Please select from the following topics for more information:
Business Partner Arrangements
Question 1: In arrangements where a service provider is reimbursed by the third party administrator (TPA), and then the carrier reimburses the TPA, will the TPA need to pass the service provider detail to the carrier for reporting?
Answer: Yes, 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.
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 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 prior to submission.
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, NCCI cannot begin to process the file. So, the submission will be rejected and returned to the data provider exactly as received.
What NCCI 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 those 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 data in our actuarial analysis.
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 Diagnostic Code, or will the carrier be allowed to use internal codes from its system or a vendor's system?
Answer: NCCI will compare the codes reported by the data provider against the standard codes defined and maintained by the various industry organizations. For the code source, refer to the specific data element in Part 5―Data Dictionary of the
Medical Data Call Reporting Guidebook.
Although NCCI will not reject individual records for invalid or missing codes, the correct reporting of the field will be considered an overall factor in the quality and acceptance 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 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.
Question 3: Currently, the ICD-9 Diagnostic Code is one of the required data elements for the NCCI Medical Data Call. It is my understanding that medical providers must comply with the October 1, 2015 date for using ICD-10 for diagnosis coding. Will NCCI accept ICD-10 codes as valid?
Answer: Yes, NCCI is prepared to accept the ICD-10 codes. Report the ICD code indicated on the medical bill in the same field currently used to report ICD-9 codes (Primary ICD-9 Code, positions 208–221, and Secondary ICD-9 Code, positions 222–235).
Question 1: How did NCCI verify market share for Medical Data Call participation?
Answer: For participation, market share was determined using the three most recent years (2009–2011) of Net Direct Written Premium taken from either the NAIC data or Call #1 on file at NCCI.
Question 2: How will I know if I need to report Medical Call data?
Answer: NCCI evaluates Medical Call participation on a regular basis. Participation is limited to carriers with at least 1% market share in any one applicable state over the most recent three years. Eligible carriers are notified through written communication and are provided lead time for system preparation.
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: The Claim Number Identifier is a linking field and must match the unit statistical claim number. Since each carrier's systems and business partner arrangements are different, each carrier will have to make a business decision to either require it from the vendor, supply it to the vendor, or populate it in their own system prior to submission.
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: NCCI understands 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, NCCI 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 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: If the items in question are services for which your company pays medical benefits, and they can be captured at the detail level, they should be reported for the Medical Data Call. However, medical expenses incurred for the benefit of the carrier, and thus reported under allocated expenses for Unit Stat, should not be reported for the Medical Data Call.
Question 4: Will reimbursements to the claimant or employer for a bill that they have paid be 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: Is the procedure code indicated on the bill the code that should be reported in the Paid Procedure Code field?
Answer: That depends. The paid procedure code should always reflect the code used to determine the reimbursement, which may not always be the same code indicated on the bill. For example, for an inpatient hospital bill the billed services are often coded using Hospital Revenue Codes and, yet, according to the state fee schedule, the reimbursement is based on a Diagnosis Related Group (DRG). In these cases, the DRG should be reported as the Paid Procedure Code for every bill line to which the DRG reimbursement applies. The Secondary Procedure Code field should reflect the underlying CPT/HCPC or Revenue Code billed by the hospital.
Medical Data Call Reporting Guidebook provides the rules for reporting the Paid and Secondary Procedure Codes in Part 5, items 12 and 23, respectively.
Question 6: What is meant by Paid Procedure Code Modifier?
Answer: The Paid Procedure Code Modifier 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 indicates reduced service―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.
Question 8: Should I report transactions where the amount paid is zero?
Answer: Yes, transactions where the paid amount is zero should be reported as long as a paid amount of zero is deemed to be the final payment amount after the transaction has been processed (e.g., denying a payment because the service wasn't medically necessary) and the reason for a zero paid amount is not due to a duplicated billing.
However, if a claim is denied prior to reporting any transactions to NCCI (e.g., denying a payment because it's a non-workers compensation injury), no transactions should be sent for that claim. If medical transactions were reported to NCCI prior to the claim being denied, those transactions should be cancelled.
Question 9: Is there a default diagnosis code we should use for reporting transactions for which we have not received a diagnosis code from the pharmacy vendor?
Answer: When a diagnosis code is not present, it is acceptable to leave the field blank.
Question 10: Is it acceptable to use default values for the Place of Service or Taxonomy fields when reporting pharmacy bills that do not provide these codes?
Answer: You can use the following default values for pharmacy bills:
- Provider Taxonomy Code = 333600000X
- Place of Service Code = 01
Question 11: Is there a preferred hierarchy for reporting Paid Procedure Codes when more than one may be applicable?
Answer: NCCI's preferred hierarchy for reporting Paid Procedure Codes is as follows:
Note: This applies to Paid Procedure Code (Field #16, pos 153–177) and to Secondary Procedure Code (Field #28, pos 290–314).
- APC or DRG
Question 12: Is there a preferred hierarchy for reporting Network Service Code (Field #25, pos 274)?
Answer: NCCI's preferred hierarchy for reporting Network Service Code is as follows:
- HMO (H)
- Participation Agreement (P)
Question 13: If ICD Procedure Code is the basis for reimbursement, how do we report it?
Answer: ICD Procedure Code is typically used as the basis for reimbursement in two scenarios:
a. Reimbursement schedule set by ICD Procedure Code, such as GA Outpatient Surgery Fee Schedule. NCCI's recommendation is to submit the principal ICD Procedure Code as the Paid Procedure Code on every line and submit the CPT/HCPCS Code (if any) as the Secondary Procedure Code. If principal ICD Procedure Code is not present, submit the CPT/HCPCS as the Paid Procedure Code and the Revenue Code as the Secondary.
b. A special grouping system is developed and the ICD Procedure Code is assigned to each group, such as the NY Products of Ambulatory Surgery (PAS) system for Outpatient Surgery/ASC. NCCI's recommendation is to submit the CPT/HCPCS as the Paid Procedure Code and the Revenue Code as the Secondary.
Question 14: Is there a way for a carrier to perform a quality preview (similar to a pre-edit) of a submitter's data?
Answer: Yes, NCCI recommends that medical data submitters submit files using the same format and naming convention that is used for certification purposes: medical.*.tst
The asterisk (*) indicates where up to 30 additional characters may be inserted to help identify the file within the medical data provider's system
Question 15: How do I report the Place of Service Code for facility and hospital services on the Medical Data Call?
Answer: To assist in reporting this information, a Place of Service Crosswalk has been developed. This crosswalk derives the Place of Service Code from the Type of Bill Code and has been provided below as a downloadable PDF:
Place of Service Crosswalk (PDF)
Question 1: How should payment transactions that are voided or stop paid be handled?
Answer: If a payment transaction is reported to NCCI prior to the void or stop pay, the transaction will be cancelled in order to remove it from NCCI's database. If the void or stop pay occurs before a transaction is reported, then the void or stop pay transaction will not need to be reported. For instructions on reporting cancellations, refer to Part 6 of the
Medical Data Call Reporting Guidebook.
Question 2: How do we report changes to a previously reported claim?
Answer: Key fields that change require a cancellation record to first remove the record from the database. After cancelling the previously reported record, submit a new record with all key fields including those that did not change. 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.
Question 1: What support will I receive from NCCI to help me avoid
Medical Incentive Program(MIP) assessments?
Medical Data Collection tool was enhanced to include views where you can track your performance against
MIP criteria. Additionally, NCCI has a dedicated team in place to validate medical data and proactively reach out to you when your data appears to be incomplete and/or is not passing edit thresholds.
Tools and Resources
Question 1: Is a password required to access the
Medical Data Call Reporting Guidebook on
Answer: Yes, to receive access to the Medical Data Call Reporting Guidebook you can contact our Customer Service Center at
Uses of Data
Question 1: Will NCCI share the medical data with other research organizations such as the Workers Compensation Research Institute (WCRI)?
Answer: NCCI will not share the medical data we collect with outside 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.