Denial Incorrect - Missing Documentation

When a claims administrator incorrectly denies request for Second Review 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:

Request for Second Review (SBR)

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 a Request for Second Review submitted via facsimile. The Request for Second Review included a completed SBR-1 Form and a modified CMS 1500. 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 electronically submitted Request for Second Review. The Request for Second Review included a completed SBR-1 Form and a modified CMS 1500. Per the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Second Review and SBR-1 Form. See Regulations and Rules cited below.

How to file an Audit Complaint

When a claims administrator incorrectly denies your request for Second Review you should:

Contact Claims Administrator

Inform claims administrator that your request for Second Review was compliant, complete, and included the required supporting documents.
Explain to the claims administrator that you have verifiable proof the claims administrator received documents submitted with the request for Second Review.
Alert the claims administrator that you intend to file an Audit Complaint to report the misprocessing of your request for Second Review.

File Audit Complaint

Create Audit Complaint:

DaisyBillers:

From Bill History, choose Denial Incorrect: Denial received incorrectly citing missing documentation.
Additional Complaint Information noted 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.

Either request an IBR or file a Lien (Required for additional payment)

File application for Independent Bill Review (IBR) within thirty days of receipt of the explanation of review (EOR).
File a lien within 18 months of the date of service citing the defendant allegedly failed to comply with the relevant requirements, timelines, and procedures set forth in Labor Code sections 4622, 4603.3, and 4603.6 and the related Rules of the Administrative Director - WCAB Rule §10451.1(c)(1)(D).