Tristar Risk Management

Also known as Tristar
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Contact Information
Name
Tristar Risk Management
Type
TPA
daisyBill Payer ID
db67976
Hours of Operation
08:00 AM - 04:30 PM CDT
Telephone Numbers
Main
(562) 495-6600
Main
(562) 495-6600
Bill Review
Definiti Healthcare Management
(949) 716-1891 x 5
CorVel Enterprise Comp, Inc.
(800) 987-1007
Medata Service Bureau
(800) 854-7591 x 1
Tristar Managed Care
(877) 287-4782
EK Health Services, Inc.
(888) 507-0616
Medex Healthcare Inc.
(949) 221-1700
CA Medical Provider Networks (MPNs)
Company Website

Tristar NATIONAL DATA

1,356
Total Provider Count
7,549
Total Injury Count
39,024
Total Bill Count
e-Bill
Bill Delivery
7%
Duplicate Bill %
14
Avg Days To Pay

Tristar CALIFORNIA DATA - REIMBURSEMENT STATISTICS

CA Average Days to Pay

For each bill sent from daisyBill software to Tristar, our technology tracks the count of business days it took Tristar to process the bill.

For the listed California workers’ comp fee schedules, this table reflects the average count of business days from Tristar’s receipt of a bill until the daisyBill client received an explanation of review (EOR) and payment from Tristar.

* California requires claims administrators to pay e-bills for medical treatment within 15 working days of receipt of the e-bill.

California Workers' Comp Fee Schedule
Average Days to Pay
Medical *
15.1
Interpreter
12.9
Medical-Legal
14.6
Facility *
17.7
Copy Service
13.7

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, Tristar uses Preferred Provider Organizations (PPOs) to reduce the reimbursements paid to providers.

For Tristar medical treatment bills, this table reflects the OMFS Reimbursement Due to daisyBill clients for medical treatment provided to injured workers. Tristar Reimbursement Reduction reflects the amount Tristar failed to pay daisyBill clients. The Tristar Reduced Reimbursement reflects the reimbursement amount Tristar ultimately reimbursed daisyBill providers.

86%
Official Medical Fee Schedule (OMFS)
OMFS Reimbursement Due
$841,335
100.0%
Tristar Reimbursement Reduction
$115,251
13.7%
Tristar Reduced Reimbursement
$726,084
86.3%

Tristar CALIFORNIA DATA - EDI COMPLIANCE

Since October 2012, California law has mandated that claims administrators accept electronic medical bills (e-bills) and adhere to specific timeframes established by the Division of Workers’ Compensation (DWC) Medical Billing and Payment Guide. These timeframes govern the following Electronic Data Interchange (EDI) transactions:

  • 837 (e-bill) Receipt: The provider's initial submission of the electronic medical bill and subsequent Second Review appeals.

  • 277 Acknowledgement (ACK) Receipt: An electronic confirmation from the claims administrator indicating that the e-bill has been received and whether it has been accepted or rejected.​

  • 835 Explanation of Review (EOR) Receipt: A detailed electronic response from the claims administrator outlining the adjudication results of the e-bill, including payment details or reasons for denial.

By tracking this EDI data, daisyBill helps providers identify trends, resolve billing discrepancies, and maintain transparency in the workers’ comp electronic billing process.

X12 837 e-Bill Acceptance

California law requires Tristar to accept workers’ comp e-bills and Second Review appeals submitted electronically by providers. daisyBill transmits all bills and appeals using the X12 837 EDI standard, as mandated by DWC Rule 7.1.

When Tristar fails to accept e-bills compliantly, daisyBill resorts to non-EDI methods (fax, email, or mail) to submit paper bills for processing.

The table below shows how often Tristar properly accepts e-bills sent via the required X12 837 EDI standard and how often Tristar's failure forces providers to submit paper bills.

92%
X12 837 EDI Compliant
Bill Transmission
Original Bill
Second Review Appeal
Total
X12 837 EDI Compliant
837 Accept
23,319
98%
471
22%
23,790
92%
Yes
837 Not Accept
459
2%
1,673
78%
2,132
8%
No

X12 277 Acknowledgement (ACK) - Timeliness

California requires Tristar to electronically send a 277 Acknowledgement (277 ACK) to the provider within two working days of receiving an e-bill. This notice confirms whether Tristar accepted or rejected the e-bill for payment adjudication. If the 277 ACK indicates acceptance, it serves as proof that Tristar received the e-bill for processing.

The table below shows how often Tristar sends 277 ACK notices to daisyBill clients within the required two working days after receiving an e-bill.

99%
X12 277 Timeliness Compliant
Bill Transmission
Original Bill
Second Review Appeal
Total
X12 277 Timeliness Compliant
277 Receipt 2 Working Days
23,078
99%
471
100%
23,549
99%
Yes
277 Receipt 3+ Working Days
240
1%
0
0%
240
1%
No

X12 277 Acknowledgement - Invalid e-Bill Rejections

daisyBill tracks the following criteria from Tristar 277 Acknowledgement (277 ACK) responses to e-bills:

277 Accept: Confirms that the e-bill was accepted for payment adjudication.

277 Reject: Indicates that the e-bill was rejected, with an associated STC Category and STC Code explaining the reason.

STC Invalid – Reject Second Review: An improper rejection of a Second Review appeal using invalid STC Category and/or STC Code.

STC Invalid – Reject Category/Code: A rejection where the STC Category and/or STC Code provided is invalid or not allowed.

STC Invalid – Reject Prior Accept: An incorrect rejection of an e-bill that was previously accepted via an earlier 277 ACK.

These criteria provide detailed insight into how often Tristar appropriately processes or improperly rejects e-bills and appeals.

93%
X12 277 STC Compliant
Bill Transmission
Original Bill
Second Review Appeal
Total
X12 277 STC Compliant
277 Accept
21,753
93%
107
23%
21,860
92%
Yes
277 Reject
241
1%
0
0%
241
1%
Yes
STC Invalid - Reject Second Review
0
0%
364
77%
364
2%
No
STC Invalid - Reject Injury Claim Valid
854
4%
0
0%
854
4%
No
STC Invalid - Reject Category/Code
285
1%
0
0%
285
1%
No
STC Invalid - Reject Prior Accept
185
1%
0
0%
185
1%
No

X12 835 Explanation of Review

An electronic Explanation of Review (EOR) is transmitted using the X12 835 EDI standard and provides details on the adjudication of an e-bill. DWC Rule 7.1 requires Tristar to electronically send an Explanation of Review (EOR) to the provider using the X12 835 EDI standard.

For Original e-Bills, Tristar must electronically send the EOR within 15 working days after receiving the e-bill.

For Second Review Appeals, Tristar must electronically send the EOR within 14 calendar days after receiving the Second Review e-bill.

The table below shows how often Tristar sends X12 835 EORs to daisyBill clients within the required timeframes.

2%
X12 835 Compliant
X12 EDI Standard
Original e-Bill
Second Review Appeal
Total
X12 835 Compliant
835 Receipt 15 Working Days
456
2%
7
7%
463
2%
Yes
835 Missing
17,570
81%
88
82%
17,658
81%
No
835 Late
2,555
12%
8
7%
2,563
12%
No
835 Invalid Data
1,173
5%
4
4%
1,177
5%
No

Tristar CALIFORNIA DATA - PENALTY & INTEREST

If Tristar 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 Tristar reported paying our clients.

The Penalty & Interest Balance Due displayed here is the amount Tristar failed to self-execute to daisyBill clients as mandated by California law.

$447,629
Penalty and Interest Balance Due
Total Penalty & Interest Due*
$457,922
Self-Executed Penalty & Interest Paid
$10,293
Penalty & Interest Balance Due
$447,629
Bill Transmission Year
Bill Count
EOR Receipt Count
EOR Missing Count*
Payment Late Count
Penalty Due
Interest Due
Total P&I Due
2019
30,513
24,241
79%
6,272
21%
2,464
10%
$106,690
$21,745
$128,434
2020
22,883
20,139
88%
2,744
12%
2,269
11%
$73,526
$13,262
$86,787
2021
28,937
26,871
93%
2,066
7%
2,525
9%
$77,726
$12,844
$90,570
2022
19,650
17,230
88%
2,420
12%
1,113
6%
$47,824
$7,763
$55,588
2023
16,405
8,574
52%
7,831
48%
997
12%
$38,277
$6,230
$44,507
2024
23,606
13,881
59%
9,725
41%
864
6%
$39,450
$3,270
$42,720
2025
7,082
4,416
62%
2,666
38%
265
6%
$9,082
$233
$9,316
Total
149,076
115,352
77%
33,724
23%
10,497
9%
$392,575
$65,347
$457,922

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 Tristar 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 Tristar 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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