California Workers' Compensation: Navigating Independent Bill Review (IBR) and Fee Disputes

Under California Labor Code Section 4603.6 and Title 8 California Code of Regulations Section 9792.5.4, disputes over medical treatment billing for accepted industrial injuries cannot be brought before the Workers' Compensation Appeals Board (WCAB) unless statutory medical fee dispute resolution procedures have been followed.

1. Mandatory Pre-Condition: Request for Second Review

Before any provider may file an application for Independent Bill Review (IBR), the provider must request a Second Review from the claims administrator within 90 days of service of the original Explanation of Review (EOR).

• The Second Review request must be made on DWC Form SBR-1 or a compliant written format.
• The request must specify the contested billing items, original billed amounts, payment made, and specific legal/factual basis under the OMFS.
• The claims administrator has 14 calendar days from receipt to issue a Second Review Explanation of Review.

2. Filing the IBR Application with Maximus

If the Second Review results in no payment or an amount less than the provider claims is due under the OMFS, the provider must file an Application for Independent Bill Review within 30 calendar days of service of the second review EOR.