Second Review of Medical Treatment Bill/Medical-Legal Bill (CCR § 9792.5.5)

When an original bill is incorrectly denied, DaisyBill advises filing a Second Review.

Summary

Per section 9792.5.5 of the California Code of Regulations, if the provider disputes the amount of reimbursement allowed by a claims administrator in conjunction with the payment, adjustment, or denial of the initially submitted bill, the provider must request a second review of the payment within 90 calendar days of receipt of the EOR.

If a provider fails to submit the Second Review within 90 days, the bill “shall be deemed satisfied and neither the claims administrator nor the employee shall be liable for any further payment.” In other words, if the Second Review is late, there’s no obligation for additional payment, even if the SBR is otherwise valid.

$0 Payment for Second Reviews Submitted After 90 Days

Initial Bill Submitted via paper (Non-Electronic)

When the initial bill is submitted via paper (non-electronically), the provider must also submit the second review non-electronically via paper.

For an Initial Paper Bill, Paper SBR Required

When an initial bill is submitted via paper, submit a Request for Second Review by using either:

  • the SBR-1 form, or
  • a Modified Original Bill.

Based on the bill type, modify the bill with the correct designator in the correct box on the bill. The table below matches the bill type to the bill modification.  

Bill Type - Modified Initial Bill

Required Additional Information

When submitting a modified initial bill as a Second Review, 9792.5.5(d) requires the provider to also submit additional information. The six points of required information are:

  1. The date of the explanation of review
  2. Claim number or other unique Identifying number provided on the explanation of review
  3. Item and amount in dispute
  4. Additional payment requested and the reason therefor
  5. Additional information provided in response to a request in the first explanation of review
  6. Any other additional information provided in support of the additional payment requested

This information is included on the SBR-1 form. If you are not using the SBR-1 form, submit this information as a supporting document with the modified initial bill.

Per subdivision 9792.5.5(f), for modified initial bills, if the required additional information is missing, the claims administrator is under no regulatory obligation to respond to a Second Review.

Initial Electronic Bill

If the initial bill is submitted electronically, the second review must also be submitted electronically. For electronic initial billing, the second review must be submitted as an electronic modified bill and contain the required additional information (listed above).

Electronic Modified Initial Bill

Per the DWC Electronic Medical Billing and Payment Companion Guide, for the electronic CMS 1500, the text “BGW3” must populate box 10d of the CMS1500. Additionally, the number 7 and the original reference number used on the initial bill must populate box 22.

electronic modified initial bill.jpg

Claims Administrator Requirements: Timelines

Within 14 days of receipt of the Second Review, a claims administrator must issue a Final EOR with a written determination of each item in dispute. The final EOR must comply with the EOR requirements as outlined in Labor Code 4603 and the DWC Medical Billing and Treatment guidelines.

If additional payment is due, the balance is payable within 21 days of receipt of the Second Review.

sbr requirements claims administrators.jpg

Additional Information

California Code of Regulations § 9792.5.5

California Labor Code § 4603.2

DaisyBill Resources

Webinar: Request for Second Review

Webinar: Second Review Strategy Kit, Part I

Webinar: Second Review Strategy Kit, Part II

DaisyBill Solution

Every request for Second Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-1, as well as a compliant modified CMS 1500.

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