When an EOR incorrectly denies a request for Second Review as duplicate billing, 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 you fill out the DWC Audit Referral form.
Treatment and Services
Request for Second Review (SBR)
Request for Second Review denied as duplicate bill submission.
Additional Complaint Information - Non-electronic Submission (Fax):
EOR incorrectly denies request for Second Review as duplicate billing. The Second Review was submitted via facsimile and included a completed SBR-1 Form and a modified CMS 1500. As documented in the Bill History, the fax transmission is confirmed as received by claims administrator. See Regulations and Rules cited below.
Additional Complaint Information - Electronic Submission:
Claims administrator failed to issued a timely Final EOR within 14 days of verified receipt of a compliant request for Second review submitted electronically using the the SBR-1 Form. The Bill History documents Compliance Due Dates and the date claims administrator issued an accepted acknowledgement verifying receipt of request for Second Review. See Regulations and Rules cited below. EOR incorrectly denies request for Second Review as duplicate billing for an electronically submitted Second Review. The Second Review conformed to the DWC's Electronic Companion Guide Section 2.11.1. and included a completed SBR-1 Form. Per the Bill History, the claims administrator returned an accepted acknowledgement verifying receipt of Second Review and SBR-1 Form. See Regulations and Rules cited below.
How to file an Audit Complaint
When a claims administrator incorrectly denies your request for Second Review you should:
- Contact Claims Administrator (Optional)
- Inform claims administrator that your request for Second Review was compliant, complete, and included the required supporting documents.
- Explain to the claims administrator that you have verifiable proof the claims administrator received documents submitted with the request for Second Review.
- Alert the claims administrator that you intend to file an Audit Complaint to report the misprocessing of your request for Second Review.
- File Audit Complaint
- Create Audit Complaint:
- From Bill History, choose Audit Complaint Type: Denial Incorrect: Request for Second Review denied as duplicate bill submission.
- Additional Complaint Information noted in the table above automatically populates the DWC Audit Referral Form.
- Additional Comments: Provide details of conversations and emails with claims administrator, if any.
- Additional Audit Complaint Document(s): EOR received incorrectly citing duplicate bill submission.
- Either request an IBR or file a Lien (Required for additional payment)
- File application for Independent Bill Review (IBR) within thirty days of receipt of the explanation of review (EOR).
- File a lien within 18 months of the date of service asserting that the defendant has waived any objection to the amount of the bill because the defendant allegedly breached a duty prescribed by Labor Code sections 4603.2 or 4603.3 or by the related Rules of the Administrative Director - WCAB Rule §10451.2(c)(1)(D).
Regulations and Rules
CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill
(c)The request for second review shall be made as follows:
(1) For a non-electronic medical treatment bills, the second review shall be requested on either:
(A) The initially reviewed bill submitted on a CMS 1500 or UB04, as modified by this subdivision. The second review bill shall be marked using the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3” in the field designated for that information to indicate a request for second review.
(B) The Request for Second Bill Review form, DWC Form SBR-1, set forth at section 9792.5.6.
(g) Within 14 days of receipt of a request for second review that complies with the requirements of subdivision (d), the claims administrator shall respond to the provider with a final written determination on each of the items or amounts in dispute by issuing an explanation of review. The determination shall contain all the information that is required to be set forth in an explanation of review under Labor Code section 4603.3, including an explanation of the time limit to raise any further objection regarding the amount paid for services and how to obtain independent bill review under Labor Code section 4603.6. The 14 day time limit for responding to a request for second review may be extended by mutual written agreement between the provider and the claims administrator.
CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill
The request for second review shall be made as follows:
(2) For an electronic medical treatment bills for professional, institutional or dental services, the request for second review shall be submitted on the correct electronic standard format, utilizing the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3” as specified in the Division of Workers’ Compensation Electronic Medical Billing and Payment Companion Guide.
California Electronic Medical Billing and Payment Companion Guide
2.11.1 Claim Resubmission Code - ASC X12N 005010X222A1, 005010X223A2,
or 005010X224A2 Billing Formats
Health care providers will use the Claim Frequency Type Code of 7 (Resubmission/Replacement) to identify resubmissions of prior medical bills (not including duplicate original submissions). (The NUBC Instruction for the use of Claim Frequency Type Codes can be referenced on the NUBC website at http://www.nubc.org/FL4forWeb2_RO.pdf ) The value is populated in Loop 2300 Claim Information CLM Health Claim Segment CLM05-3 Claim Frequency Type Code of the 005010X222A1, 005010X223A2, or 005010X224A2 electronic billing transactions. The health care provider must also populate the Payer Claim Control Number assigned to the bill by the claims administrator for the bill being replaced, when the payer has provided this number in response to the previous bill submission. This information is populated in Loop 2300 Claim Information REF Payer Claim Control Number of the 005010X222A1, 005010X223A2, or 005010X224A2 electronic billing transactions. Health care providers must also populate the appropriate NUBC Condition Code to identify the type of resubmission on electronically submitted medical bills. The Condition Code is submitted based on the instructions for each bill type, in the HI Segment for 005010X222A1 and 005010X223A2 transactions and in the NTE Segment for the 005010X224A2 transaction (the use of the NTE segment is at the discretion of the sender.) Condition codes provide additional information to the claims administrator when the resubmitted bill is a request for reconsideration/second review.
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