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SCIF: Incorrect 'Not Authorized by UR' Denials

In mid-February 2016, a DaisyBiller reported that State Comp Insurance Fund (SCIF) was incorrectly denying bills for authorized treatment as “not authorized by UR.” DaisyBill contacted SCIF, and a representative confirmed that SCIF may be erroneously denying authorized treatment as not authorized.

When SCIF Bill Review processes an Original Bill or a Second Review, neither the utilization review decision nor the attached authorization documentation determines reimbursement. Instead, SCIF Bill Review bases reimbursement on an internal adjuster notation.

When an Adjustor applies an internal notation in SCIF’s claim system, then SCIF Bill Review automatically denies the bill, regardless of prior UR authorization. SCIF Bill Review also denies any subsequent request for Second Review of this bill, again based on this internal adjuster notation.

This is the reported sequence of events:

  1. Provider obtains RFA authorization for treatment and submits treatment bill with copy of RFA authorization.
  2. SCIF Bill Review denies bill with EOR Reduction Code Message: "THE BILLED SERVICE WAS NOT AUTHORIZED BY UR." The denial is due to internal Adjustor notation in SCIF claim system.
  3. To contest incorrect denial, Provider submits request for Second Review (SBR).
  4. SCIF Bill Review automatically denies Second Review due to internal Adjustor notation in SCIF claim system.

Required Action

For SCIF Original Bills improperly denied due to lack of authorization, follow the instructions below.

Step 1. Call the Adjustor before submitting the Request for Second Review (SBR)

Request that the Adjustor remove the internal Adjustor notation.

Step 2. Note the call in ‘Bill History’

Leave a note in Bill History, including the name of the Adjustor or representative to whom you spoke.

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Step 3. File the SBR within 90 days

Within 90 days of receiving the incorrect denial, file an SBR for additional reimbursement.

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Step 4. If the SBR is denied, file an IBR

If SCIF improperly denies the SBR, you must file a request for Independent Bill Review within 30 days of receiving the SBR denial.

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Step 5. File an Audit Complaint

Take 10 seconds and file an Audit Complaint. For Audit Complaint type, choose ‘Incorrect Denial: Denial received incorrectly citing lack of authorization for authorized services’.

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You’re all set!

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