When a claims administrator incorrectly denies a bill citing missing documentation, 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.
Treatment and Services
Denial incorrectly citing missing documentation.
Additional Complaint Information - Non-electronic Submission (Fax):
EOR incorrectly states supporting documents not received with an Original Bill submitted via facsimile. The Bill History documents the fax transmission is confirmed as received by claims administrator. See Regulations and Rules cited below.
Additional Complaint Information - Electronic Submission:
EOR incorrectly states supporting documents were not received for an Original Bill and Supporting Documents submitted electronically. The electronic transmission conformed to the DWC's Electronic Companion Guide. As documented in the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Original Bill and Supporting Documents. See Regulations and Rules cited below.
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.
- Explain to the claims administrator that you have verifiable proof the claims administrator received documents submitted with the Original Bill.
- File Audit Complaint
- Create Audit Complaint:
- From Bill History, choose Audit Complaint Type: Incorrect Denial: Denial received incorrectly citing lack of documentation for electronically or faxed bill.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
- 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 missing documentation. 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.
Regulations and Rules
Division of Workers’ Compensation Medical Billing and Payment Guide Section 3.0: Complete Bills
(a) To be complete a submission must consist of the following:
(1) The correct uniform billing form/format for the type of health care provider.
(2) The correct uniform billing codes for the applicable portion of the OMFS under which the services are being billed, including the correct ICD code as specified in Section 3.1.0 – 3.2.1.
(3) The uniform billing form/format must be filled out according to the requirements specified for each format in Appendix A and/or the Companion Guide. Nothing in this paragraph precludes the claims administrator from populating missing information fields if the claims administrator has previously received the missing information.
(4) A complete bill includes required reports and supporting documentation specified in subdivision (b).
"Required report" means a report which must be submitted pursuant to title 8, California Code of Regulations sections 9785 – 9785.4 or pursuant to the OMFS. These reports include the Doctor’s First Report of Injury, PR-2, PR-3, PR-4 and their narrative equivalents, as well as any report accompanying a “By Report” code billing.
(w) “Supporting Documentation” means those documents, other than a required report, necessary to support a bill. These include, but are not limited to an invoice required for payment of the DME item being billed. Supporting documentation includes any written authorization for services that may have been received.
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.