ANSWER: To appeal workers' comp incorrectly paid DMEPOS bills due to the claims administrator failure to pay the allowed 120% of the Medicare CMS rate, we suggest language similar to this:
“Pursuant to Labor Code 5307.1 and CCR Section 9789.60, the workers’ compensation DMEPOS maximum is 120% of the Medicare CMS rate for California.”
For reference, the DWC site states in its FAQ section:
This is an example from an SBR using DaisyBill's SBR Generator:
Remember: For an SBR, the Amount in Dispute should be the difference between the fee schedule amount effective on the date of service and the amount paid. The SBR-1 form does not require the fee schedule amount; instead, it requires the amount in the dispute which should be the expected amount minus the allowed amount.
California Labor Codes
California Code of Regulations (CCR)
Division of Workers’ Compensation Websites
DaisyBill’s easy billing software guarantees that workers’ comp bills are always submitted compliantly. For more information about California’s workers’ comp electronic billing, book a demo and see how easily DaisyBill solves workers' comp billing problems.