Claims Administrator: Sedgwick Claims Management Services

Issue: Inaccurate Adjustment Reason Codes contained in Sedgwick’s EOR denials

Status: Open

Description:  Sedgwick denying bills incorrectly with DWC Bill Adjustment Reason Code G10--'Bill is submitted without necessary documentation needed for bill processing'.  In fact, with DaisyBill’s submission tracking, it was verified that the bills included all required supporting information.  Upon investigation, a representative from Genex, the bill review company responsible for reviewing the bill, verified that it had received all required information and that Genex’s actual reason for denial was entirely different.  

DaisyBill contacted Sedgwick to alert them of this mistake affecting provider payment for services rendered to injured workers.  We pointed out that inaccurate denial codes on EORs prevent providers from submitting necessary information required for payment.  Inaccurate Adjustment Codes lead to prolonged exchanges of unhelpful information for which, ultimately, the provider suffers.  Incidentally, Sedgwick also non-compliantly furnished paper EORs in response to electronic bills.

This incorrect Adjustment Code issue highlights the necessity of submitting Requests for Second Bill Review for each and every underpayment or $0 payment.  Second Bill Reviews are mandatory to preserve providers’ ability to get paid, even when the fault for errors lies with a claims administrator.  If you subscribe to workcompliens.com, Richard Boggan posted a good article today on the reasons Second Bill Reviews are so critical.

Steps to Take:

• DaisyBiller:  If you are a DaisyBiller and you receive a paper denial citing G10, please upload the denial EOR to the appropriate denied bill and open a case with DaisyBill.  DaisyBill is tracking these bills and is working directly with Sedgwick for proper reprocessing.
• Non-DaisyBiller:  If you are not a DaisyBiller, review your Sedgwick EORs to make sure that denial reasons are correct.  If you detect an error such as the one described above, contact your billing platform or Sedgwick for a new and correct EOR.

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