LWP Invalid 277 ACKs: False 'Claim Not Found' Rejects - 851 Audit Complaints

LWP Invalid 277 ACKs: False 'Claim Not Found' Rejects - 851 Audit Complaints

Third-Party Administrator (TPA) LWP Claims Solutions is in violation of California workers’ comp e-billing law. LWP’s persistent failure to honor state requirements places an undue burden on medical practices, and defeats the purpose of e-billing, which was designed to make workers’ comp more efficient and facilitate the treatment of injured workers.

Below, see the details of the latest batch of formal Audit Complaints daisyBill submitted to the Division of Workers’ Compensation, on behalf of our clients and all California providers who choose to treat injured workers.

LWP: Ignoring CA Law

To: XXXXXXXX@dir.ca.gov

Subject: #1 LWP Invalid 277 ACKs: False 'Claim Not Found' Rejects - 851 Audit Complaints


For California workers’ compensation EDI transactions the Division of Workers’ Compensation (DWC) issued a comprehensive Electronic Medical Billing and Payment Companion Guide that lists EDI requirements that providers and payers must follow.

LWP fails to adhere to 277 Acknowledgement (ACK) requirements mandated by the DWC.

EDI Noncompliance: For 1,750 e-bills, Data Dimensions (the clearinghouse vendor representing LWP) sent providers 851 invalid 277 ACKs. Each 277 ACK rejected an e-bill submitted for an LWP claim citing “Property Casualty Claim Number: Claim Not Found.”

daisyBill data indicates that 49% of the rejected e-bills are falsely rejected because LWP paid other bills for the same injury claim. LWP fails to coordinate with Data Dimensions to maintain a functional claims feed process. Previously accepted and processed e-bills should not be subsequently rejected with a 277 ACK indicating “Claim Not Found.”

Since Data Dimensions does not forward the rejected e-bills to LWP, this EDI noncompliance results in a significant administrative cost for providers as follows:

  • In addition to the cost incurred to submit the e-bill that Data Dimensions rejected, the provider incurs an additional cost to resend a duplicate paper bill to LWP.

Below we offer extensive evidence documenting how LWP and its clearinghouse act in tandem to ignore California EDI 277 Acknowledgement requirements, thereby preventing providers from submitting compliant e-bills for treatment provided to injured workers.

277 ACK - Noncompliant STC Rejection Explained

Per Chapter 9 Companion Guide Acknowledgments, when a provider transmits an e-bill to a payer (or the payer’s clearinghouse), within two working days of receipt of an e-bill, the payer must send the provider an ASC X12N/005010X214 Health Claim Acknowledgment (277) advising either the e-bill was accepted or rejected for payment adjudication.

  • This e-bill processing step, prior to adjudication, is to verify that the bill concerns an actual employment-related condition that has been reported to the employer and subsequently reported to the claims administrator. 

For the period 1/1/2022 through 7/31/2022, for 851 e-bills submitted to LWP, the clearinghouse Data Dimensions:

  1. Sent the provider a timely 277 Acknowledgment accepting the e-bill for processing with a Claim Status Category Code and Claim Status Code as follows:

  • A1 - The bill has been received.
  • 20 - Accepted for processing.

  1. Subsequently sent the provider an untimely 277 Acknowledgment rejecting the e-bill for processing with an A6 STC Claim Status Category Code and 629 Claim Status Code listed in Table A found below.

daisyBill data indicates that for (at least) 49% of the rejected e-bills, LWP is aware that an actual employment-related condition has been reported to LWP. The high rate of false 277 ACK rejections makes it impossible to send e-bills to LWP.

Table A: 277 ACK: Noncompliant Category-Code Rejecting e-Bills

277 ACK: STC Category-Code (Current)

277 STC Reject Description (Current)

Other Injury Bills Paid

Bill Count

% of Total

A6-629

Property Casualty Claim Number

No

899

51%

A6-629

Property Casualty Claim Number

Yes

851

49%

Grand Total

1750

100%

CSV: Invalid 277 ACKs - False 'Claim Not Found' Rejects - Attached is a CSV listing 851 e-bills daisyBill providers submitted to LWP where LWP failed to accept the e-bill sent in the X12 837 format. The table below indicates the relevant CSV columns demonstrating the following:

  1. Column O: 277 ACK Receipt Due Date - Two working days after Data Dimensions received e-bill,
  2. Columns P & Q: Receipt Date of the initial 277 ACK accepting the e-bill,
  3. Columns S & T: Receipt Date of the subsequent untimely 277 ACK rejecting the same e-bill,
  4. Columns U: STC Category-Code sent falsely rejecting the e-bill,
  5. Column AW: STC Reject Description, and
  6. Column BA: Indicates other bills paid for the same injury claim

Column O

277 Ack Receipt Due Date

2022-08-02

Column P

277 Ack: Receipt Date (First Accept/Reject)

2022-08-01

Column Q

277 Ack: Type (First Accept/Reject)

Accept

Column R

277 Ack: Category-Code (First Accept/Reject)

A1-20

Column S

277 Ack: Receipt Date (Current)

2022-08-08

Column T

277 Ack: Type (Current)

Reject

Column U

277 Ack: Category-Code (Current)

A6-629

Column AW

277 STC Reject Description

Property Casualty Claim Number

Column BA

Injury Bills Paid

Yes

Audit Complaint Details

This Audit Complaint Data submitted to the DWC represents a credible complaint and credible information of claims handling violations for 851 e-bills submitted to LWP by providers that treat injured workers.

Effective October 2012, DWC Rule 7.1 requires the claims administrator to accept workers’ comp e-bills from providers in the X12 837 format.

Noncompliance: Per Chapter 9 Companion Guide Acknowledgments, when a provider transmits an e-bill to a payer (or the payer’s clearinghouse), within two working days of receipt of an e-bill, the payer must send the provider an ASC X12N/005010X214 Health Claim Acknowledgment (277) to advising either the e-bill was accepted or rejected for payment adjudication.

While the claims administrator initially adhered to the above noted 277 ACK requirements, the claims administrator subsequently sent an untimely 277 ACK rejecting 851 e-bills submitted between 1/1/2022 and 7/31/2022.

Per Chapter 7 of the Medical Billing and Payment Guide, a clearinghouse may issue a rejected 277 Acknowledgement for the following seven reasons:

  1. Invalid form or format – indicate which form should be used.
  2. Missing Information – indicate specifically which information is missing by using the appropriate 277 Claim Status Category Code with the appropriate Claim Status Code.
  3. Invalid data – Indicate specifically which information is invalid by using the appropriate Claim Status Category Code with the appropriate Claim Status Code
  4. Missing attachments – indicate specifically which attachment(s) are missing.
  5. Missing required documentation – indicate specifically what documentation is missing.
  6. Injured worker’s claim of injury is denied.
  7. There is no coverage by the claims administrator.

CCR §10106.1(c)(3) instructs that the Audit Unit “shall review and compile complaints” that indicate a claims administrator is “failing to meet their obligations under Divisions 1 or 4 of the Labor Code or regulations of the Administrative Director.”

Pursuant to LAB §129, CCR §10106.1(c)(3) provides the DWC Audit Unit may target audit subjects based on: “...credible complaints and/or information received by the Division of Workers' Compensation that indicate possible claims handling violations, except that the Audit Unit will not target audit subjects based only on anonymous complaints unless the complaint(s) is supported by credible documentation.


daisyBill fights the good fight on behalf of workers’ comp providers. Reach out to see how we can help your practice obtain fast, correct reimbursement for treating injured workers.

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