E/M Data: CPT 99214 Reimbursement 2022
Far too often, California providers are not receiving Official Medical Fee Schedule (OMFS) rates for Evaluation and Management (E/M) for injured workers — as evidenced by our data on CPT 99214, an extremely common E/M procedure code for established patients.
In 2022, CPT 99214 was the E/M procedure code most frequently reported by workers’ comp doctors using daisyBill. For 2022 dates of service, daisyBill clients sent 408,473 bills that included CPT 99214, making it a perfect code from which to extrapolate reimbursement and denial patterns by each claims administrator.
With the data below, we crunch the numbers and explore the implications for California workers’ comp.
CPT 99214: 2022 Data Summary
Below is a summary of the data collected from the 239 claims administrators to which daisyBill doctors submitted bills with E/M code CPT 99214. The data reveal that for dates of service in 2022, claims administrators collectively:
- Denied payment for CPT 99214 10% of the time across all bills that included CPT 99214
- Paid California doctors 83% of OMFS rates, which equals 111% of Medicare rates for the same services — despite OMFS rates set at 134% of Medicare rates in 2022
- An Explanation of Review (EOR) is missing for 8% of e-bills featuring CPT 99214 (for these bills, either the claims administrator has not yet paid the bill or the claims administrator non-compliantly returned a paper EOR)
CPT Code 99214 (Moderate Level E/M) |
2022 Dates of Service Data |
Count of bills featuring CPT 99214 |
408,473 |
Count of bills: CPT 99214 Paid |
336,314 |
Count of bills: CPT 99214 Denied |
40,599 |
CPT 99214 Denal % |
10% |
% of OMFS Rate Paid for CPT 99214 |
83% |
% of Medicare Rate Paid for CPT 99214 |
111% |
Explanation of Review (EOR) Missing |
31,560 |
% of Bills Missing EOR |
8% |
CPT 99214: Claims Administrators - High Denials AND Low Payments
For dates of service 2022, below are the 22 claims administrators with the highest payment denial rates and the lowest reimbursement rates. These claims administrators:
- Received 100 or more bills with CPT 99214, and
- Denied payment for CPT 99214 more than 10% of the time
- Cumulatively reimbursed doctors less than 111% of the Medicare reimbursement rate (83% OMFS rate)
Doctors billing the claims administrators below are urged to scrutinize their EORs and submit Second Review appeals when payment for CPT 99214 is denied or reduced improperly.
Claims Administrator |
Count: Bills With CPT 99214 |
Count: CPT 99214 Denied |
CPT 99214 Denial % |
% of OMFS Rate Paid |
% of Medicare Rate Paid |
Gallagher Bassett |
25,701 |
4,300 |
17% |
80% |
107% |
CorVel |
15,272 |
1,739 |
11% |
80% |
107% |
Liberty Mutual Insurance |
12,767 |
1,493 |
12% |
78% |
105% |
AmTrust North America |
9,420 |
1,137 |
12% |
69% |
93% |
Insurance Company of the West |
6,961 |
1,300 |
19% |
73% |
99% |
The Hartford |
5,078 |
579 |
11% |
72% |
96% |
Employers Compensation Insurance Company |
4,130 |
1,488 |
36% |
81% |
109% |
Helmsman Management Services |
3,778 |
492 |
13% |
76% |
102% |
Pacific Compensation Insurance Company |
2,902 |
443 |
15% |
70% |
94% |
CompWest Insurance Company |
2,427 |
429 |
18% |
82% |
110% |
Farmers Insurance |
1,980 |
296 |
15% |
70% |
93% |
Guard Insurance Group |
1,490 |
295 |
20% |
74% |
99% |
Omaha National Group |
1,094 |
278 |
25% |
82% |
110% |
Enstar Group |
681 |
223 |
33% |
72% |
97% |
Hanover Insurance Company |
437 |
109 |
25% |
75% |
101% |
Applied Underwriters |
431 |
64 |
15% |
80% |
107% |
Berkley Net Underwriters, LLC |
424 |
111 |
26% |
74% |
100% |
United Heartland |
276 |
36 |
13% |
78% |
105% |
Nordstrom Workers' Compensation |
259 |
59 |
23% |
81% |
109% |
National Liability and Fire Insurance Company |
228 |
38 |
17% |
76% |
102% |
Tokio Marine Management |
138 |
61 |
44% |
70% |
93% |
ARGO - Argonaut Insurance Company |
115 |
14 |
12% |
77% |
104% |
CPT 99214: Claims Administrators - Highest Denial Rates
California law monetarily incentivizes claims administrators to falsely deny bills. When a doctor fails to submit a Second Review appeal to dispute a false payment denial within 90 days, the claims administrator keeps the doctor’s revenue.
When denial rates by individual claims administrators for CPT 99214 appear excessive, it is possible that these claims administrators frequently deny payment improperly.
Below we list the 24 claims administrators that:
- Received 100 or more bills with CPT 99214, and
- Denied CPT 99214 15% or more of the time
Providers must pay close attention to payment denials received from this list of 24 claims administrators.
Claims Administrator |
Count: Bills With CPT 99214 |
Count: CPT 99214 Denied |
CPT 99214 Denial % |
% of OMFS Rate Paid |
% of Medicare Rate Paid |
Gallagher Bassett |
25,701 |
4,300 |
17% |
80% |
107% |
Insurance Company of the West |
6,961 |
1,300 |
19% |
73% |
99% |
Employers Compensation Insurance Company |
4,130 |
1,488 |
36% |
81% |
109% |
Pacific Compensation Insurance Company |
2,902 |
443 |
15% |
70% |
94% |
Republic Indemnity |
2,691 |
429 |
16% |
97% |
130% |
Next Level Administrators |
2,456 |
675 |
28% |
82% |
111% |
CompWest Insurance Company |
2,427 |
429 |
18% |
82% |
110% |
Benchmark Insurance Company |
2,156 |
329 |
15% |
101% |
135% |
CNA Insurance |
1,665 |
255 |
15% |
90% |
120% |
Guard Insurance Group |
1,490 |
295 |
20% |
74% |
99% |
Omaha National Group |
1,094 |
278 |
25% |
82% |
110% |
Midwest Insurance |
1,072 |
173 |
16% |
87% |
117% |
Enstar Group |
681 |
223 |
33% |
72% |
97% |
Protective Insurance |
673 |
117 |
17% |
85% |
114% |
Church Mutual Insurance Company |
506 |
91 |
18% |
85% |
114% |
Mitsui Sumitomo Insurance |
497 |
119 |
24% |
95% |
128% |
Hanover Insurance Company |
437 |
109 |
25% |
75% |
101% |
Berkley Net Underwriters, LLC |
424 |
111 |
26% |
74% |
100% |
Packard Claims Administration |
313 |
73 |
23% |
87% |
116% |
Nordstrom Workers' Compensation |
259 |
59 |
23% |
81% |
109% |
National Liability and Fire Insurance Company |
228 |
38 |
17% |
76% |
102% |
Berkley Specialty Underwriting Managers |
184 |
50 |
27% |
87% |
117% |
Tokio Marine Management |
138 |
61 |
44% |
70% |
93% |
Constitution State Services |
128 |
21 |
16% |
95% |
127% |
CPT 99214: Claims Administrators - Lowest Reimbursements Rates
Below we list the 21 claims administrators that reimbursed providers the lowest amounts for CPT 99214. All of these claims administrators:
- Received 100 or more bills with CPT 99214, and
- Cumulatively paid less than the Medicare reimbursement rate for CPT 99214
Claims Administrator |
Count: Bills With CPT 99214 |
Count: CPT 99214 Denied |
CPT 99214 Denial % |
% of OMFS Rate Paid |
% of Medicare Rate Paid |
AmTrust North America |
9,420 |
1,137 |
12% |
69% |
93% |
Insurance Company of the West |
6,961 |
1,300 |
19% |
73% |
99% |
The Zenith |
5,478 |
498 |
9% |
71% |
96% |
The Hartford |
5,078 |
579 |
11% |
72% |
96% |
Pacific Compensation Insurance Company |
2,902 |
443 |
15% |
70% |
94% |
Farmers Insurance |
1,980 |
296 |
15% |
70% |
93% |
Guard Insurance Group |
1,490 |
295 |
20% |
74% |
99% |
Marriott Claims Service Corp |
1,276 |
33 |
3% |
70% |
94% |
City of San Diego (CA) |
1,184 |
26 |
2% |
59% |
79% |
Risico Claims Management, Inc. |
1,062 |
12 |
1% |
68% |
92% |
County of Riverside (CA) |
700 |
29 |
4% |
72% |
97% |
Enstar Group |
681 |
223 |
33% |
72% |
97% |
Sempra Energy Employee Care Services |
680 |
32 |
5% |
71% |
95% |
Fresno Unified School District (CA) |
386 |
0 |
0% |
52% |
69% |
Contra Costa County Risk Management (CA) |
272 |
12 |
4% |
70% |
94% |
Nationwide Insurance Companies |
228 |
18 |
8% |
65% |
88% |
CopperPoint Mutual |
193 |
12 |
6% |
61% |
82% |
Contra Costa County Schools Insurance Group (CA) |
171 |
2 |
1% |
62% |
84% |
Tokio Marine Management |
138 |
61 |
44% |
70% |
93% |
Nationwide Agribusiness Companies |
135 |
6 |
4% |
64% |
86% |
Brotherhood Mutual Insurance |
130 |
8 |
6% |
72% |
97% |
CPT 99214 Data: All Claims Administrators 2022
Below we list all 131 claims administrators to which daisyBill doctors reported CPT 99214 one hundred or more times in 2022.
For example, Employers Insurance denied payment for CPT 99214 36% of the time in 2022. We find it difficult to imagine that doctors billed CPT 99214 erroneously 36% of the time. We find it just as difficult to imagine that Employers’ overall reimbursement rates (just 109% of Medicare rates) represent reasonable compensation for the levels of E/M service delivered.
Remember: always submit Second Review appeals for improper denials or adjustments — it can save your practice literally millions.
Note: daisyBill analytics updates these totals daily, based on bill entry date of service and receipt of electronic EORs. Accordingly, data may have changed slightly compared to our recent breakdowns of E/M reimbursement rates by the State Compensation Insurance Fund (SCIF) and The Zenith.
Claims Administrator |
Count: Bills With CPT 99214 |
Count: CPT 99214 Denied |
CPT 99214 Denial % |
% of OMFS Rate Paid |
% of Medicare Rate Paid |
Sedgwick Claims Management Services |
78,691 |
7,582 |
10% |
87% |
116% |
State Compensation Insurance Fund (CA) |
32,487 |
2,595 |
8% |
75% |
101% |
Gallagher Bassett |
25,701 |
4,300 |
17% |
80% |
107% |
Intercare Holdings Insurance, Inc. |
22,345 |
1,228 |
6% |
87% |
116% |
Zurich Insurance North America |
15,586 |
1,581 |
10% |
79% |
107% |
CorVel |
15,272 |
1,739 |
11% |
80% |
107% |
ESIS, Inc. |
14,260 |
1,354 |
10% |
81% |
108% |
Liberty Mutual Insurance |
12,767 |
1,493 |
12% |
78% |
105% |
Berkshire Hathaway Homestate Companies |
11,574 |
1,109 |
10% |
84% |
113% |
Travelers |
11,257 |
1,555 |
14% |
102% |
137% |
Broadspire |
9,792 |
437 |
5% |
82% |
110% |
AmTrust North America |
9,420 |
1,137 |
12% |
69% |
93% |
Cannon Cochran Management Services Inc. |
8,800 |
805 |
9% |
93% |
125% |
Athens Administrators |
8,276 |
297 |
4% |
85% |
114% |
Insurance Company of the West |
6,961 |
1,300 |
19% |
73% |
99% |
Tristar Risk Management |
6,104 |
195 |
3% |
79% |
106% |
Keenan & Associates |
6,015 |
253 |
4% |
79% |
106% |
The Zenith |
5,478 |
498 |
9% |
71% |
96% |
The Hartford |
5,078 |
579 |
11% |
72% |
96% |
Employers Compensation Insurance Company |
4,130 |
1,488 |
36% |
81% |
109% |
Adminsure, Inc. |
3,842 |
158 |
4% |
90% |
120% |
Helmsman Management Services |
3,778 |
492 |
13% |
76% |
102% |
Los Angeles County Metropolitan Transit Authority (CA) |
3,581 |
31 |
1% |
84% |
112% |
Sentry Insurance |
3,493 |
287 |
8% |
88% |
118% |
LWP Claims Solutions |
2,947 |
71 |
2% |
90% |
121% |
Pacific Compensation Insurance Company |
2,902 |
443 |
15% |
70% |
94% |
City of Los Angeles (CA) |
2,857 |
260 |
9% |
78% |
105% |
Republic Indemnity |
2,691 |
429 |
16% |
97% |
130% |
Acclamation Insurance Management Services |
2,635 |
88 |
3% |
81% |
109% |
Chubb Group of Insurance Companies |
2,487 |
259 |
10% |
86% |
115% |
Next Level Administrators |
2,456 |
675 |
28% |
82% |
111% |
CompWest Insurance Company |
2,427 |
429 |
18% |
82% |
110% |
Benchmark Insurance Company |
2,156 |
329 |
15% |
101% |
135% |
Pacific Claims Management |
2,139 |
47 |
2% |
89% |
119% |
Preferred Employers Insurance Company |
2,129 |
258 |
12% |
87% |
117% |
Farmers Insurance |
1,980 |
296 |
15% |
70% |
93% |
American Claims Management, Inc |
1,750 |
189 |
11% |
101% |
136% |
CNA Insurance |
1,665 |
255 |
15% |
90% |
120% |
Nassco / General Dynamics |
1,564 |
79 |
5% |
87% |
117% |
Guard Insurance Group |
1,490 |
295 |
20% |
74% |
99% |
County of Santa Clara (CA) |
1,458 |
37 |
3% |
99% |
132% |
Elite Claims Management |
1,334 |
126 |
9% |
78% |
104% |
Affirmative |
1,312 |
10 |
1% |
102% |
138% |
Albertsons / Safeway / Vons |
1,289 |
152 |
12% |
104% |
140% |
Alaska National Insurance |
1,282 |
184 |
14% |
87% |
116% |
Marriott Claims Service Corp |
1,276 |
33 |
3% |
70% |
94% |
Beta Healthcare Group Risk Management Authority |
1,240 |
113 |
9% |
86% |
116% |
City of San Diego (CA) |
1,184 |
26 |
2% |
59% |
79% |
City and County of San Francisco (CA) |
1,119 |
24 |
2% |
101% |
136% |
Omaha National Group |
1,094 |
278 |
25% |
82% |
110% |
California Insurance Guarantee Association |
1,089 |
21 |
2% |
77% |
103% |
AmeriTrust Group, Inc. |
1,074 |
22 |
2% |
105% |
141% |
Midwest Insurance |
1,072 |
173 |
16% |
87% |
117% |
Risico Claims Management, Inc. |
1,062 |
12 |
1% |
68% |
92% |
County of San Diego (CA) |
947 |
17 |
2% |
94% |
126% |
Strategic Comp |
821 |
88 |
11% |
98% |
131% |
Cottingham & Butler Claim Services, Inc. |
784 |
46 |
6% |
90% |
120% |
Crum & Forster |
769 |
77 |
10% |
78% |
105% |
Self-Insured Schools of California (CA) |
750 |
28 |
4% |
96% |
129% |
Markel First Comp Insurance |
721 |
106 |
15% |
83% |
111% |
AIG Claims, Inc. |
714 |
92 |
13% |
85% |
114% |
PMA Companies |
709 |
15 |
2% |
80% |
107% |
County of Riverside (CA) |
700 |
29 |
4% |
72% |
97% |
City of Los Angeles Department of Water and Power (CA) |
683 |
63 |
9% |
75% |
100% |
Enstar Group |
681 |
223 |
33% |
72% |
97% |
Sempra Energy Employee Care Services |
680 |
32 |
5% |
71% |
95% |
Protective Insurance |
673 |
117 |
17% |
85% |
114% |
County of San Bernardino (CA) |
671 |
17 |
3% |
79% |
106% |
Matrix Absence Management |
602 |
10 |
2% |
81% |
109% |
American Equity Underwriters |
598 |
41 |
7% |
88% |
118% |
Allianz |
593 |
61 |
10% |
85% |
114% |
WCF Insurance |
591 |
53 |
9% |
95% |
127% |
Sutter Health |
549 |
39 |
7% |
89% |
120% |
Pegasus Risk Management Services |
544 |
1 |
0% |
95% |
127% |
Church Mutual Insurance Company |
506 |
91 |
18% |
85% |
114% |
Mitsui Sumitomo Insurance |
497 |
119 |
24% |
95% |
128% |
GuideOne Insurance |
482 |
50 |
10% |
89% |
120% |
Innovative Claim Solutions, Inc. |
482 |
4 |
1% |
97% |
130% |
National Interstate Insurance |
454 |
20 |
4% |
101% |
135% |
Hanover Insurance Company |
437 |
109 |
25% |
75% |
101% |
Applied Underwriters |
431 |
64 |
15% |
80% |
107% |
Berkley Net Underwriters, LLC |
424 |
111 |
26% |
74% |
100% |
Pacific Gas & Electric |
408 |
31 |
8% |
83% |
112% |
County of Sacramento (CA) |
397 |
4 |
1% |
100% |
135% |
Uninsured Employers Benefits Trust Fund N. CA |
391 |
0 |
0% |
96% |
128% |
Fresno Unified School District (CA) |
386 |
0 |
0% |
52% |
69% |
Tribal First |
383 |
2 |
1% |
90% |
121% |
Charles Taylor TPA |
380 |
13 |
3% |
102% |
136% |
Disneyland Resorts California |
348 |
5 |
1% |
101% |
135% |
JT2 Integrated Resources |
336 |
0 |
0% |
87% |
117% |
Packard Claims Administration |
313 |
73 |
23% |
87% |
116% |
Schools Insurance Authority (CA) |
303 |
38 |
13% |
88% |
119% |
None |
293 |
10 |
3% |
86% |
115% |
United Heartland |
276 |
36 |
13% |
78% |
105% |
Contra Costa County Risk Management (CA) |
272 |
12 |
4% |
70% |
94% |
Garden Grove Unified School District (CA) |
261 |
0 |
0% |
95% |
127% |
Nordstrom Workers' Compensation |
259 |
59 |
23% |
81% |
109% |
Intact Insurance Specialty Solutions |
233 |
21 |
9% |
78% |
105% |
Creative Risk Solutions |
233 |
0 |
0% |
98% |
132% |
Nationwide Insurance Companies |
228 |
18 |
8% |
65% |
88% |
National Liability and Fire Insurance Company |
228 |
38 |
17% |
76% |
102% |
Workers' Compensation Administrators, LLC |
222 |
1 |
1% |
95% |
127% |
ClaimQuest, Inc. |
218 |
8 |
4% |
90% |
121% |
Contract Claims Services Inc. |
214 |
4 |
2% |
85% |
114% |
Southern California Edison |
210 |
19 |
9% |
92% |
124% |
CopperPoint Mutual |
193 |
12 |
6% |
61% |
82% |
QBE North American |
190 |
17 |
9% |
92% |
123% |
City of Santa Monica (CA) |
188 |
1 |
1% |
88% |
118% |
Berkley Specialty Underwriting Managers |
184 |
50 |
27% |
87% |
117% |
City of Torrance (CA) |
176 |
10 |
6% |
78% |
105% |
Trindel Insurance Fund |
175 |
2 |
1% |
87% |
117% |
Contra Costa County Schools Insurance Group (CA) |
171 |
2 |
1% |
62% |
84% |
Gallo Wine Claims |
167 |
1 |
1% |
94% |
127% |
Hazelrigg Claims Management Services |
164 |
2 |
1% |
84% |
113% |
Association of California Water Agencies JPIA |
149 |
0 |
0% |
77% |
103% |
Salus |
146 |
1 |
1% |
104% |
139% |
Department of Labor |
141 |
18 |
13% |
109% |
146% |
Midwestern Insurance Alliance |
139 |
7 |
5% |
98% |
132% |
Tokio Marine Management |
138 |
61 |
44% |
70% |
93% |
Nationwide Agribusiness Companies |
135 |
6 |
4% |
64% |
86% |
Brotherhood Mutual Insurance |
130 |
8 |
6% |
72% |
97% |
City of San Jose (CA) |
130 |
1 |
1% |
76% |
102% |
Municipal Pooling Authority (CA) |
129 |
3 |
2% |
80% |
108% |
Constitution State Services |
128 |
21 |
16% |
95% |
127% |
Workers Compensation Fund (Utah) |
123 |
9 |
7% |
88% |
119% |
City of Riverside (CA) |
118 |
0 |
0% |
90% |
121% |
ARGO - Argonaut Insurance Company |
115 |
14 |
12% |
77% |
104% |
City of Sacramento (CA) |
106 |
1 |
1% |
78% |
105% |
City of Burbank (CA) |
106 |
1 |
1% |
85% |
114% |
Finish Line Self Insurance Group |
103 |
6 |
6% |
74% |
100% |
Murphy and Beane |
103 |
7 |
7% |
88% |
119% |
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