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How to file effective second bill reviews for workers' compensation



August 05, 2014
Area(s) of Interest: Payor Issues and Reimbursement Workers' Compensation 

This is the second in a two-part series focusing on coding, compliance and documentation issues relating specifically to Workers’ Compensation billing. This month’s tip comes from Catherine Montgomery, the founder and CEO of DaisyBill, which offers software solutions for workers’ compensation medical billing.

Previously discussed was the importance of filing second bill reviews (SBR) for workers’ compensation medical bills, even if the underpayment is small. In the increasingly unforgiving workers’ comp billing environment , it is incumbent upon providers to make sure that billing staff or third-party billers correctly submit SBRs.

Providers should assess and potentially overhaul their SBR procedures. Incorrect or untimely SBRs will result in denied bills, even if your SBR is late by even one day or is non-compliant in even one field. It is critical that billing staff or third-party billers understand that if the only dispute involves the payment amount and if a provider fails to submit a compliant SBR within 90 days, the claims administrator has no obligation to pay. This is true even if the error in payment originated with the claims administrator. Also, if an SBR is not successful, filing an independent bill review (IBR) is a provider’s next step – but only if an SBR was previously submitted.

The practice is ultimately responsible, so it is critical that practices regularly ask for and review:

  • Copies of the SBRs being submitted on your behalf, and
  • Reports of SBR activity
    • Number of days sent after explanation of review (EOR)
    • Percentage of SBRs sent
    • Dollar amount of additional payment collected from SBRs

Carefully examine the SBRs to make sure they adhere to the following mandated timeframes, forms and information requirements. At the end of the day, if your bill is denied due to errors of your staff, it is you that does not get paid for the treatment provided to injured workers.

SBR Timeframes

SBR submission must occur within 90 days of the receipt of an EOR or within 90 days of the Workers Compensation Appeals Board resolving any threshold issues that prevented adjudication of the bill.

The claims administrator must issue a final EOR within 14 days from receipt of your SBR.

SBR Forms

An SBR can be submitted either on paper or electronically. If on paper, a provider can use either an appropriately modified replica of the original bill or an SBR-1 form, with the exception that medical-legal bills can only be appealed on an SBR-1 form.

If submitted on a copy of the original bill, the original bill must be modified as follows:

  • CMS 1500 – Modify with “BGW3” in box 10D
  • UB04 – Modify with “BGW3” in boxes 18-28
  • ADA Dental Claim Form 2006 – “Request for Second Review” in field 1
  • NCPDP – “Request for Second Review” written on form

Required SBR Information

Whether submitted electronically or on paper, either on a modified copy of the original bill or on an SBR-1 Form, the SBR must contain:

  • Date of original EOR
  • Claim number or other unique ID number from the EOR
  • Item in dispute
  • Dollar amount in dispute
  • Additional payment requested
  • Reason for SBR (i.e. short paid, not paid per contract, not a bundled code, etc.)
  • Additional information provided in response to an EOR or other additional supporting information.

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