Third-Party Administrator (TPA) Adminsure recently offered a perfect example of how workers’ comp can work beautifully when claims administrators take their responsibilities to providers seriously — even in the event of a technical problem.

Briefly, Adminsure’s non-electronic Explanations of Review (EORs) were missing something critical: the procedure codes for the services billed. But within 2 days of daisyBill reporting this issue to Adminsure, the TPA took the necessary steps to fix their EORs and come into compliance with California requirements.

EORs Must Be Complete to Be Compliant

daisyBill noticed that paper EORs issued by Adminsure listed the amounts billed and remitted for the services rendered — but without listing procedure codes for the services rendered, as in the example below.

Not only does this make it difficult for the provider to determine whether Adminsure paid correctly; listing the procedure codes on the EOR is a requirement per the Division of Workers’ Compensation (DWC)’s Medical Billing and Payment Guide. The Guide’s instructions for EORs list “Paid Procedure Code” as “R,” as in “Required.”

Fortunately, the issue did not affect electronic EORs (e-EORs) from Adminsure, which means that payment information for each procedure code posted correctly in daisyBill software. Nonetheless, we alerted Adminsure to the paper EOR non-compliance, and were pleased to see Adminsure move quickly and decisively to resolve the problem.

For all the times daisyBill reports non-compliance to claims administrators only to be ignored, rebuffed, or otherwise forced to take drastic action (like filing Audit Complaints), we commend Adminsure. This TPA was informed of a problem, solved it, and minimized its impact on the providers who treat California’s injured workers.

If only all claims administrators took a similar approach to compliance.

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