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Med-Legal Fee Schedule Report Cards

Since California’s new MLFS took effect on April 1, 2021, some claims administrators have proven better than others at properly reimbursing new billing codes and modifiers. With our Report Cards, providers can see which claims administrators get Medical-Legal payment right, which get it wrong, and how to appeal incorrect payments.

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ML200 - Mitsui Sumitomo Insurance: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/02/2021

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ML201 - Benchmark Insurance Company: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/01/2021

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ML200 - Guard Insurance Group: Grade B

Claims administrator properly processed reimbursement for ML200. The lower grade reflects that the explanation of review (EOR) incorrectly lists 99199 as the ‘Rev./Proc. Code.’

Date of Service: 04/05/2021

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ML202 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML202. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/06/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML204 - Contra Costa Schools Insurance Group: Grade A

Claims administrator properly processed reimbursement for ML204.

Date of Service: 04/13/2021

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ML200 - ESIS, Inc.: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/06/2021

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ML201 / MLPRR - Broadspire: Grade F

Claims administrator failed to properly reimburse ML201 and MLPRR. Broadspire incorrectly reduced reimbursement by taking a noncompliant PPO reduction.

Date of Service: 04/13/2021

EOR Adjustment Reason: G4 - This charge was adjusted to comply with the rate and rules of the contract indicated.

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ML201 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML201. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/09/2021

EOR Adjustment Reason: 561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code.

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ML201 / MLPRR - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML201 and MLPRR. Sedgwick incorrectly denied valid medical-legal codes as “not in the fee schedule.”

Date of Service: 04/06/2021

EOR Adjustment Reason: 549 - The service(s) on this claim have been denied because the provider billed using a procedure code that is not in the fee schedule

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ML200 - Benchmark Insurance Company: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/02/2021

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ML200 - CorVel: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/05/2021

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ML201 - ESIS, Inc.: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/01/2021

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ML200 - Berkshire Hathaway Homestate Companies: Grade B

Claims administrator properly processed reimbursement for ML200. The lower grade reflects that the explanation of review (EOR) incorrectly lists 99199 as the ‘Procedure Code/Mod.’

Date of Service: 04/16/2021

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ML202 - CorVel: Grade B

Claims administrator properly processed reimbursement for ML202. The lower grade reflects that the explanation of review (EOR) incorrectly lists ML201 as the reimbursed code.

Date of Service: 04/19/2021

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ML200 - Intercare Holdings Insurance, Inc.: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/12/2021

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ML200 - Beta Healthcare Group Risk Management Authority: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/12/2021

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ML201 - Sedgwick Claims Management Services: Grade B

Claims administrator properly processed reimbursement for ML201. The lower grade reflects that the explanation of review (EOR) incorrectly lists 99199 as the ‘Reimbursed Code.’

Date of Service: 04/01/2021

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ML200 - Benchmark Insurance Company: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/09/2021

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ML200 - AmTrust North America: Grade F

Claims administrator failed to properly reimburse ML200. AmTrust incorrectly re-coded ML200 to ML100.

Date of Service: 04/02/2021

EOR Adjustment Reason: G5 - This charge was adjusted for the reasons set forth in the attached letter.

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ML201 - Barrett Business Services Inc.: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/09/2021

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ML201 - Athens Administrators: Grade F

Claims administrator failed to properly reimburse ML201. Athens incorrectly reduced reimbursement by failing to adjudicate service with Modifier 93.

Date of Service: 04/14/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML200 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML200. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/09/2021

EOR Adjustment Reason: 561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code.

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ML200 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML200. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/02/2021

EOR Adjustment Reason: 561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code.

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ML203 - AIG Claims, Inc.: Grade F

Claims administrator failed to properly reimburse ML203. AIG incorrectly denied valid medical-legal code as not in the fee schedule.

Date of Service: 04/01/2021

EOR Adjustment Reason: 2 - This charge will be re-evaluated upon receipt of the proper procedure codes or procedure code/modifier combination as listed in the fee schedule.

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ML200 - CorVel: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/20/2021

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ML201 - AmTrust North America: Grade F

Claims administrator failed to properly reimburse ML201. AmTrust incorrectly re-coded ML201 to ML102.

Date of Service: 04/08/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML203 - AIG Claims, Inc.: Grade F

Claims administrator failed to properly reimburse ML203. AIG incorrectly denied valid medical-legal code as not in the fee schedule.

Date of Service: 04/01/2021

EOR Adjustment Reason: 2 - This charge will be re-evaluated upon receipt of the proper procedure codes or procedure code/modifier combination as listed in the fee schedule.

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ML201 - Intercare Holdings Insurance, Inc.: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/05/2021

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ML200 - Liberty Mutual Insurance: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/13/2021

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ML201 - Liberty Mutual Insurance: Grade F

Claims administrator failed to properly reimburse ML201. Liberty Mutual incorrectly reduced reimbursement by failing to process code with Modifiers 93 and 94.

Date of Service: 04/08/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - Helmsman Management Services: Grade F

Claims administrator failed to properly reimburse ML201. Helmsman Management Services incorrectly reduced reimbursement by failing to process code with Modifier 93.

Date of Service: 04/02/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML202 - Benchmark Insurance Company: Grade A

Claims administrator properly processed reimbursement for ML202.

Date of Service: 04/01/2021

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/08/2021

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/08/2021

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/24/2021

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/08/2021

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ML201 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/03/2021

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ML201 - Broadspire: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/09/2021

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ML201 - Broadspire: Grade B

Claims administrator properly processed reimbursement for ML201. The lower grade reflects that the explanation of review (EOR) incorrectly lists 99199 as the ‘Rev./Proc. Code.’

Date of Service: 04/05/2021

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ML201 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/08/2021

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ML203 / MLPRR - Beta Healthcare Group Risk Management Authority: Grade F

Claims administrator failed to properly reimburse MLPRR. Beta Healthcare Group incorrectly reduced reimbursement for record review citing “charge exceeds the official medical fee schedule allowance.”

Date of Service: 04/01/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - Farmers Insurance: Grade F

Claims administrator failed to properly reimburse ML201. Farmers incorrectly re-coded ML201 to ML103.

Date of Service: 04/05/2021

EOR Adjustment Reason: 270 - Please resubmit the bill with new ML codes with documentation and SBR for reconsideration.

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ML201 - AmTrust North America: Grade F

Claims administrator failed to properly reimburse ML201. AmTrust incorrectly re-coded ML201 to ML102.

Date of Service: 04/13/2021

EOR Adjustment Reason: 270 - No allowance has been recommended for this procedure/service/supply.

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ML203 / MLPRR - Helmsman Management Services: Grade F

Claims administrator failed to properly reimburse ML203 and MLPRR. Helmsman Management Services incorrectly denied valid medical-legal code as not reimbursable.

Date of Service: 04/01/2021

EOR Adjustment Reason: 531 - Please re-submit with the appropriate HCPCS/CPT Code.

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ML203 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML203.

Date of Service: 04/15/2021

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ML201 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/20/2021

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ML201 - Guard Insurance Group: Grade F

Claims administrator failed to properly reimburse ML201. Guard Insurance Group incorrectly denied valid medical-legal code as exceeding fee schedule allowance.

Date of Service: 04/01/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/17/2021

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ML201 - Liberty Mutual Insurance: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/20/2021

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ML200 - Sedgwick Claims Management Services: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/05/2021

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ML200 - Next Level Administrators: Grade A

Claims administrator properly processed reimbursement for ML200

Date of Service: 04/10/2021

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ML200 - Next Level Administrators: Grade A

Claims administrator properly processed reimbursement for ML200

Date of Service: 04/17/2021

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ML202 - Athens Administrators: Grade A

Claims administrator properly processed reimbursement for ML202.

Date of Service: 04/06/2021

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ML200 - Marriott Claims Service Corp: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/08/2021

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ML201 - Benchmark Insurance Company: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/01/2021

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ML202 - AIG Claims, Inc.: Grade F

Claims administrator failed to properly reimburse ML202. AIG incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/06/2021

EOR Adjustment Reason: 2 - This charge will be re-evaluated upon receipt of the proper procedure codes or procedure code/modifier combination as listed in the fee schedule.

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ML200 - AIG Claims Inc.: Grade F

Date of Service: 04/09/2021

EOR Adjustment Reason: 2 - This charge will be re-evaluated upon receipt of the proper procedure codes or procedure code/modifier combination as listed in the fee schedule.

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ML200 - CorVel: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/02/2021

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ML201 - CorVel: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/02/2021

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ML201 - Broadspire: Grade A

Claims administrator properly processed reimbursement for ML201. 

Date of Service: 04/20/2021

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ML201 - Helmsman Management Services: Grade A

Claims administrator properly processed reimbursement for ML201. 

Date of Service: 04/13/2021

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ML201 / MLPRR - Adminsure: Grade A

Claims administrator properly processed reimbursement for ML201 and MLPRR.

Date of Service: 04/02/2021

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ML201 - Adminsure: Grade A

Claims administrator properly processed reimbursement for ML201 and MLPRR.

Date of Service: 04/03/2021

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ML201 - State Compensation Insurance Fund (CA): Grade F

Claims administrator failed to properly reimburse ML201. State Compensation Insurance Fund (CA) incorrectly denied valid medical-legal codes as “not compensable.”

Date of Service: 04/07/2021

EOR Adjustment Reason: M1 - Workers' compensation claim adjudicated as non-compensable. Carrier not liable for claim or service/treatment.

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ML202 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML202. Sedgwick incorrectly underpaid valid medical-legal code as “exceeds the official medical fee schedule allowance.”

Date of Service: 04/06/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - ESIS: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/03/2021

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ML200 - Adminsure: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/24/2021

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ML201 - CorVel: Grade A

Claims administrator properly reimbursed ML201.

Date of Service: 04/13/2021

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ML200 - Helmsman Management Services: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/01/2021

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ML200 - Liberty Mutual: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/28/2021

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ML201 - Adminsure: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/13/2021

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ML200 - Contra Costa Schools Insurance Group: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/22/2021

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ML200 - Sedgwick Claims Management Services: Grade F

Claims administrator failed to properly reimburse ML200. Sedgwick incorrectly denied valid medical-legal code as “not considered a valid reimbursable code.”

Date of Service: 04/02/2021

EOR Adjustment Reason: 561 - According to the state fee schedule, this procedure code is not considered a valid reimbursable code. Please re-submit with a valid code.

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ML200 - Guard Insurance Group: Grade F

Claims administrator failed to properly reimburse ML200. Guard incorrectly reduced reimbursement by taking a noncompliant PPO reduction.

Date of Service: 04/05/2021

EOR Adjustment Reason: G4 - This charge was adjusted to comply with the rate and rules of the contract indicated.

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/29/2021

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ML202 - Intercare Holdings Insurance, Inc: Grade A

Claims administrator properly processed reimbursement for ML202.

Date of Service: 04/09/2021

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ML202 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML202.

Date of Service: 04/09/2021

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ML203 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML203.

Date of Service: 04/12/2021

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ML200 - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/27/2021

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ML201 - Next Level Administrators: Grade F

Claims administrator failed to properly reimburse ML201. Next Level Administrators incorrectly underpaid valid medical-legal code as “exceeds the official medical fee schedule allowance.

Date of Service: 04/01/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - Liberty Mutual Insurance: Grade F

Claims administrator failed to properly reimburse ML201. Liberty Mutual incorrectly underpaid valid medical-legal code as “exceeds the official medical fee schedule allowance.

Date of Service: 04/03/2021

EOR Adjustment Reason: G1 - The charge exceeds the official medical fee schedule allowance. The charge has been adjusted to the scheduled allowance.

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ML201 - Guard Insurance Group: Grade F

Claims administrator failed to properly reimburse ML201. Guard incorrectly incorrectly reduced reimbursement by taking a noncompliant PPO reduction.

Date of Service: 04/17/2021

EOR Adjustment Reason: G4 - This charge was adjusted to comply with the rate and rules of the contract indicated.

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ML201 - CorVel: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/03/2021

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ML200 - Enstar Group: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/23/2021

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ML203 / ML205 - Sentry Insurance: Grade A

Claims administrator properly processed reimbursement for ML203 and ML205.

Date of Service: 04/25/2021

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ML201 / MLPRR - State Compensation Insurance Fund (CA): Grade A

Claims administrator properly processed reimbursement for ML201 and MLPRR.

Date of Service: 04/26/2021

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ML203 / MLPRR - Sedgwick Claims Management Services: Grade A

Claims administrator properly processed reimbursement for ML203 and MLPRR.

Date of Service: 04/23/2021      

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ML201 - Next Level Administrators: Grade A

Claims administrator properly processed reimbursement for ML201.

Date of Service: 04/02/2021

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ML200 - Next Level Administrators: Grade A

Claims administrator properly processed reimbursement for ML200.

Date of Service: 04/24/2021

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