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Division of Workers' Compensation (DWC)

e-billing frequently asked questions (FAQs)

Topic covered in this section:
The basics
Bill appeal/reconsideration

About the basics

Q: When did the electronic billing regulations become effective?

A: The regulations requiring claims administrators to accept electronic submission of medical bills become became effective Oct. 18, 2012. The regulations and guides have been updated effective Jan. 1, 2013.

Q: How do the regulations affect medical providers and facilities?

A: On and after Oct. 18, 2012, all health care providers, health care facilities and billing agents/assignees providing medical treatment may electronically submit medical bills to the claims administrator for payment. The medical bills shall conform to the electronic billing standards and rules set forth in the Medical Billing and Payment Guide, the Electronic Medical Billing and Payment Companion Guide and the regulations, which are posted on the DWC website.

Q: Are medical providers and facilities required to submit bills electronically on and after Oct. 18, 2012?

A: No. Electronic bill submission is optional for the medical provider or facility.

Q: If the provider or facility chooses to use e-billing, 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: 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: On and after Oct. 18, 2012, 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: The electronic billing rules 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 section 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 e-billing@dir.ca.gov.

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 Regulations section 9792.5.4 et seq. 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 Regulations section 9792.5.4 et 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 on independent bill review on the DWC website.

April 2013