California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 1.1 - Workers' Compensation Information System › Section 9702 - Electronic Data Reporting

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each claims administrator shall transmit
					 data elements, by electronic data interchange in the manner set forth in the
					 California EDI Implementation Guide for First and Subsequent Reports of Injury
					 and the California EDI Implementation Guide for Medical Bill Payment Records,
					 to the WCIS by the dates specified in this section. Each claims administrator
					 shall, at a minimum, provide complete, valid, accurate data for the data
					 elements set forth in this section. The data elements required in subdivisions
					 (b), (c), (d) and (e) are taken from California EDI Implementation Guide for
					 First and Subsequent Reports of Injury and the California EDI Implementation
					 Guide for Medical Bill Payment Records. Claims administrators shall only
					 transmit the data elements that are set forth in the California EDI
					 Implementation Guide for First and Subsequent Reports of Injury and the
					 California EDI Implementation Guide for Medical Bill Payment Records. Each
					 transmission of data elements shall include appropriate header and trailer
					 records as set forth in the California EDI Implementation Guide for First and
					 Subsequent Reports of Injury and the California EDI Implementation Guide for
					 Medical Bill Payment Records.
(b)
					 Each claims administrator shall submit to the WCIS on each claim, within ten
					 (10) business days of knowledge of the claim, each of the following data
					 elements known to the claims administrator:
Data Element
								Name
DN
ACCIDENT DESCRIPTION /CAUSE
38
CAUSE OF INJURY CODE
37
CLAIM ADMINISTRATOR ADDRESS LINE 1
10
CLAIM ADMINISTRATOR ADDRESS LINE 2
11
CLAIM ADMINISTRATOR CITY
12
CLAIM ADMINISTRATOR CLAIM NUMBER
15
CLAIM ADMINISTRATOR FEIN
8
CLAIM ADMINISTRATOR NAME
9
CLAIM ADMINISTRATOR POSTAL CODE
14
CLAIM ADMINISTRATOR STATE
13
CLASS
								CODE(3)
59
DATE DISABILITY BEGAN
56
DATE LAST DAY WORKED
65
DATE OF
								HIRE(1)
61
DATE OF INJURY
31
DATE OF RETURN TO WORK
68
DATE REPORTED TO CLAIM
								ADMINISTRATOR
41
DATE REPORTED TO EMPLOYER
40
EMPLOYEE ADDRESS LINE
								1(1)
46
EMPLOYEE ADDRESS LINE
								2(1)
47
EMPLOYEE
								CITY(1)
48
EMPLOYEE DATE OF BIRTH
52
EMPLOYEE DATE OF DEATH
57
EMPLOYEE FIRST NAME
44
EMPLOYEE LAST NAME
43
EMPLOYEE MIDDLE
								INITIAL(1)
45
EMPLOYEE
								PHONE(1)
51
EMPLOYEE POSTAL
								CODE(1)
50
EMPLOYEE
								STATE(1)
49
EMPLOYER ADDRESS LINE 1
19
EMPLOYER ADDRESS LINE 2
20
EMPLOYER CITY
21
EMPLOYER FEIN
16
EMPLOYER NAME
18
EMPLOYER POSTAL CODE
23
EMPLOYER STATE
22
EMPLOYMENT STATUS
								CODE(1)
58
GENDER CODE
53
INDUSTRY CODE
25
INITIAL TREATMENT CODE
39
INSURED REPORT NUMBER
26
INSURER FEIN
6
INSURER NAME
7
JURISDICTION
4
MAINTENANCE TYPE CODE
2
MAINTENANCE TYPE CODE DATE
3
MARITAL STATUS
								CODE(2)
54
NATURE OF INJURY CODE
35
NUMBER OF
								DEPENDENTS(2)
55
OCCUPATION DESCRIPTION
60
PART OF BODY INJURED CODE
36
POLICY EFFECTIVE DATE
29
POLICY EXPIRATION DATE
30
POLICY NUMBER
28
POSTAL CODE OF INJURY SITE
33
SALARY CONTINUED INDICATOR
67
SELF INSURED INDICATOR
24
SOCIAL SECURITY
								NUMBER(4)
42
TIME OF INJURY
32
WAGE(1)
62
WAGE
								PERIOD(1)
63
____________________
(1)
					 Required only when provided to the claims administrator.
(2) Death Cases Only.
(3) Required for insured claims only;
					 optional for self-insured claims.
(4) If the Social Security Number (DN 42) is
					 not known, use a string of eight zeros followed by a six.
Data elements omitted under this subsection because they
						were not known by the claims administrator shall be submitted within sixty (60)
						days from the date of the first report under this
						subsection.