Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.0. Rules For Medical Treatment Billing and Payment on or After October 15, 2011

9792.5.7. Requesting Independent Bill Review.

(a) If the provider further contests the amount of payment made by the claims administrator on a bill for medical treatment services or goods rendered on or after January 1, 2013, submitted pursuant to Labor Code sections 4603.2 or 4603.4, or bill for medical-legal expenses incurred on or after January 1, 2013, submitted pursuant to Labor Code section 4622, following the second review conducted under section 9792.5.5, the provider shall request an independent bill review. Unless consolidated under section 9792.5.12, a request for independent bill review shall only resolve:

(1) For a bill for medical treatment services or goods, a dispute over the amount of payment for services or goods billed by a single provider involving one injured employee, one claims administrator, and either one date of service and one billing code or one hospital stay, under the applicable fee schedule adopted by the Administrative Director or, if applicable, under a contract for reimbursement rates under Labor Code section 5307.11 covering one range of effective dates.

(2) For a bill for medical-legal expenses, a dispute over the amount of payment for services billed by a single provider involving one injured employee, one claims administrator, and one comprehensive, follow-up, or supplemental medical legal evaluation report as defined in section 9794.

(b) Unless as permitted by section 9792.5.12, independent bill review shall only be conducted if the only dispute between the provider and the claims administrator is the amount of payment owed to the provider. Any other issue, including issues of contested liability or the applicability of a contract for reimbursement rates under Labor Code section 5307.11 shall be resolved before seeking independent bill review. Issues that are not eligible for independent bill review shall include:

(1) The determination of a reasonable fee for services where that category of services is not covered by a fee schedule adopted by the Administrative Director or a contract for reimbursement rates under Labor Code section 5307.11.

(2) The proper selection of an analogous code or formula based on a fee schedule adopted by the Administrative Director, or, if applicable, a contract for reimbursement rates under Labor Code section 5307.11, unless the fee schedule or contract allows for such analogous coding.

(c) The request for independent bill review must be made within 30 calendar days of:

(1) The date of service of the final written determination issued by the claims administrator under section 9792.5.5(f), if a proof of service accompanies the final written determination.

(2) The date of receipt of the final written determination by the provider, if a proof of service does not accompany the final written determination and the claims administrator has documentation of receipt.

(3) The date that is five (5) calendar days after the date of the United States postmark stamped on the envelope in which the final written determination was mailed if the final written determination is sent by mail and there is no proof of service or documentation of receipt.

(4) The date of resolution in favor of the provider of any issue of contested liability.

(5) The date of service of an order of the Workers' Compensation Appeal Board resolving in favor of the provider any threshold issue that would have precluded a provider's right to receive compensation for medical treatment services or goods provided in accordance with Labor Code section 4600 or for medical-legal expenses defined in Labor Code section 4620.

(d)(1) The request for independent bill review shall be made in one of the following manners:

(A) Completing and electronically submitting the online Request for Independent Bill Review form, which can be accessed on the Internet at the Division of Workers' Compensation's website. The website link for the online form can be found at http://www.dir.ca.gov/dwc/IBR.htm. Electronic payment of the required fee of $335.00 shall be made at the time the request is submitted.

(B) Mailing the Request for Independent Bill Review form, DWC Form IBR-1, set forth in section 9792.5.8, and simultaneously paying the required fee of $335.00 as instructed on the form.

(2) The provider shall include with the request form submitted under this subdivision, either by electronic upload or by mail, a copy of the following documents which shall be indexed and arranged so that each of the following categories of documents can be separately identified:

(A) The original billing itemization;

(B) Any supporting documents that were furnished with the original billing;

(C) If applicable, the relevant contract provisions for reimbursement rates under Labor Code section 5307.11;

(D) The explanation of review that accompanied the claims administrator's response to the original billing;

(E) The provider's request for second review of the claims administrator's original response to the billing;

(F) Any supporting documentation submitted to the claims administrator with that request for second review;

(G) The final written determination of the second review (explanation of review) issued by the claims administrator to the provider.

(e) The provider may request that two or more disputes that would each constitute a separate request for independent bill review be consolidated for a single determination under section 9792.5.12.

(f) The provider shall concurrently serve a copy of the request for independent bill review upon the claims administrator with a copy of the supporting documents submitted under subdivision (d). Any document that was previously provided to the claims administrator or originated from the claims administrator need not be served if a written description of the document and its date is served.

Note: Authority cited: Sections 133, 4603.6, 5307.3 and 5307.6, Labor Code. Reference: Sections 4060, 4061, 4061.5, 4062, 4600, 4603.2, 4603.3. 4603.4, 4603.6, 4620, 4621, 4622, 4625, 4628 and 5307.6, Labor Code.

HISTORY

1. New section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 9-30-2013 order, including amendment of subsections (a)-(a)(2), (c), (d)(1)(A) and (d)(2), transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).