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

Any

CPT Code(s)

Any

Payable

Yes

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”.

Per LAB 4609 § (c)(2), the provider has the right to request that the claims administrator demonstrate its entitlement to pay the provider a reduced contracted rate. Once requested, the claims administrator must make this demonstration within 30 business days of receipt of the request.

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.

The failure of a payor to make the demonstration to a properly documented request of the provider within 30 business days shall render the payor responsible for the lesser of the provider’s actual fee or, as applicable, any fee schedule pursuant to this division, which amount shall be due and payable within 10 days of receipt of written notice from the provider, and shall bar the payor from taking any future discounts from that provider without the provider’s express written consent until the payor can demonstrate to the provider that it is entitled to pay a contracted rate as provided in this subdivision.

Optional Language if Attaching IBR Decision

Attached is a copy of an OVERTURN IBR Decision indicating this incorrect PPO discount will be overturned when reviewed by IBR.

Recommended Supporting Documents

Other Second Review Topics

Good luck with it!

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