Denial Incorrect - Missing Documentation

When a claims administrator incorrectly denies request for Second Review citing missing documentation, 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 received incorrectly citing missing documentation.

Additional Complaint Information:

EOR incorrectly states supporting documents not received with a request for Second Review submitted via facsimile. The Second Review included a complete SBR-1 Form and modified CMS 1500. The Bill History documents the fax transmission is confirmed as received by claims administrator. 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:

  1. Contact Claims Administrator
  • Inform claims administrator that your request for Second Review was complete and compliant 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.
  1. File Audit Complaint
  • Create Audit Complaint:

DaisyBillers:

  1. From Bill History, choose Audit Complaint Type: Denial Incorrect: Denial received incorrectly citing missing documentation.
  2. Additional Complaint Information noted in the table 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 missing documentation. It is not necessary to include the bill or medical reports.
  1. 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

Non-electronic Submission

CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill Subdivision (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.

Per Labor Code § 4603.3 and CCR § 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.

Per Labor Code §4603.4 and the DWC Medical Billing and Payment Guide, effective 10/18/2012 claims administrators must accept electronic claims for payment of medical services per the rules outlined in the DWC Electronic Medical Billing and Payment Companion Guide.

Electronic Submission

CCR § 9792.5.5 Second Review of Medical Treatment Bill or Med-Legal Bill:

Subdivision (c) 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 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.

Additional Information

California Labor Code § 4603.2

California Labor Code § 4603.3

California Labor Code § 4603.4

California Labor Code § 4603.6

California Code of Regulations § 9792.5.5

California Code of Regulations § 9792.5.6

DWC Medical Billing and Payment Guide

California Electronic Medical Billing and Payment Companion Guide

DaisyBill Resources

Blog Post: Audit Complaints – Making Things Right in Workers’ Comp

Webinar: Audit Complaints for Work Comp

DaisyBill Solution

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

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