To appeal incorrect reimbursements or bill denials, California providers must submit timely and compliant requests for second review. To date, DaisyBill clients have recovered over $30 million in additional revenue by submitting these second review appeals.

But claims administrators aren’t the only ones who make mistakes.

Providers should also submit a second review appeal if, upon receiving an Explanation of Review (EOR), the provider determines that the original bill was submitted incorrectly. But crucially, providers may not make any adjustments to the original bill. The bill a provider submits with a second review request must be exactly the same as the original, with no changes other than those designating the submission as a second review appeal.

Second Review Appeal Rules

Senate Bill 863 established second review as the means of appeal when a provider disputes the reimbursement amount paid by a claims administrator. The second review process is subject to strict requirements. If the provider fails to meet those requirements, the second review appeal is void — and any hope of compelling the claims administrator to remit the correct payment is gone.

Labor Code Section 4603.2 and California Code of Regulations (CCR) Section 9792.5.5 dictate the rules for the Second Review appeals, which address:

• Timeliness: Providers must submit the appeal within 90 calendar days from receipt of the Explanation of Review (EOR). Per Labor Code § 4603.2, failure to timely submit the second review means “the bill shall be deemed satisfied and neither the employer nor the employee shall be liable for any further payment.”

• Format: Providers must use either a modified original bill or DWC Form SBR-1. (We strongly recommend using the DWC Form SBR-1 ).

• Delivery: Providers must use the same delivery method (i.e., paper or electronic) as the original bill. Electronic appeals must utilize the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3”

• Reason: Providers must state clearly and specifically the reason for disputing the incorrect payment.

• Documentation: Providers must include all relevant supporting documentation with their second review appeal.

Importantly, the regulations also stipulate that the second review appeal may not address any services not included in the original bill. CCR § 9792.5.5(d) states:

The request for second review shall include...The original dates of service and the same itemized services rendered as the original bill. No new dates of service or additional billing codes may be included.

The Consequences of Non-Compliance

§ 9792.5.5(f) goes on to specify that while the claims administrator “may” respond to a request for second review that does not comply with the requirements, such responses are not subject to the usual deadlines and rules that apply to claims administrators.

Translation: if the provider fails to follow the rules, the claims administrator may respond at their own discretion, or not at all.

The Division of Workers’ Compensation (DWC)’s Electronic Billing and Payment Companion Guide further emphasizes the requirement for second review appeals to address only the contents of the original bill — and the claims administrator’s freedom to disregard appeals that include alterations to the bill (emphasis ours):

All elements, fields, and values in the Reconsideration/Second Review bill
transaction, except the Reconsideration/Second Review specific qualifiers and Claim Supplemental Information PWK segment, must be the same as the original bill transaction...The Claims Administrator may reject an appeal/reconsideration/request for second review bill transaction if...the bill information does not match the corresponding original bill transaction…

As we explained in a previous post, once you receive an EOR explaining the reimbursement, it is appropriate (and wise) to submit a second review appeal to correct a provider billing error. However, the provider must include an explanation of the error in their written rationale for the appeal. The bill itself, including any errors, must remain the same.

Claims administrators and their clearinghouses reject second review appeals in which the bill submitted for review doesn’t match the original bill. They are well within their rights to do so, even when the provider is correct about the reimbursement amount owed.

Providers, know the rules, follow them, and protect your revenue.

Make second review appeals easy. DaisyBill’s Billing Software generates instant, compliant SBRs, so you can get the reimbursement you’ve earned. Schedule a free demonstration, and see what DaisyBill can do for your office.

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