Attached you will find a generic complaint letter for physicians and providers to use when initiating a complaint with the Audit Unit. This letter will allow a physician or a provider to complain about four (4) distinct infractions:

1. Failing to timely respond to a request for authorization (DFR)
2. Failing to timely respond to a request for authorization (PR-2)
3. Failing to self-impose the statutory increase/interest if a treatment bill is paid late.
4. Failing to self-impose the statutory increase/interest if a med-legal bill is paid late.

The failure to timely respond to a request for authorization (DFR or PR-2) is sanctionable for any payor who had a UR program in place from 1/1/99 - 12/31/03, during which time it was optional. During the time frame outlined, CCR 9792.6 mandated the payor to respond within seven (7) working days from receipt of the DFR or PR-2. The Audit Unit will accept complaints today, about a failure to respond in writing, for a DFR or a PR-2 submitted anytime between 1/1/99 - 12/31/03.

Effective 1/1/04, every payor is mandated to have a UR program in place, and timely respond to any DFR or PR-2 in writing. The time frame to respond is no later than fourteen (14) calendar days for a DFR or PR-2 received by a payor post 1/1/04.

This document is written in MS Word, and it is a 'form field' document. This document can be downloaded and customized for any individual physician or provider. Any questions about how to customize this complaint letter, for any particular physician or provider can be directed to me at my email address below.

For convenience, I am also attaching a 'Physician Checklist' to assist in determining if a payor has failed to comply with any of the above-indicated infractions. This checklist addresses the various time-frames for compliance, depending on the date the DFR, PR-2, treatment bill, or med-legal bill was received.

York McGavin
ymcgavin@socal.rr.com

	PHYSICIAN AUDIT COMPLAINT.doc  (29 KB)
	PHYSICIAN-CHECKLIST.doc  (24 KB)