Audit Complaint for Processing Overdue: No Response

When a claims administrator remits no response to a Request for 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 you fill out the DWC Audit Referral form.

Bill Type:

Medical-Legal

Submission Type:

Request for Second Review (SBR)

Complaint Category:

Processing Overdue

Complaint Reason:

No response to Med-Legal Second Review

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

To date no response received from claims administrator 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. As documented in the Bill History, the fax transmission is confirmed as received by claims administrator. See Regulations and Rules cited below.

Additional Complaint Information - Electronic Submission:

To date no response received from claims administrator for a request for Second Review submitted electronically. 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 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 Second Review with supporting documentation.
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 Audit Complaint Type: Processing Overdue: No response to Med-Legal Second Review
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): None

Submit duplicate Second Review or file a lien

Request for Second Review must be submitted within 90 days of receipt of explanation of review or the date of service of an order of the Workers’ Compensation Appeal Board resolving any threshold issue that would preclude a provider’s right to receive compensation for the submitted bill.

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

Non-electronic Submission

Per Labor Code § 4603.3 and CCR § 9792.5.6 (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.

CCR § 9792.5.5 (c)(4)

For medical-legal bills, the second review shall be requested on the Request for Second Bill Review form, DWC Form SBR-1, set forth at section 9792.5.6.

Electronic Submission

CCR § 9792.5.5 (c)(4)

For medical-legal bills, the second review shall be requested on the Request for Second Bill Review form, DWC Form SBR-1, set forth at section 9792.5.6.

The DWC Newsline No. 03-12 of January 13, 2012 states: "The Division of Workers’ Compensations has received complaints from qualified medical evaluators (QMEs) that bills are being rejected by claims administrators because they are not on the standardized forms. By statute, medical providers are required to bill using standardized paper billing forms effective Oct. 15, 2011. This is a new requirement for medical treatment bills only. It does not apply to medical-legal bills.

However, the requirement to use the standardized paper billing forms does not apply to medical-legal billings, such as those performed in panel QME or other official QME or agreed medical evaluator, (AME) cases. Therefore, it is not appropriate to reject or object to a medical-legal bill because it was not submitted on a standardized form."

Accordingly, it is not appropriate to reject or object or not timely process a medical-legal bill because it was submitted on a standardized form via electronic billing.