When a claims administrator does not remit an electronic EOR as required by the DWC Billing and Payment Guide, 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: How can I tell that penalty and interest is due?
A: If a claims administrator remits untimely payment (within 60 days of receipt of a med-legal bill), they incur a 10% penalty and 7% accrued interest per annum.
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.
Reason for Audit Complaint
Use this section to help fill out the DWC Audit Referral form.
Bill Type:
Treatment and Services
Submission Type:
Original Bill
Complaint Category:
e-Billing Non-Compliant
Complaint Reason:
Electronic EOR was not remitted for an electronically submitted bill.
Additional Complaint Information:
Claims administrator did not remit an electronic EOR as required by the DWC Billing and Payment Guide Section 7.0 of and Appendix B. Original bill and supporting documents submitted electronically, and claims administrator returned an accepted acknowledgement.
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 the Original Bill with supporting documents.
- File Audit Complaint
- Create Audit Complaint:
DaisyBillers:
- From Bill History, choose Audit Complaint Type: Electronic Billing Noncompliant: Electronic EOR was not remitted for an electronically submitted bill.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
Non DaisyBillers: Link to DWC’s Audit Referral Form (link to Form Directions).
- Additional Comments: Provide details of conversations and emails with claims administrator, if any.
- Additional Audit Complaint Document(s): EOR received; PDF of Bill History showing Bill Submission details
- 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
Per the Division of Workers’ Comp Billing and Payment Guide, an “Explanation of Review” (EOR) means the explanation of payment or the denial of the payment as defined in Appendix B. Paper EORs conform to Appendix B - 3.0. Electronic EORs are issued using the ASC X12N/005010X221A1 Health Care Claim Payment/Advice (835).
DWC Medical Billing and Payment Guide, Section 7.1
Except for bills that have been rejected at the Acknowledgment stage, the ASC X12N/005010X221A1 Health Care Claim Payment/Advice (835) must be transmitted to the provider within 15 working days of receipt of the electronic bill, extended by the number of days the bill was placed in pending status under 7.1(a)(3)(A), if any. The 005010X221A1 should be issued to notify the provider of the payment, denial of payment, or objection to the entire bill or portions of the bill as set forth below. The 005010X221A1 serves as the Explanation of Review, and notice of denial or objection.
Additional Information
Division of Workers’ Compensation Medical Billing and Payment Guide
DaisyBill Resources
Blog Post: Audit Complaints – Making Things Right in Workers’ Comp
Webinar: Audit Complaints for Workers’ Compensation
DaisyBill Solution
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.