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EOR Noncompliant: EOR remitted by claims administrator lacks required information

Zurich Issuing Deficient Electronic EORs

For bills submitted electronically, Zurich no longer issues paper Explanations of Review (EORs). While we commend Zurich for embracing e-billing, many Zurich electronic EORs lack critical and required bill adjudication information.

Both California Labor Code 4603.3 and the DWC Medical Billing and Payment Guide mandate claims administrators must issue complete EORs which must include clear explanations codes.

Zurich’s electronic EORs are noncompliant. DaisyBill alerted both Zurich and their clearinghouse, Jopari; we are waiting on a response from both entities.

Recommended Action

If you receive a deficient EOR from Zurich:

  1. Submit a Second Review.  Include language referencing Labor Code 4603.3 and the DWC Medical Billing and Payment Guide which outlines EOR requirements.  We suggest the following as the Second Review Reason:

The EOR remitted for this original bill lacks required information explaining the reduction in payment.  Per Labor Code 4603.3(3) “The basis for any adjustment, change, or denial of the item or procedure billed“ is a required element of an EOR.

Further, DWC Medical Billing and Payment Guide, Appendix B outlines electronic EOR requirements for medical treatment bills submitted electronically.

The Attached copy of an OVERTURN IBR decision indicates that this reimbursement will be overturned when reviewed by IBR.

  1. Create an Audit Complaint. Be sure to select ‘EOR remitted by claims administrator lacks required information.’
  2. Let DaisyBill Know.  Report Error on a Bill and select Error Type ‘Other’.  We want to improve the workers compensation billing process for all parties involved.  

Resources

IBR Decisions

Overturn for Unclear EOR - Example 1

Overturn for Unclear EOR - Example 2

Labor Code

4603.3

(a) Upon payment, adjustment, or denial of a complete or incomplete itemization of medical services, an employer shall provide an explanation of review in the manner prescribed by the administrative director that shall include all of the following:

(1) A statement of the items or procedures billed and the amounts requested by the provider to be paid.
(2) The amount paid.
(3) The basis for any adjustment, change, or denial of the item or procedure billed.
(4) The additional information required to make a decision for an incomplete itemization.
(5) If a denial of payment is for some reason other than a fee dispute, the reason for the denial.

(6) Information on whom to contact on behalf of the employer if a dispute arises over the payment of the billing. The explanation of review shall inform the medical provider of the time limit to raise any objection regarding the items or procedures paid or disputed and how to obtain an independent review of the medical bill pursuant to Section 4603.6.

(b) The administrative director may adopt regulations requiring the use of electronic explanations of review.

California Division of Workers’ Compensation Medical Billing and Payment Guide Version 1.2.2

Appendix B. Standard Explanation of Review / Remittance Advice                                 

Electronic Explanation of Review / Remittance Advice

The electronic EOR is conveyed to the provider by transmission of the ASC X12/005010X221A1 Payment/Advice (835) Technical Report Type 3. Electronic EORs must comply with the 005010X221A1 and the related workers’ compensation instructions found in the California Division of Workers’ Compensation Electronic Billing and Payment Companion Guide, Chapter 7.

The Table 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk includes the DWC Bill Adjustment Reason Codes, a description of the billing problem the code is describing, the Explanatory Message, and any special instructions or additional information required when using that code. The national standard 005010X221A1 does not support use of the DWC Bill Adjustment Reason Codes. The 005010X221A1 utilizes the Claims Adjustment Reason Codes (CARCs) and the Remittance Advice Remark Codes (RARCs) to convey EOR information from the payer to the provider. For workers’ compensation, Table 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk sets forth a subset of the CARCs and RARCs that are to be used in the 005010X221A1 transmission. The table provides a crosswalk between the DWC Bill Adjustment Reason Codes and DWC explanatory messages and the corollary CARC and RARC combinations used in electronic EORs.

For instructions relating to use of CARC Codes 191, 214, 221 or W1 refer to the California Division of Workers’ Compensation Electronic Billing and Payment Companion Guide, Chapter 7 for specific workers’ compensation instructions.

When receiving an electronic EOR via 005010X221A1, medical providers can determine the DWC Bill Adjustment Reason Code from the combination of CARC and RARC. In most cases, each CARC/RARC combination only maps to one DWC Bill Adjustment Reason Code. The DWC Matrix Crosswalk is presented in two different orders for the convenience of both paper and electronic EOR receivers. The first is presented in DWC Bill Adjustment Reason Code order (Table1.0). The second is in CARC order (Table 2.0).

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