When a claims administrator authorizes billed services, then later denies the bill citing a lack of authorization, we strongly recommend that you file an Audit Complaint. Doing so could improve California workers’ comp billing for the entire community.
Frequently Asked Questions
Q: What’s an Audit Complaint?
A: Audit Complaints are designed to alert the DWC to non-compliant behavior on the part of a claims administrator. Using your Audit Complaints, the DWC can intervene and correct a claims administrator’s improper bill processes.
Q: Will a claims administrator know if I file an Audit Complaint against them?
A: Not if you don’t want them to. The DWC allows you to file Audit Complaints confidentially, so reporting improper behavior poses no risk to your relationship with the claims administrator.
Q: Will filing an audit complaint guarantee correct reimbursement?
A: Not necessarily – the DWC cannot promise that every complaint will result in an audit or investigation. The DWC does intervene when appropriate, though, and the data collected from an Audit Complaint can ultimately lead to improvements across the entire California workers’ comp community.
Reason for Audit Complaint
Use this section to help fill out the DWC Audit Referral form.
Bill Type:
Treatment and Services
Submission Type:
Original Bill
Complaint Category:
Incorrect Denial
Complaint Reason:
Denial incorrectly cites lack of authorization for authorized services.
Additional Complaint Information:
Billed services authorized by claims administrator. Claims administrator denied services by wrongly citing services were not authorized.
How to file an Audit Complaint
When a claims administrator incorrectly denies your Original Bill you should:
- Contact Claims Administrator (Optional)
- Inform claims administrator that your Original Bill was complete and compliant, and included the required supporting documents.
- Request further information regarding the reason for the incorrect denial of services.
- File Audit Complaint
- Create Audit Complaint:
DaisyBillers:
- From Bill History, choose Audit Complaint Type: Incorrect Denial: Denial received incorrectly citing lack of authorization for authorized services.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
Non DaisyBillers: Link to DWC’s Audit Referral Form (link to Form Directions).
- Additional Comments: Provide details of conversations and emails with claims administrator, if any.
- Additional Audit Complaint Document(s): Provide any explanation of review (EOR) received incorrectly citing injury as not authorized. It is not necessary to include the bill or medical reports.
- Submit a request for Second Review (Required for additional payment)
- Within 90 days of receipt of the original EOR file a request for Second Review to dispute the incorrect reimbursement.
Additional Information
Division of Workers’ Compensation Medical Billing and Payment Guide
DaisyBill Resources
Blog Post: Audit Complaints – Making Things Right in Workers’ Comp
Webinar: Audit Complaints for Workers’ Compensation
DaisyBill Solution
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.