Medical Data Call Reporting FAQs

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 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: Although NCCI will validate each data element, we will not reject a record 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; the submission will be rejected and returned to the data provider exactly as received.

What we will do is Quality Tracking—a process that uses tolerance levels based on the criticality of the data element.

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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 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.

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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 their system or 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 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 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 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.

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Participation

Question 1:   How did NCCI verify market share for the Medical Data Call participation?

Answer:  For 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 how much lead time will we have to get our systems ready ? 
 

Answer: The next participation will occur in January 2011 and new participants will have a 12-month lead time to comply. Any carrier that thinks they will be identified at that time due to expanding their book of business should consider using the lead time they have now to, at a minimum, plan their medical reporting project.

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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: 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: 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 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?

(Updated 4/1/10)

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:   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. A 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 primary code in the Paid Procedure Code field, and the Secondary Procedure Code in the Secondary Procedure Code field.

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.

(Questions 8—13 added 4/1/10)

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 is a non-WC injury), no transactions should be sent for that claim. If medical transactions were reported to NCCI prior to the claim’s being denied, those transactions should be cancelled.

Answer: When a diagnosis code is not present, it is acceptable to leave the field blank.

Answer: You can use the following default values for pharmacy bills:

• Provider Taxonomy Code = 333600000X
• Place of Service Code = 01

Answer: NCCI’s preferred hierarchy for reporting Paid Procedure Codes is as follows:

• APC or DRG
• State-Specific
• National
• Revenue/In-House

Note: This applies to Paid Procedure Code (Field # 16, pos 153–177) and to Secondary Procedure Code (Field # 28, pos 290–314)

Answer: NCCI's preferred hierarchy for reporting Network Service Code is as follows:

• PPO(Y)
• HMO (H)
• Participation Agreement (P)

Answer:

ICD-9 Procedure Code is typically used as basis for reimbursement in two scenarios:

a. Reimbursement schedule set by ICD-9 Procedure Code, such as GA Outpatient Surgery Fee Schedule.
Our recommendation is to submit the principal ICD-9 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-9 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-9 Procedure Code is assigned to each group, such as the NY Products of Ambulatory Surgery (PAS) system for Outpatient Surgery/ASC.
Our recommendation is to submit the CPT/HCPCS as the Paid Procedure Code and the Revenue Code as the Secondary.

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Transactional Reporting

Question 1:    Should the first report for the Third Quarter 2010 include existing claims with medical expense incurred 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 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. 

Question 3:    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. 

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Tools and Resources

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 Manger Dashboard -type tool for managing the carrier’s data, which will provide statistics on file acceptance, quality tracking, and quarter-end validation.

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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 their affiliate's state-specific data.