When a claims administrator fails to issue timely EOR for an Original Bill, 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
Untimely EOR issued for Original Bill submission.
Additional Complaint Information - Non-electronic Submission (Fax):
Claims administrator failed to issue an EOR within 30 days for an Original bill and Supporting Documents submitted via facsimile. The Bill History documents Compliance Due Dates and fax transmission receipt of Original Bill and Supporting Documents. See Regulations and Rules cited below.
Additional Complaint Information - Electronic Submission:
Claims administrator failed to issue an electronic EOR within 15 working days for an Original Bill and Supporting Documents submitted electronically. The Bill History documents Compliance Due Dates The Bill History documents Compliance Due Dates and the date claims administrator issued an accepted acknowledgement verifying receipt of of Original Bill and Supporting Documents. See Regulations and Rules cited below.
How to file an Audit Complaint
When a claims administrator incorrectly processes 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:
- From Bill History, choose Audit Complaint Type: Non-compliant EOR: Untimely EOR issued for Original Bill submission.
- 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): Explanation of review (EOR) received from claims administrator.
Regulations and Rules
Labor Code §4603.2 and DWC Medical Billing and Payment Guide mandate that a claims administrator shall alert the provider within 30 days of receipt of the itemized bill if the claims administrator contests, denies or considers the bill or supporting documents incomplete.
DWC Medical Billing and Payment Guide, Section 7.1 Timeframes
(3) ASC X12C/005010X214 Health Care Claim Acknowledgment (277) – within two working days of receipt of an electronically submitted bill, the claims administrator shall send a Health Care Claim Acknowledgement 005010X214 electronic notice of whether or not the bill submission is complete. The 005010X214 details what errors are present, and if necessary, what action the submitter should take. A bill may be rejected if it is not submitted in the required electronic standard format or if it is not complete as set forth in Section One – 3.0, except as provided in 7.1(a)(3)(A)(i) which requires the pending of bills that have a missing attachment or claim number. Such notice must use the 005010X214 transaction set as defined in Companion Guide Chapter 9 and must include specific information setting out the reason for rejection.
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.
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