Sedgwick Claims Management Services, Inc.

Also known as Sedgwick
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Contact Information
Name
Sedgwick Claims Management Services, Inc.
Type
TPA
daisyBill Payer ID
db89053
Hours of Operation
08:00 AM - 08:00 PM EDT
Telephone Numbers
Main
(866) 495-7844
Main
(866) 495-7844
Bill Review
CorVel Corporation (OR)
(800) 987-1007
Careworks Managed Care Services (formerly WellComp)
(800) 932-5535 x 3
Conduent (formerly Bunch Care Solutions, LLC)
(866) 851-7739
Medata Service Bureau
(800) 854-7591 x 1
Sedgwick CMS - National Bill Review
(866) 495-7844 x 7
Genex Services, Inc.
(800) 240-0809
CA Medical Provider Networks (MPNs)
Company Website

Sedgwick NATIONAL DATA

3,880
Total Provider Count
120,957
Total Injury Count
587,449
Total Bill Count
e-Bill
Bill Delivery
4%
Duplicate Bill %
8
Avg Days To Pay
Sedgwick data

Sedgwick CALIFORNIA DATA - REIMBURSEMENT STATISTICS

CA Average Days to Pay

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

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

* 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 *
8.1
Copy Service
5.7
Interpreter
9.3
Medical-Legal
11.1
Facility *
10.6
Pharmacy *
7.4

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

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

85%
Official Medical Fee Schedule (OMFS)
OMFS Reimbursement Due
$70,915,903
100.0%
Sedgwick Reimbursement Reduction
$10,702,635
15.1%
Sedgwick Reduced Reimbursement
$60,213,268
84.9%

Sedgwick 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.

837 e-Bill Sent

California law requires Sedgwick 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 Sedgwick 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 Sedgwick properly accepts e-bills sent via the required X12 837 EDI standard and how often Sedgwick's failure forces providers to submit paper bills.

99%
X12 837 EDI Compliant
X12 837 EDI
Original Bill
Second Review Appeal
Total
X12 837 EDI Compliant
837 Sent
359,276
99%
35,034
97%
394,310
99%
Yes
837 Not Accepted
4,476
1%
1,067
3%
5,543
1%
No

277 Acknowledgement (ACK) - Timeliness

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

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

100%
X12 277 Timeliness Compliant
X12 277 ACK Receipt
Original Bill
Second Review Appeal
Total
X12 277 Timeliness Compliant
277 Receipt Timely - 2 Working Days
358,975
100%
34,991
100%
393,966
100%
Yes
277 Receipt - 3+ Working Days
98
0%
0
0%
98
0%
No

277 Acknowledgement - Erroneous e-Bill Rejections

daisyBill tracks the following criteria from Sedgwick 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 Injury Claim Valid: An incorrect rejection of an e-bill where the claims administrator previously paid another bill associated with the same injury claim.

  • 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 Sedgwick appropriately processes or improperly rejects e-bills and appeals.

99%
X12 277 STC Compliant
277 ACK STC Code
Original Bill
Second Review Appeal
Total
X12 277 STC Compliant
277 ACK Accept
355,157
99%
33,895
97%
389,052
99%
Yes
277 ACK Reject
57
0%
0
0%
57
0%
Yes
277 Reject Error - Improper Second Review / Appeal Rejection
0
0%
1,096
3%
1,096
0%
No
277 Reject Error - Valid Injury Claim
1,276
0%
0
0%
1,276
0%
No
277 Reject Error - Invalid STC Category/Code
1,787
0%
0
0%
1,787
0%
No
277 Reject Error - Prior ACK Accept Sent
796
0%
0
0%
796
0%
No

835 Explanation of Review (EOR) Receipt

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 Sedgwick to electronically send an Explanation of Review (EOR) to the provider using the X12 835 EDI standard.

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

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

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

41%
X12 835 Compliant
X12 835 Receipt
Original Bill
Second Review Appeal
Total
X12 835 Compliant
835 Posted
151,095
43%
7,402
22%
158,497
41%
Yes
835 Balance Errors - Posted
114,823
32%
3,677
11%
118,500
30%
No
835 Missing
43,552
12%
7,694
23%
51,246
13%
No
835 Late Receipt - Posted
43,891
12%
9,242
27%
53,133
14%
No
835 Invalid - Unpostable
1,970
1%
5,922
17%
7,892
2%
No

Sedgwick CALIFORNIA DATA - PENALTY & INTEREST

If Sedgwick 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 Sedgwick reported paying our clients.

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

$4,936,889
Penalty and Interest Balance Due
Total Penalty & Interest Due*
$5,028,041
Self-Executed Penalty & Interest Paid
$91,152
Penalty & Interest Balance Due
$4,936,889
Bill Transmission Year
Bill Count
EOR Receipt Count
EOR Missing Count*
Payment Late Count
Penalty Due
Interest Due
Total P&I Due
2019
135,484
116,497
86%
18,987
14%
6,517
6%
$301,281
$160,007
$461,288
2020
195,269
164,433
84%
30,836
16%
13,218
8%
$710,680
$281,024
$991,704
2021
305,588
256,801
84%
48,787
16%
17,933
7%
$829,219
$339,050
$1,168,269
2022
336,223
295,032
88%
41,191
12%
14,041
5%
$565,146
$189,967
$755,114
2023
393,433
341,075
87%
52,358
13%
16,479
5%
$617,292
$197,409
$814,702
2024
478,459
426,074
89%
52,385
11%
15,517
4%
$557,507
$101,002
$658,509
2025
200,469
177,888
89%
22,581
11%
4,599
3%
$162,082
$16,374
$178,455
Total
2,044,925
1,777,800
87%
267,125
13%
88,304
5%
$3,743,207
$1,284,834
$5,028,041

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 Sedgwick 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 Sedgwick 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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