When a claims administrator fails to issue timely EOR for a Second Review, 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.
Request for Second Review (SBR)
Untimely Final EOR issued for Med-Legal Second Review.
Additional Complaint Information - Non-electronic Submission (Fax):
Claims administrator failed to issue a timely Final EOR within 14 days of verified receipt of a compliant request for Second review submitted via a compliant SBR-1 Form. The Bill History documents Compliance Due Dates and fax transmission receipt of Second Review. See Regulations and Rules cited below.
Additional Complaint Information - Electronic Submission:
Claims administrator failed to issue a timely Final EOR within 14 days of verified receipt of a compliant request for Second review submitted electronically using the the SBR-1 Form. The Bill History documents Compliance Due Dates and the date claims administrator issued an accepted acknowledgement verifying receipt of request for Second Review. 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.
Regulations and Rules
Per Labor Code § 4603.3 and CCR § 9792.56 (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.
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.