When a claims administrator remits no response to an Original Bill and supporting documents, 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.
Treatment and Services
No response to Original Bill
Additional Complaint Information - Non-electronic Submission (Fax):
To date, no response received from claims administrator for an 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:
To date, no response received from claims administrator for an 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: No response to Original Bill.
- 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): EOR received; PDF of Bill History showing Bill Submission details
- 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 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.
Per Labor Code §4603.2 and the DWC Medical Billing and Payment Guide, payments shall be made within 45 days after receipt of each separate, itemization of medical services provided, together with any required reports and any written authorization for services that may have been received by the physician.
Section 6.4 of the DWC Medical Billing and Payment Guide (a): Any non-electronically submitted bill determined to be complete, 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).
DWC Medical Billing and Payment Guide, Section 7
Bill Processing and Payment Requirements for Electronically Submitted Medical Treatment Bills
(3) ASC X12C/005010X214 Health Care Claim Acknowledgment (277) – within two working days of receipt of an electronically submitted bill, the claims administrator shall send a Health Care Claim Acknowledgement 005010X214 electronic notice of whether or not the bill submission is complete. The 005010X214 details what errors are present, and if necessary, what action the submitter should take. A bill may be rejected if it is not submitted in the required electronic standard format or if it is not complete as set forth in Section One – 3.0, except as provided in 7.1(a)(3)(A)(i) which requires the pending of bills that have a missing attachment or claim number. Such notice must use the 005010X214 transaction set as defined in Companion Guide Chapter 9 and must include specific information setting out the reason for rejection.
DWC Medical Billing and Payment Guide, Section 7.1
Except for bills that have been rejected at the Acknowledgment stage, the ASC X12N/005010X221A1 Health Care Claim Payment/Advice (835) must be transmitted to the provider within 15 working days of receipt of the electronic bill, extended by the number of days the bill was placed in pending status under 7.1(a)(3)(A), if any. The 005010X221A1 should be issued to notify the provider of the payment, denial of payment, or objection to the entire bill or portions of the bill as set forth below. The 005010X221A1 serves as the Explanation of Review, and notice of denial or objection.
DWC Medical Billing and Payment Guide 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 audit penalties per Title 8, California Code of Regulations section 10111.2 (b) (10), (11).
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