Sedgwick Claims Management Services, Inc.
Sedgwick NATIONAL DATA
Sedgwick CALIFORNIA DATA - REIMBURSEMENT STATISTICS
CA Average Days to Pay
For each bill sent from daisyBill software to Sedgwick, our technology tracks the count of business days it took Sedgwick to process the bill.
For the listed California workers’ comp fee schedules, this table reflects the average count of business days from Sedgwick’s receipt of a bill until the daisyBill client received an explanation of review (EOR) and payment from Sedgwick.
* California requires claims administrators to pay e-bills for medical treatment within 15 working days of receipt of the e-bill.
CA Official Medical Fee Schedule
The California Official Medical Fee Schedule (OMFS) establishes the reimbursement amounts due to providers for medical treatment furnished to injured workers. However, rather than reimbursing providers the reimbursement amounts due per the OMFS, Sedgwick uses Preferred Provider Organizations (PPOs) to reduce the reimbursements paid to providers.
For Sedgwick medical treatment bills, this table reflects the OMFS Reimbursement Due to daisyBill clients for medical treatment provided to injured workers. Sedgwick Reimbursement Reduction reflects the amount Sedgwick failed to pay daisyBill clients. The Sedgwick Reduced Reimbursement reflects the reimbursement amount Sedgwick ultimately reimbursed daisyBill providers.
Sedgwick CALIFORNIA DATA - EDI COMPLIANCE
Commencing October 2012, California law mandates claims administrators must accept the electronic submission of complete medical bills (‘e-bills’) from providers. For e-bills, the California Division of Workers’ Compensation (DWC) Medical Billing and Payment Guide establishes timeframes by which claims administrators (aka payers) must acknowledge, object to, pay, and provide an Explanation of Review (EOR) in response to all e-bills sent by workers’ comp providers.
Using the collective data from daisyBill clients’ e-bills, below the data reports how often Sedgwick both complied and failed to comply with the mandated California e-billing requirements and timeframes when processing e-bills sent by daisyBill clients.
X12 837 e-Bill Acceptance
California law requires Sedgwick to accept workers’ comp e-bills from providers, including accepting Second Review appeals providers send electronically.
daisyBill transmits all bills and Second Review appeals electronically to Sedgwick using the X12 837 EDI standard as required by DWC Rule 7.1. When Sedgwick fails to compliantly accept an e-bill, daisyBill uses a non-EDI method (fax, email or mail) to transmit a paper bill to Sedgwick for processing.
For bills submitted last quarter, the table below reports the frequency at which Sedgwick compliantly accepts e-bills daisyBill compliantly sent using the required X12 837 EDI standard. The table also reports the frequency at which Sedgwick fails to compliantly accept e-bills, thereby forcing providers to submit non-EDI paper bills to Sedgwick.
To learn more, review the sample Audit Complaints daisyBill submits to the California DWC to report EDI noncompliance
X12 277 Acknowledgement - Timeliness
Within two working days after receipt of an e-bill, Sedgwick must electronically send the provider a X12 277 Acknowledgement (277 ACK) verifying that Sedgwick either accepted or rejected the e-bill for payment adjudication. Upon receipt of a 277 ACK that accepts an e-bill, the provider has proof that Sedgwick received the e-bill for processing.
The table below reports how often Sedgwick compliantly sends 277 ACK notices to daisyBill clients within two working days of receipt of the e-bill.
Review the sample Audit Complaints daisyBill submits to the California DWC to report EDI non-compliance.
X12 277 Acknowledgement - Invalid e-Bill Rejections
For rejected e-bills, the 277 ACK includes STC segments with a Claim Status Category Code (STC Category) and a Claim Status Code (STC Code) explaining the reason for the e-bill rejection. The DWC allows claims administrators to reject e-bills only for a strictly defined set of (mostly technical) reasons. A 277 ACK cannot function as an electronic Explanation of Review (e-EOR) to deny payment.
The table below lists the instances where Sedgwick sent 277 ACKs with invalid STC Category and STC Codes that non-compliantly rejected e-bills for reasons other than allowed by the DWC. Rather than properly returning electronic Explanations of Review (e-EORs) explaining reasons for payment denial, Sedgwick non-compliantly rejected the e-bills with improper STC Category and Codes.
Review the sample Audit Complaints daisyBill submits to the California DWC to report EDI non-compliance.
X12 835 e-EOR
DWC Rule 7.1 requires Sedgwick to electronically send an Explanation of Review (EOR) to the provider using the X12 835 EDI standard. When a provider sends an Original e-bill, Sedgwick must electronically send the EOR within 15 working days after receipt of the e-bill from the provider. For Second Review e-bills, Sedgwick must electronically send the provider an EOR within 14 calendar days after receipt of the Second Reiew e-bill from the provider.
The table below reports the frequency at which Sedgwick compliantly sends X12 835 EORs to daisyBill clients.
Review the sample Audit Complaints daisyBill submits to the California DWC to report EDI noncompliance.
Sedgwick CALIFORNIA DATA - PENALTY & INTEREST
If Sedgwick fails to remit payment within mandated time frames, California law requires the claims administrator to “self-execute” Penalty and Interest payments directly to the provider. Often claims administrators fail to self-execute these Penalities and Interest (P&I).
Using e-billing data, daisyBill calculates the Total P&I Due to daisyBill clients and the amount of P&I Sedgwick reported paying our clients.
The Penalty & Interest Balance Due displayed here is the amount Sedgwick failed to self-execute to daisyBill clients as mandated by California law.
Once a bill payment is 45 calendar days overdue, daisyBill calculates Penalty and Interest amounts owed. Total P&I Due may slightly overstate the amount owed by Sedgwick in the instances where the underlying employer is a government employer, as California allows government employers 60 calendar days to timely reimburse workers' comp bills.
*EOR Missing Count reflects the instances where Sedgwick failed to electronically send the provider an EOR, therefore, daisyBill could not calculate whether P&I is due for these e-bills where the EOR is missing. Data updates daily.
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