Can I request second review when bills for automatically authorized services are denied?

Yes, you can! When the claims administrator incorrectly denies a bill for authorized services rendered, providers should request second review.

For automatically authorized services, we recommend including documentation (sample letter below) that substantiates the treatment’s eligibility for automatic authorization.

Three important points:

  1. Unlike standard authorization, the claims administrator has no input in determining the necessity or appropriateness of the treatment. The claims administrator cannot modify or deny automatically authorized treatment.
  2. Like standard authorization, automatic authorization cannot be rescinded for any reason.
  3. While Labor Code § 4610 requires the provider to submit an RFA within 5 days of treatment, and to submit the original bill within 30 days (for non-emergency treatment) or 180 days (for emergency treatment), failure to meet these deadlines is not grounds for non-payment.

Even if the RFA, DLSR, or original bill is untimely submitted, the claims administrator must pay for automatically authorized services rendered.

Submit your request for second review according to the usual requirements:

  • Timeliness: Submit Second Review appeal within 90 calendar days from receipt of the Explanation of Review (EOR).
  • Format: Use either a modified original bill or DWC Form SBR-1. (We strongly recommend using the DWC Form SBR-1 ).
  • Delivery: Use the same delivery method (i.e., paper or electronic) as the original bill.
  • Reason: Articulate the rationale for disputing the incorrect payment.
  • Documentation: Provide all relevant supporting documentation.

For automatic authorization, attach the following sample letter. It contains language sufficient to substantiate the eligibility of treatment for automatic authorization, and the claims administrator’s obligation to pay.

Click here to download as a printable pdf.

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.


Was this article helpful?

Search results for: