daisyBill contacted Sedgwick regarding e-bills for treatment rendered to employees of the County of Los Angeles (claims beginning with 5000 or ending in D), for which Sedgwick administers claims. From the first quarter of 2021 through the first quarter of 2022, Sedgwick failed to return electronic Explanations of Review (EORs) for 11,492 e-bills.

Sedgwick’s Vice President responded quickly, and pledged to work with LA County, as well as with Sedgwick’s bill review vendor, Medata, and Sedgwick’s clearinghouse, Data Dimensions (formerly WorkCompEDI), to solve the problem.

Within a day, daisyBill received word from Medata that the errors were due to a technical issue between Medata and Data Dimensions. Less than a week after daisyBill reached out to Sedgwick, the failure was repaired, and LA County resumed sending e-EORs.  

Sedgwick’s proactive handling of the LA County problem demonstrates how claims administrators should approach compliance to address technical failures.

Next week, daisyBill will contact Sedgwick about its failure to timely return e-EORs for other employers. Fingers crossed, Sedgwick will again take proper responsibility for meeting California e-billing requirements.

Claims Administrators: Responsible for Vendor Compliance

As we explain in this primer on electronic EORs, when providers bill electronically, the claims administrator must return the EOR electronically within 15 working days, in a format known as an X12 835 file.

Returning compliant, timely ‘835s’ closes the reimbursement loop and provides a verifiable record of the e-bill’s adjudication and payment.

But in most cases, claims administrators lack the technology to furnish 835s. For that reason, claims administrators use clearinghouses. Clearinghouses accept provider e-bills and return 835s on behalf of the claims administrator.

Claims administrators hire bill review vendors to adjudicate bills, and clearinghouses to help process those bills. But it remains the claims administrator’s legal responsibility to process and pay provider e-bills timely and compliantly, no matter what other entities the claims administrator chooses to involve.

Or, as the Division of Workers’ Compensation (DWC)’s e-billing guide puts it, “Entities or persons using agents [like bill review and clearinghouse vendors] are responsible for the acts or omissions of those agents…”

The Non-Compliance Alert for Sedgwick, which daisyBill appends to the Bill History for all affected bills in our system, is shown below (happy resolution included).

In early May, daisyBill contacted Sedgwick’s VP regarding 11,492 e-bills where the County failed to send daisyBill clients the mandated electronic EORs (X12 835s) for e-bills clients submitted the first quarter of 2021 through the first quarter 2022.

For more information, read How to e-Bill: 835 Electronic EORs.

For County of Los Angeles Unit D, Medata is the bill review and Data Dimensions is the designated clearinghouse.

To their immense credit, Sedgwick’s VP replied to daisyBill immediately and alerted daisyBill that they instructed Medata and Data Dimensions to address this EDI non-compliance. As a result of these efforts, daisyBill clients are now receiving timely electronic EORs (X12 835s) from County of Los Angeles Unit D.

The table below summarizes daisyBill’s persistence in monitoring the EDI non-compliance and making sure the entities responsible resolve the error.

🌼 As of now, daisyBillers do not need to take any action regarding this resolved EDI non-compliance. Once the clearinghouse noted above delivers the 835s to daisyBill, daisyBill will automatically post the 835s to your bills. Have a Flower Power Day!

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.

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