- DWC
Topic covered in this section:
The basics
Bill appeal/reconsideration
About the basics
Q: Are medical providers and health care facilities required to submit medical treatment bills electronically?
A: No. Electronic bill submission is optional for the medical provider or facility.
Q: Are claims administrators required to accept electronic medical treatment bills?
A:Yes, claims administrators have been required to accept electronic medical treatment bills since the regulations became effective Oct. 18, 2012. Electronic billing is optional for the provider, but claims administrator acceptance of electronic bills is mandatory.
Q: I am a QME. Can I electronically submit my bill for a medical-legal evaluation and be paid within 15 days?
A:No. Electronic billing is allowed for medical treatment bills, not for medical-legal bills. Medical-legal bills should be submitted on paper and must be paid within 60 days of receipt of required reports and documents, unless the claims administrator contests liability within the 60 day period.
Q: If the provider or facility chooses to use e-billing to submit medical treatment bills, what must the provider or facility do?
A: Adhere to the specifications in the Medical Billing and Payment Guide and the Companion Guide and the regulations at title 8, California Code of Regulations sections 9792.5.0 – 9792.5.3. A medical provider or facility that chooses to submit bills electronically must also be able to receive an electronic response from the claims administrators. This includes electronic acknowledgements and electronic remittance advice.
Q: Does the medical provider or facility have to accept Electronic Funds Transfer (EFT) to participate in e-billing?
A: No, use of EFT is optional and not a pre-condition for e-billing.
Q: Is there a time limit to submit a medical bill?
A: Yes. There are different time requirements for submitting a bill (12 months, 180 days, or 30 days) depending on the type of service and other factors as set forth in the California Labor Code.
For services rendered, or inpatient discharges, on or after January 1, 2017, there is a statutory requirement that medical bills be submitted within 12 months of the date of service, or within 12 months of the date of discharge for an inpatient bill. (California Labor Code section 4603.2.)
Effective January 1, 2018, California Labor Code section 4610 was revised to provide a shorter time for submitting specified bills. Effective January 1, 2018, bills for services that are exempt from prospective review under Labor Code section 4610, subdivision (b), must be submitted within 30 days of the date of service. (Labor Code section 4610, subdivision (d) (1).) However, for emergency services rendered in a general acute care hospital, the bill must be submitted within 180 days. (Labor Code section 4610, subdivision (d) (2).)
To gain a full understanding of the statutory provisions on timely bill submission, review the language of section 4610, in conjunction with section 4603.2.
Q: When will the provider or facility be paid if the treatment bill is submitted using e-billing?
A: Uncontested portions of the bill must be paid within 15 working days of receipt of the bill.
Q: How do the electronic billing regulations affect claims administrators?
A: All claims administrators must accept electronic submission of medical treatment bills. The claims administrator may establish its own in-house capacity to handle electronic medical bills or may contract with a vendor to provide electronic bill handling services. The claims administrator must send the provider electronic acknowledgments and remittance advice (explanation of review).
Q: What rules are applicable to electronic billing and bill response?
A: Theelectronic billingrules and rules for handling the electronic bills are contained in the following documents:
- Medical Billing and Payment Guide
- Electronic Medical Billing and Payment Companion Guide
- Regulations at title 8, CCR sections 9792.5.0 - 9792.5.3
- Documents incorporated by reference into the guides and rules (for example the ASC X12 Technical Reports Type 3 and the National Council on Prescription Drug Programs Implementation Guides.)
Q: Where can a member of the public send suggestions for changes to the electronic billing rules/guides?
A: Please send your suggestion to[email protected].
Bill appeal/reconsideration
Q: If a provider disagrees with the amount that was paid on the bill, how can the provider request the claims administrator to reconsider the bill?
A: After an Explanation of Review (EOR) is received on an original bill submission, a health care provider, health care facility, or billing agent/assignee that disputes the amount paid may submit an appeal/reconsideration/request for second review to the claims administrator within 90 days of service of the explanation of review. For electronic billing, the EOR is the ASC X12N/005010X221 Health Care Claim Payment / Advice (835). The request for second review must conform to the requirements of the Division of Workers’ Compensation Medical Billing and Payment Guide, the Electronic Medical Billing and Payment Companion Guide, and regulations at title 8, California Code of Regulationssection 9792.5.4et seq. You may access the most recent guides and regulations on the DWC e-billing webpage. If the dispute is the amount of payment and the health care provider, health care facility, or billing agent/assignee does not request a second review within 90 days of the service of the explanation of review, the bill shall be deemed satisfied and neither the employer nor the employee shall be liable for any further payment.
Q: If the provider still disagrees with the amount paid after the second review, can the provider submit another appeal/reconsideration request to the claims administrator?
A: No. If the only dispute is the amount paid on the bill, the provider should not request another review with the claims administrator, but must seek independent bill review.
Q: Is there a time limit for seeking independent bill review?
A:Yes. After a health care provider, health care facility, or billing agent/assignee submits a request for second review, the claims administrator will review the bill and issue an EOR which is the final written determination by the claims administrator on the bill. After the EOR is received on the second bill review submission, a health care provider, health care facility, or billing agent/assignee that still disputes the amount paid may submit a request for independent bill review within 30 days of service of the EOR. The request for independent bill review must conform to the requirements of title 8, California Code of Regulationssection 9792.5.4et seq. If the health care provider, health care facility, or billing agent/assignee fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final.
Q: How can I find out the procedures for seeking independent bill review?
A:You can find more information onindependent bill reviewon the DWC website.
October 2022
