From our provider RBRVS webinar yesterday we gathered there are some questions out there about what the components are for a compliant second review submitted on paper. As reminder, second reviews replaced the appeals process as of 1/1/13. Prior to 1/1/13 work comp bills could be appealed indefinitely although at some point you were likely wasting your breath.
In the post 1/1/13 world you can’t “appeal” but you can request second review. Should you not request a timely second review for a payment dispute “ the bill shall be deemed satisfied and neither the claims administrator nor the employee shall be liable for any further payment.” (§ 9792.5.5).
To compliantly submit a second review send:
A properly (and completely) filled out DWC Form SBR-1. For med-legal bills the request for second review must be on the DWC Form SBR-1
A copy of the original bill with the appropriate modification indicating a second review (“BGW3” in box 10d on a CMS 1500 and the original bill ID number as issued by the claims administrator from the EOR in box 22 under “Original Ref No”) and include supporting documentation with the following:
- The date of the explanation of review
- The claim number or other unique EOR identifier provided on the explanation of review.
- The item(s) and amount(s) in dispute.
- The reason additional payment is being requested (i.e. short paid, not paid per contract, not a bundled code etc.)
- The additional information provided in response to a request in the first explanation of review or any other additional information provided in support of the additional payment requested.
AND submit it within 90 days of:
The date of service of the explanation of review provided by a claims administrator if a proof of service accompanies the explanation of review.
The date of receipt of the explanation of review by the provider, if a proof of service does not accompany the explanation of review.
The claims administrator has 14 days from receipt of your second review to issue a determination. In the case your second review is not successful, Independent Bill Review (IBR) is your only recourse.
DaisyBill Pro Tip: DaisyBill tracks bills for you so you review bills as soon as they are paid to determine if a second review is required. If so, you just enter the reason for additional payment and click submit. We take care of the rest!
For more information on Second Bill Reviews, visit the DaisyBill Webinar Library:
Read More About Second Reviews:
- Second Bill Reviews for Work Comp: Claims Admin Mistakes
- Second Bill Reviews in 500 Words or Less
- Correct e-Bill Processing, Part II: Second Bill Review
Originally published on Petal to the Metal and migrated to this blog upon the merger of the two blogs.
Edited 11-9-15 to update links