When a Second Review is incorrectly denied by a claims administrator due to Missing Documentation, daisyBill can help. If the bill was submitted using daisyBill, follow these instructions to contact the claims administrator and/or file an Audit Complaint.
Common reasons that claims administrators incorrectly deny Second Review for missing documentation include:
- Adjusters do not forward documentation to Bill Review.
- If the documentation is incorrect, insufficient, or unreadable, claims administrators will deny a bill for missing documentation.
- Claims administrators ‘misplace’ the documentation.
- Claims administrators incorrectly demand the original Explanation of Review (EOR).
If your Second Review is falsely denied due to “missing documentation,” follow daisyBill’s recommended steps.
Additional Payment Recommendations
To recoup the additional money due when a Second Review is incorrectly denied as a missing documentation, daisyBill recommends the following steps:
- Contact the claims administrator and request that they reprocess the Second Review. See instructions below.
- If payment is not received within 30 days of the date of the Final EOR denying the Second Review for missing documentation, file an application for Independent Bill Review within 30 days of receipt of the EOR denying the Second Review.
Contact the Claims Administrator
- Call the adjuster or relevant bill review department:
- Ask the adjuster or bill review representative to locate the actual bill in their system.
- Ask if the submitted Supporting Documents are present with the CMS1500 (also known as a HCFA).
- If the Supporting Documents are located in their system:
- Compare the number of pages in their system compared to the number of submitted pages.
- Ask for the representative to explain the reason for the bill denial.
- If the Supporting Documents are not located in their system:
- If the claims administrator denies receiving the complete supporting documentation, immediately open a Support Case.
- Create a note on the bill history to record details of the conversation including the person’s name and telephone number to whom you spoke their role (e.g., bill review, adjuster).
File Audit Complaint
For Second Reviews incorrectly denied as missing documentation, immediately file an Audit Complaint with the DWC. (See daisyBill’s 5 Second Audit Compliant for directions.) In order for the DWC to take action against noncompliant claims administrators, providers must alert the DWC by filing audit complaints.
At daisyBill, we find Incorrect Denials incredibly frustrating. These unjustified denials indicate either:
- Claims administrators are not paying attention to the bills they receive, so it doesn’t matter whether providers submit complete and timely bills and Second Reviews, or
- The claims administrators are incorrectly denying bills with the intent of creating even more friction to prevent providers from receiving payment for services rendered to injured workers.
Either way, the providers end up paying in money, time, and resources when trying to get paid. It’s bad business, simply put, and every provider must take action and file an Audit Complaint when bills are incorrectly denied.