When an original bill is incorrectly denied or underpaid, DaisyBill advises filing a Second Review. 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.
To store language for Request for Second Review reasons, use DaisyBill’s Second Review Reasons. When the claims administrator incorrectly denies a Med-Legal report or service, we recommend language similar to the Second Review reasons below.
Official Medical Fee Schedule
Medical-Legal
CPT Code(s)
ML102
ML103
ML104
ML 105
ML 106
Services provided in conjunction with any of these codes.
Payable
Yes
EOR Denial Reason
Denials of Medical-Legal reports and expenses are straightforward. For the most part, claims administrators deny based on a provider’s failure to bill for a cost or expense associated with proving or disproving a contested claim, including meeting five required conditions for a Medical-Legal report.
Second Review Reason (SBR-1 Form)
Medical-Legal Report Denial
The actual SBR reason is also straightforward; namely, countering the denial with specific assertions that the bill does, indeed, meet the five required conditions.
Reason for Requesting Second Review
The attached comprehensive medical-legal evaluation report, follow-up medical-legal evaluation report, or a supplemental medical-legal evaluation report meets all of the following conditions per CCR § 9793(h)
- The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
- The report is obtained at the request of a party or parties and addresses the disputed medical fact or facts specified by the party, or parties.
- The report is capable of proving or disproving a disputed medical fact essential to the resolution of a contested claim.
- No notice of settlement was received prior to preparing the requested medical-legal report
- The Medical-Legal report was served timely.
Second Review Reason (SBR-1 Form)
Medical-Legal Expense Denial
If any of the following services are provided in conjunction with a medical legal evaluation and then subsequently denied, use the second review reason below to dispute the incorrect denial.
- X-rays
- Laboratory fees
- Other diagnostic tests
- Medical reports
- Interpreter's fees, as needed
Reason for Requesting Second Review
Per CCR § 9793(h) this procedure code qualifies as a medical-legal expense. It is a cost or expense incidental to the preparation of a medical-legal report requested by the party or parties that addresses a disputed medical fact or facts as specified by the party or parties.
Relevant Regulations
- California Code of Regulations, Title 8, § 9793(h)
- California Code of Regulations, Title 8, § 10451.1
If Your SBR is Denied...
When the dispute is solely about the amount of payment allowed, then the next step is filing an IBR. All other disputes regarding payment for medical-legal services require a Petition of Determination, along with an accompanying Declaration of Readiness to Proceed, filed with the WCAB.