Prime Administrators, a Third-Party Administrator (TPA), has been blatantly non-compliant with California workers' comp billing and payment requirements for the last five years (and likely more).

California law requires all claims administrators to accept providers’ electronic bills (e-bills) for injured worker treatment.

Despite this California law, Prime Administrators, also known as Affirmative, has steadfastly refused to accept e-bills, drastically increasing billing friction and the time and administrative resources practices expend to treat injured workers.

As the daisyData below demonstrate, Prime failed to accept 29,432 bills electronically from 2020 to 2024. Furthermore, our billing data indicate that Prime Administrators takes, on average, over 30 working days to pay California providers rather than the 15 working days required in response to an e-bill.

Each e-bill violation is a significant inconvenience for providers—for whom non-compliance with bill submission requirements means immediate, automatic non-payment.

On behalf of our clients, daisyBill submitted a formal Audit Complaint reporting all 29,432 violations to the California Division of Workers’ Compensation (CA DWC).

We urge the CA DWC to impose appropriate consequences to protect providers, injured workers, and employers.

Prime Administrators/Affirmative: Openly Non-Compliant

Below are statistics for each year from 2020 to 2024, during which Prime Administrators depleted the time and resources of California practices. Providers could not submit any of the bills below electronically as e-bills despite the clear mandate established by California Law.

This lack of compliance is more than just an inconvenience.

California Labor Code Section 4603.4 authorizes the CA DWC to require all claims administrators to accept e-bills. The CA DWC Electronic Medical Billing and Payment Companion Guide dictates that claims administrators accept e-bills in the standard X12 837 format. If the claims administrator lacks the technology to do so, they may utilize a clearinghouse (as almost every claims administrator does).

So what is Prime Administrators’ excuse?

Below, our Claims Administrator and Network Directory data show that Prime/Affirmative did not accept a single e-bill in 2024. As a result, providers waited an average of over 30 working days for payment. In contrast, as of this writing, the average days to payment for all claims administrators in our system—the vast majority of which compliantly accept e-bills—is 9.1 working days.

Again, when providers fail to meet every e-billing requirement, the claims administrator may reject or deny the bill out of hand.

This double standard, in which providers must operate at 100% compliance at all times or face automatic consequences, exemplifies the imbalance in how the CA DWC enforces workers’ comp law.  

Our formal Audit Complaint to the CA DWC is below. We urge the agency to take appropriate action and demonstrate that California's law is binding.

Audit Complaint:

To: [redacted]@dir.ca.gov

Subject: Prime Administrators EDI Non-compliance: X12 837 e-Bill Not Accepted - 29,432

Hello [Redacted],

Below is an Audit Complaint reporting credible data that Prime Administrators (aka: Affirmative) ignores California law by failing to accept bills electronically in the X12 837 format.

Since October 2012, the acceptance of e-bills has been mandated in California. Prime Administrators has failed to accept bills electronically.

Prime Administrator's refusal to accept e-bills directly violates California law and inflicts a significant burden on California providers, forcing providers to email bills to Prime Administrators for payment.

In 2024, Prime Administrators failed to accept 11,702 (100%) e-bills (X12 837) from daisyBill providers as mandated by California law. Since 2020, Prime Administrators has failed to receive 29,432 e-bills from providers.

This Audit Complaint data represents California workers’ comp bills submitted to Prime Administrators by daisyBill providers from November 6, 2020 through December 31, 2024.

As the data below indicate, since 2020, Prime Administrators has failed to accept e-bills as California law requires. Further, the historical data suggests that Prime Administrators has made no effort to comply with California’s EDI requirement that a claims administrator accept bills electronically from providers.

Attached is a CSV list containing 29,432 bills providers submitted to Prime Administrators where Prime Administrators failed to accept the bill electronically in the X12 837 format. The attached CSV list includes the following columns:

• Column L: [Bill] Transmission Date
• Column H: Submission Method - This column is all ‘Email’ because Prime Administrators failed to accept e-bills.
• Column I: Clearinghouse - This column is BLANK because Prime Administrators failed to accept e-bills.
• Column AO: Patient Name
• Column AP: Claim Number

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