Audit Complaints: 18,160 Filed for SCIF Non-Compliance

Audit Complaints: 18,160 Filed for SCIF Non-Compliance

Using data generated by over 48,000 electronic bills sent by our provider clients in 2022, daisyBill demonstrates consistent non-compliance with California e-billing regulations by the State Compensation Insurance Fund (SCIF).

Below is the message and formal Audit Complaint daisyBill submitted to the Division of Workers’ Compensation (DWC), outlining systemic violations as follows:

  • SCIF failed to timely send electronic EORs (X12 835) to California providers, as mandated by California law, in response to 16,363 (34%) e-bill submissions
  • SCIF failed entirely to send electronic EORs (X12 835) to California providers, as mandated by California law, in response to 1,797 (4%) e-bill submissions

We urge the DWC to enforce California workers’ comp billing and payment requirements, and impose appropriate consequences on SCIF for its consistent failure to comply. SCIF’s actions impose an unnecessary administrative burden on providers, and unjustly deprive providers of due reimbursement for treating injured workers.

SCIF: Ignoring CA Law

To: XXXXXXXX@dir.ca.gov

Subject: SCIF EDI Non-compliance: X12 835 Late - 16,363 & X12 835 Missing - 1,797


Below is an Audit Complaint reporting credible data that State Compensation Insurance Fund (SCIF) ignores California EDI requirements, as follows:

  1. SCIF failed to timely send electronic EORs (X12 835) to California providers as mandated by California law in response for 16,363 (34%) submissions
  2. As of 7/12/2022, SCIF failed to send electronic EORs (X12 835) to California providers as mandated by California law in response for 1,797 (4%) submissions

DWC Rule 7.1 requires the claims administrator to electronically send an EOR to the provider using the X12 835 EDI standard within 15 working days of receipt of an e-bill.

A provider's receipt of an electronic EOR (X12 835) is a critical component of electronic billing for the following three reasons:

  1. The electronic EOR closes the payment loop for a workers’ comp e-bill, and
  2. Automatically posts to the respective e-bill, thereby significantly reducing a provider's administrative burden of manually recording payment information to the respective e-bill, and
  3. Allows the gathering of important payment data about the claims administrator that heretofore was hidden in the paper EORs mailed to individual providers.

This Audit Complaint data represents California workers’ comp e-bills submitted to SCIF by daisyBill providers from January 1, 2022 through June 15, 2022.

Attached to this email are two separate CSV documents with credible data demonstrating the following:

#1 SCIF Electronic EOR (X12 835) Late - 16,363

For January 1, 2022 through June 15, 2022, this CSV lists 16,363 e-bills daisyBill providers submitted where SCIF failed to timely return a mandated electronic EOR to the provider in response to the e-bill. The attached CSV list includes the following columns:

  • Column L: [Bill] Transmission Date
  • Column V: EOR (835) Compliance Due Date
  • Column W: EOR (835)  - The dates in this column are AFTER the EOR (835) Compliance Due Date
  • Column AN: Patient Name
  • Column AO: Claim Number

#2 SCIF Electronic EOR (X12 835) Missing - 1,797

For January 1, 2022 through June 15, 2022, this CSV lists 1,797 e-bills daisyBill providers submitted where SCIF failed to return a mandated electronic EOR to the provider in response to the e-bill. The attached CSV list includes the following columns:

  • Column L: [Bill] Transmission Date
  • Column V: EOR (835) Compliance Due Date
  • Column W: EOR (835) Receipt Date - This column is BLANK because SCIF failed to send the provider an electronic EOR (835).
  • Column AN: Patient Name
  • Column AO: Claim Number

Audit Complaint Details

This Audit Complaint Data submitted to the DWC represents a credible complaint and credible information of claims handling violations. Per Title 8, California Code of Regulations section 10111.2(b)(10),(11), SCIF should be subject to audit penalties.

Noncompliance: Claims administrator failed to send an electronic Explanation of Review (EOR) in the mandated ASC X12N/005010X221A1 (835) format, despite the claims administrator sending a 277 Acknowledgement accepting the Original Bill / Second Review Appeal.

DWC Rule 7.1 requires the claims administrator to electronically send an EOR to the provider using the X12 835 EDI standard within 15 working days of receipt of an e-bill.

Per California DWC Medical Billing and Payment Guide 7.2, any electronically submitted bill determined to be completed, not paid, or objected to within the 15 working day period, shall be subject to audit penalties per Title 8, California Code of Regulations section 10111.2(b)(10),(11).


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.

LET’S TALK

How did you like the article ?

DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.