Cal. Code Regs. Tit. 8, § 9792.5.5 - Second Review of Medical Treatment Bill or Medical-Legal Bill
(a) If the provider
disputes the amount of payment made by the claims administrator on a bill for
medical treatment services or goods rendered on or after January 1, 2013,
submitted pursuant to Labor Code section
4603.2, or
Labor Code section
4603.4, or bill
for medical-legal expenses incurred on or after January 1, 2013, submitted
pursuant to Labor Code section
4622, the
provider may request the claims administrator to conduct a second review of the
bill.
(b) The second review must be
requested within 90 days of:
(1) The date of
service of the explanation of review provided by a claims administrator in
conjunction with the payment, adjustment, or denial of the initially submitted
bill, if a proof of service accompanies the explanation of review.
(A) The date of receipt of the explanation of
review by the provider is deemed the date of service, if a proof of service
does not accompany the explanation of review and the claims administrator has
documentation of receipt.
(B) If
the explanation of review is sent by mail and if in the absence of a proof of
service or documentation of receipt, the date of service is deemed to be five
(5) calendar days after the date of the United States postmark stamped on the
envelope in which the explanation of review was mailed.
(2) The date of service of an order of the
Workers' Compensation Appeal Board resolving any threshold issue that would
preclude a provider's right to receive compensation for the submitted
bill.
(c) The request for
second review shall be made as follows:
(1)
For a non-electronic medical treatment bill, the second review shall be
requested on either:
(A) The initially
reviewed bill submitted on a CMS 1500 or UB04, as modified by this subdivision.
The second review bill shall be marked using the National Uniform Billing
Committee (NUBC) Condition Code Qualifier "BG" followed by NUBC Condition Code
"W3" in the field designated for that information to indicate a request for
second review, or, 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, or for
the NCPDP WC/PC Claim Form, the words "Request for Second Review" may be
written on the form.
(B) The
Request for Second Bill Review form, DWC Form SBR-1, set forth at section
9792.5.6. The DWC Form SBR-1 shall
be the first page of the request for second review submitted by the
provider.
(2) For an
electronic medical treatment bills for professional, institutional or dental
services, the request for second review shall be submitted on the correct
electronic standard format, utilizing the National Uniform Billing Committee
(NUBC) Condition Code Qualifier "BG" followed by NUBC Condition Code "W3" as
specified in the Division of Workers' Compensation Electronic Medical Billing
and Payment Companion Guide.
(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.
(4) For medical-legal bills,
the second review shall be requested on the Request for Second Bill Review
form, DWC Form SBR-1, set forth at section
9792.5.6.
(d) The request for second review shall
include:
(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:
(A) The date of the explanation of
review and the claim number or other unique identifying number provided on the
explanation of review.
(B) The item
and amount in dispute.
(C) The
additional payment requested and the reason therefor.
(D) 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.
(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.
(f) A claims administrator may respond to a
request for second bill review that does not comply with the requirements of
subdivision (d). Any response to such a request is not subject to the
requirements of subdivisions (g) and (h) of this section.
(g) Within 14 days of receipt of a request
for second review that complies with the requirements of subdivision (d), the
claims administrator shall respond to the provider with a final written
determination on each of the items or amounts in dispute by issuing an
explanation of review. The determination shall contain all the information that
is required to be set forth in an explanation of review under Labor Code
section
4603.3,
including an explanation of the time limit to raise any further objection
regarding the amount paid for services and how to obtain independent bill
review under Labor Code section
4603.6. The 14
day time limit for responding to a request for second review may be extended by
mutual written agreement between the provider and the claims
administrator.
(h) Based on the
results of the second review, payment of any balance no longer in dispute, or
payment of any additional amount determined to be payable, shall be made within
21 days of receipt of the request for second review. The 21-day time limit for
payment may be extended by mutual written agreement between the provider and
the claims administrator.
(i) If
the provider further contests the amount paid after receipt of the final
written determination following a second review, the provider shall request an
independent bill review pursuant to this Article.
Notes
2. New section refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 9-30-2013 order, including amendment of section, transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).
5. Editorial correction of subsections (b)(1)(A)-(B) (Register 2014, No. 9).
Note: Authority cited: Sections 133, 4603.6, 5307.3 and 5307.6, Labor Code. Reference: Sections 4060, 4061, 4061.5, 4062, 4600, 4603.2, 4603.3, 4603.4, 4620, 4621, 4622, 4625, 4628 and 5307.6, Labor Code.
2. New section refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 9-30-2013 order, including amendment of section, transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).
5. Editorial correction of subsections (b)(1)(A)-(B) (Register 2014, No. 9).
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