Today, we explain the COMPLIANT protocol for California providers to dispute the noncompliant denials that Zurich recently issued, and that were based on its completely noncompliant application of the Labor Code. As a reminder, we advise that providers ignore Zurich’s subsequent, and also incorrect, directions for appealing these noncompliant denials.

As opposed to Zurich’s incorrect directions, the appeal directions below preserve providers’ rights with respect to further recourse to collect the denied reimbursements, such as Independent Bill Reviews (IBRs) and liens. Following Zurich’s incorrect appeal instructions will leave providers unpaid and with no options to receive payment.

Claims administrators (aka ‘payers’ or ‘carriers’ or ‘insurers’) know that the strict deadlines and daunting complexity of the California appeals process will prevent many providers from submitting these Second Review appeals. Zurich is counting on the inability of the vast majority of providers to marshall the necessary resources to send hundreds of timely and compliant Second Review appeals.

In the coming weeks, we’ll be further highlighting the many ways in which claims administrators increase their profits by simply ignoring the regulatory complexities of California’s workers’ comp system (e.g. refusing to accept mandated electronic billing, failing to respond timely to bills, ignoring that penalties and interest are self-executing, reducing reimbursements below the OMFS, failing to send complete EORs, etc.).  

In California, when a claims administrator ignores California laws, there are no regulatory consequences imposed on the claims administrator; a provider’s only recourse is to stop treating injured workers. Claims administrators inflict systemic abuse on providers who treat injured workers, because there is simply no method for any provider to enforce California laws that apply to claims administrators.

Second Review Appeal Instructions

For DaisyBill clients: Use the appeal language provided below and follow these simple Instructions to Request for Second Review / Appeal: Denied Bill. DaisyBill technology knows the method the original bill was submitted and DaisyBill will submit the Second Review appeal compliantly. DaisyBillers, this process will take you 30 seconds! Start submitting those Zurich appeals.

Non DaisyBill clients: Follow the step-by-step instructions below to file a Second Review appeal in response to Zurich’s outrageous denials. Note: the instructions differ depending on whether the original bill was transmitted electronically or sent on paper, and also on the type of services that were originally billed.

Timing: Second Review Appeals Denied if Submitted After 90 Days

According to § 9792.5.5. Second Review of Medical Treatment Bill or Medical-Legal Bill, to dispute an incorrect reimbursement, the provider must submit a Second Review appeal to the claims administrator within 90 days of receipt of the Explanation of Review (EOR).  Below CCR § 9792.5.5. disallows reimbursement when a provider untimely submits a Second Review appeal:

(e) If the only dispute is the amount of payment and the provider does not request a second review within the timeframes set forth in subdivision (b), the bill shall be deemed satisfied and neither the claims administrator nor the employee shall be liable for any further payment.

Despite Zurich’s noncompliance, if a provider fails to submit a compliant and timely Second Review appeal, then Zurich owes no further reimbursement to the provider. 

Second Review Appeal Dispute Reason

When submitting the Second Review appeal, providers are required to furnish a “Reason for Requesting Second Bill Review.”  For the incorrectly denied Zurich bills, DaisyBill suggests the following reason:

Bill was incorrectly denied for failing to meet a 30-day deadline that, in fact, does not apply and is, furthermore, based on mistaken readings and conflations of Labor Codes 4610 and 4603.2.

Per Labor Code 4603.2(b): Effective for services provided on or after January 1, 2017, the request for payment with an itemization of services provided and the charge for each service shall be submitted to the employer within 12 months of the date of service or within 12 months of the date of discharge for inpatient facility services. The administrative director shall adopt rules to implement the 12-month limitation period. The rules shall define circumstances that constitute good cause for an exception to the 12-month period, including provisions to address the circumstances of a nonoccupational injury or illness later found to be a compensable injury or illness. The request for payment is barred unless timely submitted. [emphasis added]

Format and Delivery: Second Review Appeals Different for Electronic, Non-Electronic, Pharmacy, and Med-Legal

Per CCR § 9792.5.5, the allowed format and delivery of the Second Review appeal differs depending on type of bill and original method of submission.

Format and Delivery: Electronically Transmitted Original Bills for Professional, Institutional or Dental Services

Per CCR § 9792.5.5.(c)(2), providers of professional, institutional, or dental services whose original bill was submitted electronically must also submit Second Review appeals electronically, with these specific instructions:

• Utilizing the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3”

Format and Delivery: Electronically Transmitted Original Pharmacy Bills

Per CCR § 9792.5.5.(c)(3): “For an electronic pharmacy bill that used either the NCPDP Telecommunications D.0 or the NCPDP Batch Standard Implementation Guide 1.2, the method for identifying a request for second review may be addressed in the trading partner agreement, or the second review may be requested on the DWC Form SBR-1.”

Format and Delivery: Non-Electronically Submitted Original Bills for Treatment

Per CCR § 9792.5.5.(c)(1), for original bills for treatment that were submitted non-electronically, the Second Review appeal may be submitted either on a Request for Second Bill Review form, DWC Form SBR-1, or on a modified CMS 1500 or UB04.

If on DWC Form SBR-1:

• The DWC Form SBR-1 must be the first page of the Request for Second Review

If on a modified Original Bill, the Second Review bill must be marked:

• For a CMS 1500 or UB04, using the National Uniform Billing Committee (NUBC) Condition Code Qualifier “BG” followed by NUBC Condition Code “W3”
• For the ADA Dental Claim Form 2006, or ADA Dental Claim Form (2012), the words “Request for Second Review” will be marked in Field 1
• For the NCPDP WC/PC Claim Form, the words “Request for Second Review” may be written on the form

Format and Delivery: Medical-Legal Original Bills

Per CCR § 9792.5.5.(c)(4), medical-legal bills must be appealed on DWC Form SBR-1.

Information Requirements: All Forms, Formats, and Types

Whatever form or format is used, per CCR § 9792.5.5.(d), the following information must always be included:

1. The original dates of service and the same itemized services rendered as the original bill. No new dates of service or additional billing codes may be included.
2. In addition to the bill as modified in this subdivision, the second review request shall include, as applicable, the following:

1. The date of the explanation of review and the claim number or other unique identifying number provided on the explanation of review.
2. The item and amount in dispute.
3. The additional payment requested and the reason therefor.
4. 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.

Second Review Appeal Resources

DaisyBill clients know that Second Review appeals work. To date our clients have submitted over 700,000 Second Review appeals and collected an additional $53,000,0000 from disputing incorrect reimbursements.

Below is a partial list of resources published by DaisyBill about Second Review appeals.

• Webinar: Second Review Strategy Kit, Part I
• Webinar: Second Review Strategy Kit, Part II
• FAQ: CA Disputed Payment Appeal Process
• FAQ: Reasons to File a Request for Second Review
• FAQ: Second Review Compliance
• Article: $47 Million and Counting: Second Review Saves Provider Revenue
• Article: Second Review Loopholes Hurt Providers
• Article: No Response to Second Review Request? A Lien Is the Only Option
• Article: IBR Appeal Analysis for CPTs 99358 & 99359
• Complete list of blog articles about Second Review appeals

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