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Request for Second Review Compliance

Submitting Second Review requests through DaisyBill guarantees 100% compliance when submitted within 90 days of the EOR date.

This is because DaisyBill precisely follows the Division of Workers’ Comp Second Review regulations: CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill.

Per the Second Review regulations, DaisyBill submits requests for Second Review as follows:

  • For Non-Electronic Original Bills, Second Reviews are submitted via fax and include:
  1. Completed DWC Form SBR-1
  2. Modified original paper CMS 1500
  3. Original Supporting Documents
  4. Additional Supporting Documents (if attached)

  • For Electronic Original Bills, Second Reviews are submitted electronically and include:
  1. Completed DWC Form SBR-1
  2. Modified electronic CMS 1500
  3. Original Supporting Documents
  4. Additional Supporting Documents (if attached)

Non-Electronic Original Bills

For Non-Electronic Treatment Bills, the Second Review regulation Subdivision (c)(1) allows for two options when submitting a Second Review request: 

  • Subsection (c)(1)(A) Allows for submission of a modified CMS1500 with the Condition Code Qualifier BG in box 10d followed by the Condition Code W3.
  • Subsection (c)(1)(B) Allows for use of the Request for Second Bill Review form, known as the DWC Form SBR-1.

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Electronic Original Bills

For non-electronic treatment bills, the Second Review regulation Subdivision (c)(2) stipulates that electronically submitted Original Bills require electronic submission of the request for Second Review with the following information transmitted in the correct electronic standard format:

  1. Box 10D: BGW3
  2. Box 22: Completed with the number 7 as the resubmission code and the payer claim control number is used in the ‘original reference number’ field.

Claims Administrator Responsibilities

  • The Claims Administrator has 14 days of receipt of request for second review to issue a final written determination on each of the amounts in dispute by issuing an EOR.  
  • If additional monies are determined to be payable, payment shall be made within 21 days of receipt of request of second review.

DaisyBill, keeping you compliant since 2013!

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