Denial Incorrect - Authorization

When a claims administrator authorizes billed services, then later denies an SBR-1 Form citing a lack of authorization, 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 fill out the DWC Audit Referral form.

Bill Type:

Treatment and Services

Submission Type:

Request for Second Review (SBR)

Complaint Category:

Incorrect Denial

Complaint Reason:

Denial incorrectly cites lack of authorization for authorized services.

Additional Complaint Information:

Billed services authorized by claims administrator. Claims administrator denied SBR-1 Form wrongly citing services were not authorized.

How to file an Audit Complaint

When a claims administrator incorrectly denies your request for Second Review you should:

  1. Contact Claims Administrator (Optional)
  • Inform claims administrator that your request for Second Review was compliant, complete, and included the required supporting documents.
  • Request further information regarding the reason for the incorrect denial of services.
  • Alert the claims administrator that you intend to file an Audit Complaint to report the misprocessing of your request for Second Review.  
  1. File Audit Complaint
  • Create Audit Complaint:

DaisyBillers:

  1. From Bill History, choose Audit Complaint Type: Denial Incorrect: Denial incorrectly cites lack of authorization for authorized services.
  2. Additional Complaint Information noted above automatically populates the DWC Audit Referral Form.

Non DaisyBillers: Link to DWC’s Audit Referral Form (link to Form Directions).

  • Additional Comments: Provide details of conversations and emails with claims administrator, if any.
  • Additional Audit Complaint Document(s): Provide any explanation of review (EOR) received incorrectly citing injury as not authorized. It is not necessary to include the bill or medical reports.
  1. Either request an IBR or file a Lien (Required for additional payment)

Additional Information

Division of Workers’ Compensation Medical Billing and Payment Guide

DaisyBill Resources

Blog Posts:

Audit Complaints – Making Things Right in Workers’ Comp

Authorization and Declaration: RFAs and Liens Under SB 1160 (Part I)

Authorization and Declaration: RFAs and Liens Under SB 1160 (Part II)

Webinars:

Audit Complaints for Workers’ Compensation

Lien Declaration Requirement

DaisyBill Solution

With DaisyBill’s Revenue Cycle Management technology, it takes about 5 seconds to file an Audit Complaint.

BOOK A DEMO

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About Us

DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

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