How to Fill Out Providers Request for Second Bill Review

After a bill submitted by a provider is accepted by the claims administrator and the provider receives an Explanation of Review (EOR) or the claims administrator denies payment; providers retain the pick of requesting 2d Pecker Review (SBR) inside 90 days. This procedure allows providers to dispute the reimbursement corporeality made by the claims administrator "in conjunction with the payment, aligning, or denial of the initially submitted bill, if a proof of service accompanies the explanation of review" on a bill for medical handling services or goods rendered, nether California Code of Regulations  § 9792.five.5.

This article outlines what language to use when filing a Request for SBR for incorrectly denied or underpaid original medical bills and includes appropriate IBR decisions as supporting documentation.

Reason to File a Request for 2nd Review
Incorrect Denial	Correcting a Coding Mistake
	Automatically Authorized  Services Denied
	No Authorization
	PTP E/M Visit
	99358 Denied Every bit Not Reimbursable
Incorrect Reimbursement	Physical Medicine / Chiropractic / Acupuncture
	CCI Edit
	Due east / M Coding
	Network / PPOs Reductions

For more than information on Filing a Request for Second Review, delight review DaisyBill'south article on the Disputed Payment Entreatment Process  in California. To shop language for Request for 2nd Review reasons within DaisyBill software, please refer to the Second Bill Review Reasons  Help Article .

Correcting a Coding Error on a Bill

Fee Schedule	CPT Codes	Payable
Any	Whatever	Yes

If a provider determines that a beak was denied due to a coding error, DaisyBill advises filing a Second Review using the language and including the IBR decisions included in the following table as supporting documentation.

Even if the bill was submitted with errors and has not been denied withal, DaisyBill recommends requesting Second Review. There are processes for submitting corrected electronic and not-electronic original bills. However, both processes are unreliable. Exist sure to wait for the Explanation of Review (EOR) from the claims administrator before initiating the second review appeal.

NOTE : If you mistakenly left out a procedure code(s) or under-reported the number of units, simply submit an original bill ONLY for the missing process code(southward) or the additional units of service.

Theoretically, providers tin resubmit corrected bills. Instructions for doing so are located in the DWC Medical Billing and Payment Guide  for non-electronic bills, and the Electronic Billing and Payment Companion Guide  for electronic bills; notwithstanding, the guidelines for beak resubmission are contradictory and the provider may non know if the EOR has already been sent past the claims ambassador, which renders the corrected bill invalid. This option is far simpler and more than likely to result in correct payment. For more than detail, encounter our blog .

Attachment

Recommendation

Reason

Code Xxx was denied due to the following denial reason: XXX. The practice incorrectly submitted the original beak with Code Thirty. The right code for the service is XXX. Please reprocess this pecker using the correct Lawmaking Thirty.  Per CCR §9792.5.5 (d)(ane) when submitting a Second Review, "No new dates of service or additional billing codes may be included." Optional : Farther, Maximus IBR decisions have ruled that the protocol for correcting a candy nib is to submit a Second Review with the correction.

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Denial Incorrect: Automatically Authorized Services Denied

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Any	Whatever	Yes	This service requires prior dominance and none was identified

If a claims administrator denies payment for automatically authorized services, DaisyBill advises filing a Second Review using the language and including the IBR decisions included in the post-obit table as supporting documentation.

Unlike standard potency, the claims administrator has no input in determining the necessity or appropriateness of the treatment. The claims administrator cannot modify or deny automatically authorized treatment nor can authorization exist rescinded for whatever reason.

Notation: Even if the RFA, DLSR , or original beak is untimely submitted, the claims administrator must pay  for automatically authorized services rendered. While Labor Lawmaking § 4610  requires the provider to submit an RFA inside five days of treatment, and to submit the original nib within thirty days (for non-emergency treatment) or 180 days (for emergency treatment), failure to meet these deadlines is not grounds for non-payment.

For more data on appealing denial of automatically authorized services, review this web log mail service .

Attachment	Recommendation
Reason	The attached request for payment meets the requirements for authorization per Labor Lawmaking § 4610(b) which became effective for all dates of service on or later on 1/1/2018. Treatment and/or emergency services were provided and all required weather were met, as follows: Dates of injury as of January one, 2018 Inside thirty days of initial injury Body part or condition accepted as compensable Handling included in MTUS Treatment provided by an MPN or HCO member or a predesignated medico Treatment is not listed in subdivision (c) equally ineligible Pharmaceuticals Non-emergency inpatient / outpatient surgery Psychological treatment Domicile health care Imaging and radiology services, excluding ten-ray DME exceeding a combined total of $250 per the OMFS Electrodiagnostic medicine Any other services designated past Administrative Director Labor Code § 4610(b) makes no provision for non-payment for services authorized thereunder, whether or non the following documentation has been timely submitted: Request for payment within 30 days (for not-emergency treatment) or 180 days (for emergency handling) of the appointment the service DLSR 5021 class inside 5 days of the initial visit and evaluation Asking for Authorization within 5 days of the initial visit and evaluation
Supporting Documents	Whatever documentation that substantiates the treatment'southward eligibility for automatic authorization
	Sample letter (pdf)

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Denial Incorrect: No Authorization

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Whatsoever	Any	Yes	The billed service was not authorized by UR.

For incorrectly denied or underpaid original bills, DaisyBill advises filing a 2nd Review using the language and including the IBR decisions included in the following table as supporting documentation.

Attachment	Recommendation
Reason	UR authorized all billed services. Please reprocess this bill and result payment. Documented authorization submitted with original neb. The authority is included with this SBR-1 Grade. Optional: Fastened is a copy of an OVERTURN IBR Decision indicating this incorrect denial will be overturned when reviewed by IBR.

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Denial Incorrect: PTP Evaluation & Direction (E/1000) Visit

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Doctor Services	99213-99215	Yes	This service requires prior authority and none was identified.
	99203-99205

For incorrectly denied original bills, DaisyBill advises filing a Second Review using the linguistic communication and including the IBR decisions included in the following table as supporting documentation.

For assist determining the correct level of E/M lawmaking and documentation, read DaisyBill'southward Helpful Resource commodity on How to Determine the Correct Eastward/M Code .

Zipper	Recommendation
Reason	Evaluation and Management visits do not require prior authorization when performed by the designated Master Treating Doctor (PTP). Optional : Attached is a copy of an OVERTURN IBR conclusion indicates that this reimbursement volition be overturned when reviewed past IBR.

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Deprival Incorrect: PPO / Network Reduction Incorrectly Practical

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Any	Any	Yes	Reduction in accord with _____ Contract. This charge was adjusted to comply with the charge per unit and rules of the contract indicated.

Preferred Provider Organisation (PPO) and Medical Provider Network (MPN) contracts are rife with abuse, equally DaisyBill documents in the Discount Contracts weblog series . Insurance companies sometimes try to force lower reimbursement rates on providers by processing lower rates than those outlined in agreements with providers.  Providers should keep all disbelieve contracts on file to verify that discounts are correctly applied and be prepare to appeal whatsoever errors.

For incorrectly denied bills citing a PPO or Network disbelieve/reduction, DaisyBill advises filing a 2nd Review using the language and including the IBR determination included in the post-obit table as supporting documentation.

Attachment	Recommendation
Reason	An wrong PPO disbelieve charge per unit was used to summate reimbursement. Contracted rate is ___% Appropriately, please review this nib for additional payment per OMFS. Optional : Attached is a copy of an OVERTURN IBR Conclusion indicating this incorrect PPO disbelieve will be overturned when reviewed past IBR.

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Denial Incorrect: 99358 Denied Every bit Not Reimbursable

Fee Schedule	CPT Codes	Payable	EOR Deprival Reason
Physician Services	99358	Yes	Does not fall under the fee schedule guidelines of a reimbursable report.
	99359 (add-on lawmaking)

When a medical bill is incorrectly denied reimbursement for CPT Codes 99358 or 99359, DaisyBill advises filing a Second Review using the language included in the following tabular array.

For more information on codes 99358 and 99359, read DaisyBill's five Bespeak Checklist for CPT Codes 99358 and 99359  blog mail .

Attachment	Recommendation
Reason	The AMA CPT Definition of 99358 is as follows: Prolonged evaluation and management service before and/or after direct patient care; first hour. For dates of service on or after 3/1/2017 RBRVS indicate 99358 with a payment status lawmaking of "A" payable. Please pay accordingly.

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Wrong Reimbursement: Concrete Medicine / Chiropractic / Acupuncture

Fee Schedule	CPT Codes	Payable	EOR Deprival Reason
Md Services	Physical Medicine / Chiropractic / Acupuncture Multiple Procedure Payment Reduction; Pre-Dominance for Specified Process / Modality Services	Yes	Maximum units exceeded.

For underpaid Physical Medicine / Chiropractic / Acupuncture bills, DaisyBill advises filing a Second Review using the language and including the IBR decisions included in the following table equally supporting documentation.

For assist with Multiple Procedure Payment Reductions, review DaisyBill's article (and video!) covering Multiple Procedure Payment Reduction (MPPR) for Concrete Medicine .

Zipper

Recommendation

Reason

MUE incorrectly cited as reason for $0 reimbursement. § 9789.12.13  Correct Coding Initiative. (c) Medically Unlikely Edits are published by  CMS  on its website at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html  document "Practitioner Services MUE Table." See section 9789.xix for the adopted version of the Practitioner Services MUE Tabular array, by appointment of service.

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Incorrect Reimbursement: CCI Edit

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Any	Whatever	Yes	No carve up payment was made because the value of the service is included within the value of another service performed on the same day.

When a CCI Edit is incorrectly cited as a reason for $0 reimbursement, DaisyBill advises filing a Second Review using the language and including the IBR decisions included in the following table as supporting documentation.

For more data on CCI Edits and MUEs please refer to DaisyBill'due south Correct Coding Initiative  article.

Attachment

Recommendation

Reason

CCI Edit incorrectly cited as reason for $0 reimbursement. § 9789.12.13  Correct Coding Initiative.  (d) Doc NCCI Edits are published by CMS  on its website at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html . See section 9789.19 for the adopted version of the Physician CCI Edits, past engagement of service. Optional: Attached is a copy of an OVERTURN IBR Determination indicating this incorrect deprival will be overturned when reviewed by IBR.

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Incorrect Reimbursement: Evaluation & Management (Eastward/M) Downcoding

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Physician Services	99213-99215	Yes	The documentation does not support the level of service billed. Reimbursement was made for a code that is supported by the description and documentation submitted with the billing.
	99203-99205

For underpaid medical bills, DaisyBill advises filing a 2nd Review using the language and including the IBR decisions included in the following tabular array as supporting documentation.

For help determining the correct level of E/M lawmaking and documentation, read DaisyBill'due south Helpful Resource article on How to Make up one's mind the Correct Eastward/M Code .

Attachment

Recommendation

Reason (instance of 99214 incorrectly downcoded to 99213)

This CPT was paid at a lower rate than documented in the provided medical records. Per the 1995 AMA CPT guidelines, two of 3 key components (history, test, and medical conclusion making) decide established patient evaluation and management (Due east/M) level. In the case where counseling and/or coordination of intendance dominates the physician/patient encounter, time is the controlling cistron to qualify for a particular level of E/Chiliad service. The medical records document the time spent face-to-face up with the patient, a detailed history was washed, review of previous records and recently obtained records and required medical determination making.  These factors indicate that 99214 is the appropriate level of reimbursement. Optional:  Attached is a copy of an OVERTURN IBR decision, including the guidelines used to evaluate appropriate 99214 East/K level.  This IBR decision indicates that this reimbursement will exist overturned when reviewed by IBR.

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Incorrect Reimbursement: No PPO / Network Reduction

Fee Schedule	CPT Codes	Payable	EOR Denial Reason
Any	Any	Aye	Reduction in accordance with _____ Contract. This charge was adjusted to comply with the rate and rules of the contract indicated.

Preferred Provider Organization (PPO) and Medical Provider Network (MPN) contracts are rife with abuse, as DaisyBill documents in the Disbelieve Contracts blog series . Insurance companies sometimes try to strength lower reimbursement rates on providers by processing "contract" discounts when no contract actually exists or the sale of a contract to another agency was non properly disclosed. In either case, these discounts often do not apply and should exist appealed. Providers should keep all discount contracts on file and readily verifiable to avoid taking reduced rates they never agreed to.

For underpaid bills incorrectly citing a PPO or Network disbelieve/reduction, DaisyBill advises filing a 2d Review using the linguistic communication and including the IBR decision included in the following tabular array as supporting documentation.

Attachment	Recommendation
Reason	This bill payment was incorrectly discounted citing a "PPO Discount". Despite requesting proof of PPO contract, to date, no proof of PPO contract has been received. This practice and provider exercise NOT have a PPO contract or agreement authorizing this payment discount. Accordingly, delight review this bill for additional payment per OMFS. Optional: Fastened is a copy of an OVERTURN IBR Decision indicating this incorrect PPO discount volition be overturned when reviewed by IBR.
Supporting Documents	Letter to claims/contract administrator requesting proof of PPO contract

DaisyBill Resources

Webinar: Asking for Second Review

Webinar: Second Review Strategy Kit, Part I

Webinar: Second Review Strategy Kit, Function Two

DaisyBill Solution

Every request for 2nd Review submitted from DaisyBill is compliantly submitted using both a completed DWC Form SBR-one, as well every bit a compliant modified CMS 1500.

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Source: https://kb.daisybill.com/articles/california-second-bill-review-language

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