Denial Incorrect - Missing Documentation

When a claims administrator incorrectly denies a bill citing missing documentation, we strongly recommend that you file an Audit Complaint. Doing so could improve California workers’ comp billing for the entire community.

Frequently Asked Questions

Q: What’s an Audit Complaint?

A: Audit Complaints are designed to alert the DWC to non-compliant behavior on the part of a claims administrator. Using your Audit Complaints, the DWC can intervene and correct a claims administrator’s improper bill processes.

Q: Will a claims administrator know if I file an Audit Complaint against them?

A: Not if you don’t want them to. The DWC allows you to file Audit Complaints confidentially, so reporting improper behavior poses no risk to your relationship with the claims administrator.

Q: Will filing an audit complaint guarantee correct reimbursement?

A: Not necessarily – the DWC cannot promise that every complaint will result in an audit or investigation. The DWC does intervene when appropriate, though, and the data collected from an Audit Complaint can ultimately lead to improvements across the entire California workers’ comp community.

Reason for Audit Complaint

Use this section to help fill out the DWC Audit Referral form.

Bill Type:

Medical-Legal

Submission Type:

Original Bill

Complaint Category:

Incorrect Denial

Complaint Reason:

Denial received incorrectly citing missing documentation.

Additional Complaint Information - Non-electronic Submission (Fax):

EOR incorrectly states supporting documents were not received for an Original Med-Legal Bill with supporting documents submitted via facsimile. The Bill History documents the fax transmission is confirmed as received by claims administrator. See Regulations and Rules cited below.

Additional Complaint Information - Electronic Submission:

EOR incorrectly states supporting documents were not received for an Original Med-Legal Bill and Supporting Documents submitted electronically. As documented in the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Original Bill with Supporting Documents. See Regulations and Rules cited below.

How to file an Audit Complaint

When a claims administrator incorrectly denies your Original Bill you should:

Contact Claims Administrator (Optional)

Inform claims administrator that your Original Bill was complete and compliant, and included the required supporting documents.
Explain to the claims administrator that you have verifiable proof the claims administrator received documents submitted with the Original Bill.

File Audit Complaint

Create Audit Complaint:

DaisyBillers:

From Bill History, choose Denial Incorrect: Denial received incorrectly citing missing documentation.
Additional Complaint Information noted in the table above automatically populates the DWC Audit Referral Form.

Non DaisyBillers: Link to DWC’s Audit Referral Form (link to Form Directions).

Additional Comments: Provide details of conversations and emails with claims administrator, if any.
Additional Audit Complaint Document(s): Provide any explanation of review (EOR) received incorrectly citing missing documentation. It is not necessary to include the bill or medical reports.

Submit a request for Second Review (Required for additional payment)

Within 90 days of receipt of the original EOR file a request for Second Review to dispute the incorrect reimbursement.

Regulations and Rules

Labor Code 4622. (e) (1) Using the explanation of review as described in Section 4603.3, the employer shall notify the provider of the services, the employee, or if represented, his or her attorney, if the employer contests the reasonableness or necessity of incurring these expenses, and shall indicate the reasons therefor.

Labor Code 4603.3. (a) Upon payment, adjustment, or denial of a complete or incomplete itemization of medical services, an employer shall provide an explanation of review in the manner prescribed by the administrative director that shall include all of the following:
(1) A statement of the items or procedures billed and the amounts requested by the provider to be paid.
(2) The amount paid.
(3) The basis for any adjustment, change, or denial of the item or procedure billed.
(4) The additional information required to make a decision for an incomplete itemization.
(5) If a denial of payment is for some reason other than a fee dispute, the reason for the denial.
(6) Information on whom to contact on behalf of the employer if a dispute arises over the payment of the billing. The explanation of review shall inform the medical provider of the time limit to raise any objection regarding the items or procedures paid or disputed and how to obtain an independent review of the medical bill pursuant to Section 4603.6.