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Incorrect Reimbursement: PPO / Network Reduction Incorrectly Applied
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 Review Reasons. When the claims administrator incorrectly applies a PPO/Network reduction to the bill, we recommend language similar to the Second Review reason below.
Official Medical Fee Schedule
EOR Denial Reason
Reduction in accordance with _____ Contract.
Second Review Reason (SBR-1 Form)
Reason for Requesting Second Bill Review
This bill payment was incorrectly discounted [__%] with the EOR citing a “PPO Discount”. Attached is a letter dated [DATE] asking for proof of the PPO contract cited in the EOR. To date, no proof of PPO contract has been provided. This practice and provider do NOT have a PPO contract or agreement authorizing this payment discount. Accordingly, please review this bill for additional payment per OMFS. Attached is a copy of an OVERTURN IBR Decision indicating this incorrect PPO discount will be overturned when reviewed by IBR.
Recommended Supporting Documents
- IBR Case Number: CB15-0001086
- Letter to claims administrator/contract administrator requesting proof of PPO contract
Other Second Review Topics
Good luck with it!