QME Billers & Collectors: Don’t be deterred when “Your claim is denied!”

Often, collectors will call the bill reviewer or adjustor and be told “Your claim is denied.” Inexperienced collectors will hear this and give up, mistakenly believing nothing else can be done and that the denial is final.

But – there is a difference between the applicant’s claim – aka case-in-chief (CIC) – and the bill they call on (which can also be called a “medical-legal bill claim”). Confusing, right?

If the bill itself was denied, collectors must take the next step of filing a Second Bill Review request (SBR). If that is denied, collectors can then request an Independent Bill Review (IBR). As a last resort, a collector can file a non-IBR petition (which warrants its own future blog post).  

In Simplexam, we refer to “billable items” and “bill status” and reserve the word “claim” for the injured worker’s case-in-chief.

Leave a comment

Your email address will not be published. Required fields are marked *