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Denial Incorrect: Services Rendered Before Liability Decision

When an employee files a workers’ compensation claim, the employer or insurer is immediately liable for the cost of all medically necessary treatment provided before the claim is accepted or denied.

In other words, even if the employer or insurer ultimately denies a claim, treatment provided is authorized before the claims administrator issues that denial, up to $10,000.

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 in DaisyBill, use the Second Review Reasons. When a bill receives an incorrect denial for services rendered before the liability decision, we recommend language similar to the Second Review reason in this article.

Official Medical Fee Schedule

Any

CPT Code(s)

Any

Payable

Yes

EOR Denial Reason

Liability disputed.

Claim non-compensable.

Payer not liable.

Second Review

Reason for Requesting Second Bill Review

The services billed were provided before the claims administrator accepted or denied liability, during which time medically necessary services are authorized up to $10,000 per California Labor Code Section 5402(c), which states:

“Within one working day after an employee files a claim form under Section 5401, the employer shall authorize the provision of all treatment, consistent with Section 5307.27, for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000).”

Please immediately reprocess this bill and issue payment.

File Second Review

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