For incorrectly denied or underpaid Original bills, DaisyBill advises filing a Second Review and including IBR decisions as supporting documentation.

Official Medical Fee Schedule

Any

CPT Code(s)

Any

Payable

Yes

EOR Denial Reason

Reduction in accordance with _____ Contract.

This charge was adjusted to comply with the rate and rules of the contract indicated.

Second Review Reason (SBR-1 Form)

Recommended Reason

An incorrect PPO discount rate used when to calculate reimbursement.

Contracted rate is ___%

Accordingly, please review this bill for additional payment per OMFS.

Optional: 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 Overturn of Incorrect PPO Discount
• Copy of pertinent page(s) of applicable contract

DaisyBill Resources

Webinar: Request for Second Review

Webinar: Second Review Strategy Kit, Part I

Webinar: Second Review Strategy Kit, Part II

DaisyBill Solution

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.