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California Medical Transaction Data Quality Assurance Program

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California Medical Transaction Data Quality Assurance Program

The WCIRB Medical Transaction Data Quality Program was created to meet the WCIRB’s ratemaking and research needs and respond to the California Department of Insurance directive to collect medical transaction data. NAIC groups that write at least 1% of the California workers’ compensation market are required to submit data to the WCIRB on either a monthly or quarterly basis. Insurers newly eligible to participate in this program are required to begin reporting medical transaction data to the WCIRB within one year of notification of eligibility.

The due date for the quarterly Medical Data Call submission is the last calendar day of the following quarter. The timeliness of an insurer’s submissions is evaluated based on the WCIRB’s expectation of the minimum number of files to be submitted by the due date of each calendar quarter.

For each calendar quarter, if the WCIRB receives and successfully processes all expected files on or before the Timeliness Incentive Credit Submission Deadline, the insurer receives a Timeliness Incentive Credit of $1,000. These credits are subject to a non-refundable aggregate maximum credit balance of $7,500 that can be used to offset fines levied pursuant to this program.

Quarterly notices are released to insurer participants. The Medical Transaction Data Quality Notice provides a summary of the submission timeliness of the reporting quarter as well as any open medical data inquiries. The Fine and Credit Notice provides any quarterly fine imposed or incentive credit given for submission timeliness, subject to the maximums as stated in the program.

Insurers are subject to monetary fines and other administrative action for failure to submit data or to address documented data quality reporting issues in a timely manner.

If you have any questions, please contact medicaldata@wcirb.com.