When claims administrators take responsibility for their actions (and the actions of their agent vendors), workers’ comp billing and payment works better. The latest example: the California Insurance Guarantee Association. 

After daisyBill publicly posted data on CIGA’s 0% compliance rate with e-EOR requirements, CIGA’s designated clearinghouse, Data Dimensions, contacted daisyBill to address the issue.

Ultimately, Data Dimensions was able to resolve the underlying problem and bring CIGA into compliance with California e-billing regulations.

Thank you, CIGA.

CIGA: Responsible for Clearinghouse Compliance

Throughout the last quarter of 2021, CIGA failed to send the required electronic EORs in response to daisyBill providers’ e-bills.

As we explain in this primer on electronic EORs, when providers bill electronically, the claims administrator must return the EOR electronically within 15 working days, in a format known as an X12 835 file. But in most cases, claims administrators lack the technology to furnish 835s.

For that reason, claims administrators employ clearinghouses to act as the claims administrator’s EDI agent. Clearinghouses accept provider e-bills and return 835s on behalf of the claims administrator.

However, it is the claims administrator’s legal responsibility to process and pay provider e-bills timely and compliantly. Or, as the Division of Workers’ Compensation (DWC)’s e-billing guide puts it, “Entities or persons using agents [like bill review and clearinghouse vendors] are responsible for the acts or omissions of those agents…”

Data Dimensions Gets to Work

Soon after daisyBill published the Claims Administrator Directory, Data Dimensions contacted daisyBill to address CIGA’s dismal statistics regarding 835 compliance. Data Dimensions confirmed that daisyBill did not receive 835s from Data Dimensions on behalf of CIGA.

After some back-and-forth (detailed below), Data Dimensions reported on April 27 that “...the 835 issue for CIGA has been resolved at this time.” As of this writing, CIGA is currently remitting compliant 835s via Data Dimensions.

The Non-Compliance Alert for CIGA, which daisyBill appends to the Bill History for all affected bills in our system, is shown below.

In early April, daisyBill published the Claims Administrator Directory to empower all providers (not only daisyBill clients) with easy access to important information about workers’ comp claims administrators, including e-billing compliance data.

Noticeably, the Claims Directory listed California Insurance Guarantee Association (CIGA) X12 835 EOR compliance as sending zero Explanations of Review (EORs) electronically. For more information, read How to e-Bill: 835 Electronic EORs.

For CIGA, Medata is the bill review and Data Dimensions is the designated clearinghouse.

The table below summarizes daisyBill’s persistence in monitoring the EDI non-compliance and making sure the entities responsible resolve this EDI non-compliance. Should CIGA continue to fail to send daisyBill clients EORs electronically, daisyBill will file Audit Complaints with the DWC to report the non-compliance.

🌼 As of now, daisyBillers do not need to take any action regarding this resolved EDI non-compliance. Once the clearinghouse noted above delivers the 835s to daisyBill, daisyBill will automatically post the 835s to your bills. Have a Flower Power Day!

daisyBill has the technology and expertise to make workers’ comp work better. Reach out to see how we can help your practice obtain fast, correct reimbursement for treating injured workers.

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