When an EOR received from a claims administrator lacks information required by Labor Code 4603 or California Code of Regulations § 9792.5.5, 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 you fill out the DWC Audit Referral form.
Request for Second Review (SBR)
Final Second Review EOR lacks required information for Med-Legal bill
Additional Complaint Information
Final EOR received from claims administrator responding to a Request for Second Review lacks required information as Labor Code 4603.3 and CCR § 9792.5.5. See Regulations and Rules cited below.
How to file an Audit Complaint
When a claims administrator incorrectly processes your request for Second Review you should:
- Contact Claims Administrator (Optional)
- 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 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:
- From Bill History, choose EOR Non-compliant: Untimely Final EOR issued for Med-Legal Second Review.
- 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.
- File a Lien
- 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).
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.
CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill Subdivision (g) Within 14 days of receipt of a request for second review that complies with the requirements of subdivision (d), the claims administrator shall respond to the provider with a final written determination on each of the items or amounts in dispute by issuing an explanation of review. The determination shall contain all the information that is required to be set forth in an explanation of review under Labor Code section 4603.3, including an explanation of the time limit to raise any further objection regarding the amount paid for services and how to obtain independent bill review under Labor Code section 4603.6.
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