because it is for NCCI's use only.
However, NCCI is positioned to collect data on behalf of requesting independent bureaus only to the extent that the medical data is collected in the same format as NCCI's Medical Data Call. This would be accomplished through an appropriate agreement between NCCI and the Independent Bureau. In those instances, the Independent Bureau for which NCCI is acting as a data collection organization will have access to its affiliate's state specific data.
< Top