When a claims administrator representative inaccurately reports an original bill as not on file, 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: How can I tell that I should file an Audit Complaint for an original bill not on file?
A: If a claims administrator representative reports a bill as “not on file,” check your documentation. If the fax transmission confirms that the claims administrator received the bill, or if the claims administrator returned an accepted acknowledgement verifying receipt of an electronic transmission, you should file an Audit Complaint.
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.
Treatment and Services
Bill not on file with claims administrator.
Additional Complaint Information - Non-electronic Submission (Fax):
Claims administrator representative reported bill not on file. Original bill and Supporting Documents submitted via facsimile. The Bill History documents the Original Bill fax transmission was confirmed as received by claims administrator.
Additional Complaint Information - Electronic Submission:
Claims administrator representative reported bill not on file. Original Bill and Supporting Documents submitted electronically. The electronic transmission conformed to the DWC's Electronic Companion Guide. As documented in the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Original Bill and Supporting Documents.
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 Audit Complaint Type: Overdue Processing: Bill not on file with claims administrator.
- Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.
- Submit a Duplicate Bill
- Follow DWC Medical Billing and Payment Guide instructions: 5.0 Duplicate Bills, Bill Revisions and Balance Forward Billing.
- Per Labor Code 4603.2: 15% penalty and 10% accrued interest due from the date of receipt of the Original Bill.
Regulations and Rules
Labor Code § 4603.2 and the DWC Medical Billing and Payment Guide mandate that a claims administrator shall alert the provider within 30 days of receipt of the itemized bill if the claims administrator contests, denies, or considers the bill or supporting documents incomplete.
Payment and Remittance Advice / Denial / Objection
Payments shall be made within 45 days after receipt of each separate itemization of medical services provided, along with any required reports or written authorization for services received by the physician.
Per Section 6.4 of the DWC Medical Billing and Payment Guide, any complete non-electronically submitted bill not paid within 45 days (60 days for a governmental entity) or objected to within 30 days shall be subject to audit penalties per Title 8, California Code of Regulations section 10111.2 (b) (10), (11).
Section 7.1 of the DWC Medical Billing and Payment Guide states that the claims administrator has two business days from the receipt of an electronically submitted bill to send a Health Care Claim Acknowledgement 005010X214. The 005010X214 is an electronic notice of whether or not the bill is complete that details any errors present and any needed action on the part of the submitter.
The claims administrator may reject the bill if it is not submitted in the required electronic standard format or if it is not complete per the standards of the Medical Billing and Payment Guide. DaisyBill ensures that all submitted bills are complete and compliant. If such a rejection is issued, it must include specific information setting out the reason for rejection.
Payment and Remittance Advice / Denial / Objection
Claims administrators are required to transmit an ASC X12N / 005010X221A1 Health Care Claim Payment/Advice (835) to notify the provider of the payment, denial, or objection to a bill within 15 working days of receipt of the electronic bill. This number may be extended by the number of days the bill was placed in ‘pending’ status under the rules set forth in Section 7.1(a)(3)(A) of the DWC Medical Billing and Payment Guide, and the rule does not apply to bills that have been rejected at the Acknowledgement stage. The 005010X221A1 serves as the Explanation of Review, and notice of denial or objection.
Per Section 7.2 (a), any electronically submitted bill determined to be complete, not paid, or objected to within the 15 working day period shall be subject to the audit penalties set forth by Title 8, California Code of Regulations section 10111.2 (b) (10), (11).
With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.