Recently a claims administrator gave a DaisyBill client some horrible advice about appealing an incorrect payment.

A representative at Pacific Claims Management, a third party administrator, reportedly instructed the DaisyBill client not to bother using an SBR-1 form to appeal an incorrect payment. Fortunately, our client reached out to us to ask why Pacific Claims Management gave these inaccurate instructions.

According to our client, Pacific advised writing “Request for Second Review” across the top of the Explanation of Review (EOR) and then return the EOR and the original bill to Pacific. That, Pacific allegedly claimed, would be enough to satisfy Pacific’s requirements to reprocess the bill. (Of course, this raises the question why Pacific Claims Management did not accurately reimburse our client the first time?)

Pacific did, in fact, reprocess the bill, but concluded that Pacific owed no additional payment. Understandably astonished, the biller sought to appeal the incorrect denial by requesting Independent Bill Review (IBR), complete with all the requisite paperwork and a $195 processing fee.

The IBR, however, would have proved fruitless since the initial appeal was not compliant, California Department of Workers’ Compensation (DWC) and its independent reviewer, Maximus Federal Services rejects and IBR when the Second Review is not submitted compliantly.

The good news was that the non-compliant Second Review, and its subsequent denial, all occurred within the 90-day window for filing a compliant Second Review, so the biller still had time to submit a proper Second Review.

Bottom line: if a claims administrators incorrectly processes an original bill, and more money remains due, it's imperative to file a compliant Second Review. Always, always use the SBR-1 Form to appeal incorrect pavements.  Do not trust a claims administrator to reprocess a bill without the SBR-1 Form, as your appeal rights may expire and your bill will be void.

DaisyBill offers stress-free SBR management. With tools that analyze original bills for accurate reimbursement, create compliant SBR templates, and auto-populate complete requests for SBR, getting the correct reimbursement has never been easier. Schedule a free demonstration for details.

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