When a claims administrator fails to issue timely EOR for an Original Bill, 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.
Untimely EOR issued for Med-Legal Original Bill submission.
Additional Complaint Information - Non-electronic Submission (Fax):
Claims administrator failed to issue an EOR within 60 days for an Original bill and Supporting Documents submitted via facsimile. The Bill History documents Compliance Due Dates and fax transmission receipt of Original Bill and Supporting Documents. See Regulations and Rules cited below.
Additional Complaint Information - Electronic Submission:
Claims administrator failed to issue an electronic EOR within 60 working days for an Original Bill and Supporting Documents submitted electronically. The Bill History documents Compliance Due Dates The Bill History documents Compliance Due Dates and the date claims administrator issued an accepted acknowledgement verifying receipt of of Original Bill and Supporting Documents. See Regulations and Rules cited below.
How to file an Audit Complaint
When a claims administrator incorrectly processes 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 the Original Bill with supporting documents.
- File Audit Complaint
- Create Audit Complaint:
- From Bill History, choose EOR Non-compliant: Untimely EOR issued for Med-Legal Original Bill submission.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
- Additional Comments: Provide details of conversations and emails with claims administrator, if any.
- Additional Audit Complaint Document(s): Explanation of review (EOR) received from claims administrator.
Regulations and Rules
Labor Code 4622.
All medical-legal expenses for which the employer is liable shall, upon receipt by the employer of all reports and documents required by the administrative director incident to the services, be paid to whom the funds and expenses are due, as follows:
(a) (1) Except as provided in subdivision (b), within 60 days after receipt by the employer of each separate, written billing and report, and if payment is not made within this period, that portion of the billed sum then unreasonably unpaid shall be increased by 10 percent, together with interest thereon at the rate of 7 percent per annum retroactive to the date of receipt of the bill and report by the employer. If the employer, within the 60-day period, contests the reasonableness and necessity for incurring the fees, services, and expenses using the explanation of review required by Section 4603.3, payment shall be made within 20 days of the service of an order of the appeals board or the administrative director pursuant to Section 4603.6 directing payment.
(2) The penalty provided for in paragraph (1) shall not apply if both of the following occur:
(A) The employer pays the provider that portion of his or her charges that do not exceed the amount deemed reasonable pursuant to subdivision (e) within 60 days of receipt of the report and itemized billing.
(B) The employer prevails.
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