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)

1. The report is prepared by a physician, as defined in Section 3209.3 of the Labor Code.
2. 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.
3. The report is capable of proving or disproving a disputed medical fact essential to the resolution of a contested claim.
4. No notice of settlement was received prior to preparing the requested medical-legal report
5. 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.