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Division of Workers' Compensation (DWC)

Standardized paper billing frequently asked questions (FAQs)

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

About the basics

Q: When did the paper billing regulations become effective?

A: Regulations for standardized paper billing forms became effective Oct. 15, 2011. The regulations are codified at title 8 California Code of Regulations sections 9792.5.0 through 9792.5.3. The regulations and guide have been updated and are effective Jan. 1, 2013.

Q: Are medical providers and facilities required to use standardized paper billing forms for medical treatment bills?

A: Yes, medical providers and facilities that submit paper bills on or after Oct. 15, 2011 must utilize the forms that are prescribed in the Medical Billing and Payment Guide.

Q: Which forms are required to be used for submission of paper medical treatment bills?

A: They are the:

  • CMS Form 1500, revised August 2005
  • CMS Form 1450 or UB-04
  • NCPDP Workers’ Compensation/Property Casualty Claim Form, version 1.1 – 05/2009
  • ADA Dental Claim Form (2006)

Q: How will this affect medical providers?

A: On and after Oct. 15, 2011, all health care providers, health care facilities and billing agents/assignees submitting paper medical bills shall submit the bills on the uniform billing forms and in the manner prescribed in the Medical Billing and Payment Guide 2011. In addition, there are instruction manuals for each form that are incorporated by reference into the Medical Billing and Payment Guide that provide rules for completing the forms (for example the 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 08/05).

Q: When will paper medical treatment bills be paid?

A: Any complete bill for uncontested medical treatment provided must be paid by the claims administrator within 45 working days of receipt of the bill or within 60 working days if the employer is a governmental entity. If the bill is contested, denied or considered incomplete the claims administrator must notify the medical provider or facility within 30 working days of receipt of the bill.

Q: Does the Medical Billing and Payment Guide apply to bills for medical-legal services?

A: No. The Medical Billing and Payment Guide applies to medical treatment goods and services, not medical-legal services.

Q: Do the new rules and Medical Billing and Payment Guide affect the claims administrator?

A: Yes, the claims administrator must comply with time frames and procedures set forth in the rules and Medical Billing and Payment Guide.

Q: Are there new requirements relating to the Explanation of Review?

A: Yes. The Medical Billing and Payment Guide contains new rules relating to the issuance of the Explanation of Review (EOR). Claims administrators/payers may use any format for the EOR but must include all of the data elements which are designated “R” (“required”) on the 3.0 Table for Paper Explanation of Review (Medical Billing and Payment Guide, Appendix B). In addition, the EOR must use the relevant DWC Bill Adjustment Reason Codes and DWC Explanatory Messages set forth in 1.0 California DWC Bill Adjustment Reason Code / CARC /RARC Matrix Crosswalk (Medical Billing and Payment Guide, Appendix B). The DWC Bill Adjustment Reason Codes and DWC Explanatory Messages are designated “S” (“situational”) because they become required only if they are applicable to the circumstances being addressed by the EOR.

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. The Request for Second Review must conform to the requirements of the Division of Workers’ Compensation Medical Billing and Payment 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