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Task: Denial Received - Second Review

When a $0 reimbursement is posted to a Second Review submission, DaisyBill automatically moves the Bill to Processed status, generates a Denial Received - Second Review task and assigns the task to a designated DaisyBiller.

To complete the Denial Received - Second Review task determine whether additional funds remain due for the bill.

Step 1. For each Procedure Code compare the ‘Expected’ to the ‘Payment Total’

Expected: Official Medical Fee Schedule (OMFS) reimbursement amount due for the date of service. The ‘Expected’ amount includes fee-affecting workers’ comp billing ground rules (eg., surgical cascading, MPPR, NCCI, MUE) calculations. It does not include contracted or network discounts.

Payment Total: Total posted reimbursement amount allowed by claims administrator.

Expected %: Payment Total reimbursement divided by the Expected OMFS reimbursement.

Balance Due: Expected reimbursement minus Payment Total reimbursement. The Balance Due amount represents the remaining due if the bill is to be reimbursed at the OMFS reimbursement.

Step 2. For insufficient payments, choose an option from the ‘Action Bar’

IBR: Changes Bill Status to Incomplete, navigates to the Independent Bill Review (IBR) function to create an IBR submission.  For more, see the Help Article: Create IBR Submission.

Second Review: Changes Bill Status to Incomplete, navigates to the Second Bill Review (SBR) function to create an additional SBR submission. Claims Administrators are only required to process one Second Review.

Lien: Changes Bill Status to Lien, queues the bill with all other bills for the injury marked for Lien status. (But does not file a lien. This must be done outside DaisyBill.) For more information, see the Help Article: Mark Bill as Lien - Lien Filed.

Step 3. For sufficient payments, click ‘Close’

This moves the Bill to Closed status and completes the task.

Simple!

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