Processing Overdue - Bill Not on File

When a claims administrator representative inaccurately reports a Second Bill Review (SBR) as not on file, 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: How can I tell that I should file an Audit Complaint for a SBR not on file?

A: If a claims administrator representative reports a bill as “not on file,” check your documentation. If the fax transmission confirms that the claims administrator received the SBR, or if the claims administrator returned an accepted acknowledgement verifying receipt of an electronic transmission, you should file an Audit Complaint.

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.

Bill Type:

Treatment and Services

Submission Type:

Request for Second Review (SBR)

Complaint Category:

Processing Overdue

Complaint Reason:

Second Review not on file with claims administrator

Additional Complaint Information - Non-electronic Submission (Fax):

Claims administrator representative reported bill not on file. Request for Second Review submitted via facsimile. The Second Review included a completed SBR-1 Form and a modified CMS 1500. As documented in the Bill History, the fax transmission is confirmed as received. See Regulations and Rules cited below.

Additional Complaint Information - Electronic Submission:

Claims administrator representative reported bill not on file. Request for Second Review submitted electronically. The Second Review conformed to the DWC's Electronic Companion Guide Section 2.11.1. and included a completed SBR-1 Form as Additional Documentation. 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 processes 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:

daisyBillers:

From Bill History, choose Audit Complaint Type: Overdue Processing - Second Review not on file with claims administrator.
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): None

Submit duplicate Second Review or file a lien

Request for Second Review must be submitted within 90 days of receipt of explanation of review or the date of service of an order of the Workers’ Compensation Appeal Board resolving any threshold issue that would preclude a provider’s right to receive compensation for the submitted bill.

Check your eligibility to file a lien here.

Regulations and Rules

Non-electronic Submission

The California Code of Regulations § 9792.5.5 governs Second Review of Medical Treatment Med-Legal Bills. Per subdivision (c), the request for second review shall be made as follows:

For a non-electronic medical treatment bill, the second review shall be requested on either:

The initially reviewed bill submitted on a CMS 1500 or UB04. 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.
The Request for Second Bill Review form, DWC Form SBR-1, set forth at section 9792.5.6 of the CCR.

Per Labor Code § 4603.3 and CCR § 9792.5.6 (g), the claims administrator must respond to the provider with a final written determination on each of the items or amounts in dispute by issuing an explanation of review (EOR) within 14 days of receipt of a compliant request for second 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.

Electronic Submission

The California Code of Regulations § 9792.5.5 sets guidelines for second review of medical treatment and med-legal bills submitted electronically. The second review must be submitted in the correct electronic standard format, utilizing the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3.” Bills submitted through daisyBill automatically comply to this format.

From the 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.