Sedgwick Claims Management Services
Also known as Sedgwick
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Contact Information
Name
Sedgwick Claims Management Services
Type
Third-Party Administrator
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
Genex Services, Inc.
(800) 240-0809
Sedgwick CMS - National Bill Review
(866) 495-7844 x 7
CorVel Corporation MedCheck
(800) 987-1007
Medata Service Bureau
(800) 854-7591 x 1
Conduent (formerly Bunch Care Solutions, LLC)
(863) 669-0861
Careworks Managed Care Services (formerly WellComp)
(800) 932-5535 x 3
CA Medical Provider Networks (MPNs)
Company Website

Sedgwick NATIONAL DATA

3,326
Total Provider Count
94,946
Total Injury Count
403,038
Total Bill Count
9
Avg Days To Pay

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
9.1
Copy Service
8.4
Medical-Legal
10.1
Interpreter
8.5
Facility
12.3
Pharmacy
14.7

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
$9,248,340
100.0%
Sedgwick Reimbursement Reduction
$1,400,946
15.1%
Sedgwick Reduced Reimbursement
$7,847,395
84.9%

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.

$2,170,982
Penalty and Interest Balance Due
Total Penalty & Interest Due*
$2,191,145
Self-Executed Penalty & Interest Paid
$20,163
Penalty & Interest Balance Due
$2,170,982
Bill Transmission Year
Bill Count
EOR Receipt Count
EOR Missing Count*
Payment Late Count
Penalty Due
Interest Due
Total P&I Due
2019
135,447
116,282
86%
19,165
14%
6,172
5%
$286,985
$125,005
$411,990
2020
195,150
163,889
84%
31,261
16%
12,203
7%
$645,182
$167,803
$812,986
2021
305,429
253,285
83%
52,144
17%
14,809
6%
$655,491
$118,482
$773,974
2022
176,013
147,414
84%
28,599
16%
4,765
3%
$173,980
$18,216
$192,195
Total
812,039
680,870
84%
131,169
16%
37,949
6%
$1,761,638
$429,506
$2,191,145

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.

Sedgwick CALIFORNIA DATA - EDI COMPLIANCE

Commencing October 2012, California law mandates claims administrators must accept the electronic submission of complete medical bills (‘e-bills’) from providers. For e-bills, the California Division of Workers’ Compensation (DWC) Medical Billing and Payment Guide establishes timeframes by which claims administrators (aka payers) must acknowledge, object to, pay, and provide an Explanation of Review (EOR) in response to all e-bills sent by workers’ comp providers.

Using the collective data from daisyBill clients’ e-bills, below the data reports how often Sedgwick both complied and failed to comply with the mandated California e-billing requirements and timeframes when processing e-bills sent by daisyBill clients.

X12 837 e-Bill Acceptance

California law requires Sedgwick to accept workers’ comp e-bills from providers, including accepting Second Review appeals providers send electronically.

daisyBill transmits all bills and Second Review appeals electronically to Sedgwick using the X12 837 EDI standard as required by DWC Rule 7.1. When Sedgwick fails to compliantly accept an e-bill, daisyBill uses a non-EDI method (fax, email or mail) to transmit a paper bill to Sedgwick for processing.

For bills submitted last quarter, the table below reports the frequency at which Sedgwick compliantly accepts e-bills daisyBill compliantly sent using the required X12 837 EDI standard. The table also reports the frequency at which Sedgwick fails to compliantly accept e-bills, thereby forcing providers to submit non-EDI paper bills to Sedgwick.

 To learn more, review the sample Audit Complaints daisyBill submits to the California DWC to report EDI noncompliance

100%
X12 837 EDI Compliant
Bill Transmission
Original Bill
Second Review Appeal
Total
X12 837 EDI Compliant
X12 837 EDI
66,032
100%
5,727
99%
71,759
100%
Yes
Non-EDI Paper Bill - Fax
39
0%
63
1%
102
0%
No
Non-EDI Paper Bill - Email
19
0%
19
0%
38
0%
No

X12 277 Acknowledgement

Upon receipt of an e-bill, DWC Rule 71 requires Sedgwick to either accept an e-bill as complete or reject the e-bill as incomplete. Within two working days after receipt of an e-bill, Sedgwick must electronically send the provider a notice verifying that Sedgwick accepted or rejected the e-bill. DWC Rule 7.1 mandates that Sedgwick must send the electronic notice to providers using the X12 277 Acknowledgement (277 ACK) EDI standard.

The table below reports the frequency at which Sedgwick compliantly sends 277 ACK notices to daisyBill clients.

 Review the sample Audit Complaints daisyBill submits to the California DWC to report EDI noncompliance

85%
X12 277 ACK Compliant
Bill Transmission
Original Bill
Second Review Appeal
Total
X12 277 ACK Compliant
277 ACK Compliant
56,158
85%
4,982
87%
61,140
85%
Yes
277 ACK Compliant
17
0%
2
0%
19
0%
No
277 Late
8,223
12%
579
10%
8,802
12%
No
277 Reject Untimely / Prior 277 Accept
1,625
2%
139
2%
1,764
2%
No
277 Reject Second Review Appeal
0
0%
23
0%
23
0%
No

X12 835 EOR

DWC Rule 7.1 requires Sedgwick to electronically send an Explanation of Review (EOR) to the provider using the X12 835 EDI standard. When a provider sends an Original e-bill, Sedgwick must electronically send the EOR within 15 working days after receipt of the e-bill from the provider. For Second Review e-bills, Sedgwick must electronically send the provider an EOR within 14 calendar days after receipt of the Second Reiew e-bill from the provider.

The table below reports the frequency at which Sedgwick compliantly sends X12 835 EORs to daisyBill clients.

 Review the sample Audit Complaints daisyBill submits to the California DWC to report EDI noncompliance.

53%
X12 835 Compliant
X12 EDI Standard
Original e-Bill
Second Review Appeal
Total
X12 835 Compliant
835 Compliant
34,645
54%
2,032
36%
36,677
53%
Yes
835 Missing
15,439
24%
1,384
25%
16,823
24%
No
835 Late
14,041
22%
2,149
39%
16,190
23%
No
277 Reject / 835 Timely
0
0%
9
0%
9
0%
No
277 Reject / 835 Late
0
0%
7
0%
7
0%
No

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