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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

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”. 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

Other Second Review Topics

Good luck with it!

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