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Denial Incorrect: PR-2 (WC002)

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 Bill Review Library. When the claims administrator incorrectly denies a PR-2 billed with WC002, we recommend language similar to the Second Review reason below.

Official Medical Fee Schedule

California Specific Code

CPT Code(s)

WC002

Payable

Yes

EOR Denial Reason

Claims administrators frequently and incorrectly deny charges for progress reports, or PR-2s, for which California uses the state-specific code of “WC002.”  

Second Review Reason (SBR-1 Form)

Reason for Requesting Second Review

PR-2 documentation indicates Provider is the Primary Treating Physician and Injured Worker was seen for on-going medical treatment.

Per Maximus IBR decisions:  “DWC states, ‘The purpose of the 45-day rule in California Code of Regulations, Title 8, section 9785(f)(8) is to make sure that in the case of continuing treatment, that the patient’s progress is monitored no less than once every 45 days.’

However, ‘Within a 45-day period, the primary treating physician can bill for as many PR-2’s as are medically necessary.’

Recommended Supporting Documents

Relevant Regulation

Other Second Review Topics

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