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Denial Incorrect: Medical-Legal Reports and Expenses

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

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.

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