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Payment Dispute Resolution Process

State of South Carolina law (42-9-360(d)) provides that "Payment to an authorized health care provider for services shall be made in a timely manner but no later than thirty days from the date the authorized health care provider tenders request for payment to the employer's representative, unless the commission has received a request to review the medical bill."

In cases in which a medical provider has not received full payment for Workers' Compensation services pursuant to the South Carolina Workers' Compensation Act (when such payment is not adjusted through contractual agreements in place between the parties), the medical provider may observe the following procedure.

  1. If, following the earlier of the expiration of the initial 30-day billing period, or the receipt of a partial payment for services billed, the medical service provider believes they are entitled to additional payment under the Workers' Compensation Act (WCA), the medical service provider shall issue a written "2nd notice for payment" (sample form letters available here). The Commission encourages the provider to tender a "2nd Notice" via "receipt confirmed" means (ie: certified mail; commercial delivery carrier; etc.).
  2. If, 30 days following the issurance of a "2nd notice for payment," the medical services provider has:
    a.  received no response from the payer, the provider may submit a petition (petition available here) and supporting documentation to the Medical Services Division stating that:
         i.  the payer has not responded to the "2nd Notice";
        ii.  the provider is entitled to the lesser of the billed payment amount or the SCWCC Maximum Allowable
             Payment; and
       iii.   the provider desires the SCWCC to issue a finding supporting payment from the payer.
    b.  not received full payment, the provider may petition the South Carolina Workers' Compensation Commission Medical Services Division to review the case and issue a determination (petition available here). Supporting documentation as defined within the petition document must be provided to the SCWCC at the time of submission.
  3. Upon receipt and review of the provider's petition, the SCWCC may (if the provided information warrants) initiate an information discovery process. During this process, the SCWCC shall issue a "Notice of Dispute" to the payer, the employer and the provider, and shall include copies of all documentation provided to the SCWCC concerning the case. The payer shall have 30 days from the issuance of the "Notice of Dispute" to respond to the SCWCC.
    a.  In cases in which the provider alleges that the payer has not responded to the "2nd Notice", the SCWCC shall issue a notice of dispute and request that the payer provide evidence that it did respond in writing (as evidenced by certified mail receipt) to the "2nd Notice" within the 30-day period described in section 2 above.
    b.  In cases in which the provider confirms that payer has provided written response to the "2nd Notice", payer shall provide to the SCWCC documentation justifying its nonpayment or partial payment of provider's bill.
  4. Within 21 days of the earlier of the expiration of the "notice of dispute" period or the payer's response to the "notice of dispute", the SCWCC shall issue its determination of the case. If such determination instructions specific action to be taken by the parties to the case, such action must be completed within 14 days of the issuance of the SCWCC's determination.
  5. If action has not been completed within the 14-day period, the SCWCC may bind the case for docketing to be heard before the Commission. Once docketed, applicable adjudication fees will apply. At hearing, additional fines/penalties may be imposed.
  6. Please note:  The Payment Dispute Resolution Process is not designed to permit the intentional delay of payment of provider service fees. Medical Bill Review entities which are found to have withheld payment on non-substantiated grounds may be subject to administrative fines and penalties up to the suspension and/or revocation of their approval to conduct South Carolina Workers' Compensation Medical Bill Review services.

  Medical Bill Dispute Form