Application For Payment Of Additional Reimbursements Of Medical Fees {WC-MD-02}

WC-MD-02 - APPLICATION FOR PAYMENT OF ADDITIONAL REIMBURSEMENT OF MEDICAL FEES. This form is issued by the Missouri Department of Labor and Industrial Relations, Division of Workers’ Compensation, and is used by health care providers to dispute underpayment of medical services provided to an injured worker. This form applies only when the employer or insurer has made partial payment and the dispute concerns the reasonableness of the medical fee amount under §287.140, RSMo. Providers must file within one year (for services rendered after July 1, 2013) or two years (for earlier services) from the notice of dispute. Corporations and LLCs must file through a Missouri-licensed attorney. The Division assigns a medical fee dispute number upon receipt, and unresolved disputes may proceed to an administrative ruling or evidentiary hearing. www.FormsWorkflow.com