The Second Review is the cornerstone of California work-comp bill recovery. When a payer pays less than the fee schedule allows — or denies a line you believe is payable — the law gives you one structured shot to dispute the amount before the bill is considered resolved. That request is the DWC Form SBR-1, a "Request for Second Bill Review," and it must be filed within 90 days of the EOR.
What a Second Review is for (and what it isn't)
A Second Review disputes the amount paid under the fee schedule. Use it when:
- The payer applied an illegal PPO/network discount to a med-legal bill (often shown as adjustment code
PR-242, paying only a fraction of the MLFS allowance). - A modifier wasn't honored, dropping the compounded allowance.
- An ML code was downgraded (e.g., ML202 paid as a lesser code).
- MLPRR pages were cut despite a valid sender declaration.
- The bill was paid at the wrong fee-schedule rate.
It is not the tool for a dispute about whether the payer is liable for the claim at all, or whether an expense is even covered by the fee schedule. Those are threshold legal questions that belong in a lien or a Petition for Determination — file a Second Review on one of those and it goes nowhere.
The illegal PPO discount — the classic case
The most common winnable Second Review is the PPO reduction on a medical-legal bill. Networks like Coventry / First Health routinely apply a contractual discount and pay, say, 60% of the MLFS allowance. This is not permitted. Under CCR §9789.30(d), medical-legal evaluations are reimbursed at the fee-schedule rate — a PPO contract cannot discount below it. When you see PR-242 knocking down a med-legal line, that's a near-automatic Second Review.
Cite the regulation, every time. A Second Review that just says "you underpaid us" invites another denial. One that cites §9789.30(d) for the PPO issue — and references prior Maximus IBR determinations finding the same reduction improper — is far harder to brush off.
How to file
- Confirm the deadline. You have 90 days from the date of the EOR. Calendar it the day the EOR posts.
- Complete the SBR-1. Identify the original bill, the disputed line items, the amount paid, and the amount you contend is owed.
- Attach the rebuttal. State the specific reason and the controlling authority — the fee-schedule citation, the modifier rule, or the §9789.30(d) PPO argument.
- Re-attach the bill. Include the corrected/original CMS-1500 and the supporting report so the reviewer has everything in one packet.
- Submit and track. File it the same way you billed (electronically where supported) and log the filing date — the payer owes you a response.
What happens next
The payer must respond to a timely Second Review with a final EOR. If they pay the difference, you're done. If they deny it again, you have a new 30-day window to escalate to Independent Bill Review (IBR), where a neutral reviewer (Maximus) decides the amount dispute for a $180 fee — recoverable when you win. The Second Review is the gate: you cannot reach IBR without filing it first, and you cannot file it late.
This guide is general information for California workers'-comp and med-legal billers, not legal advice. Statutes, fee schedules, and forms change — confirm against the current DWC regulations for your dates of service.