Oregon > Workers Comp > Request For Review Of Decision Or Resolution Of Dispute
Medical Fee Dispute Resolution Request 2330 - Oregon
| Medical Fee Dispute Resolution Request Form. This is a Oregon form and can be used in Request For Review Of Decision Or Resolution Of Dispute Workers Comp . |
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Medical Fee Dispute Resolution Request Workers Compensation Division Notice When a dispute exists between a medical provider and an insurer, OAR 436-009-0008 allows an insurer, medical provider, or injured worker to request an administrative review by the director of the Department of Consumer and Business Services to settle the dispute. A request for administrative review must be submitted to the director within 90 days of the date the aggrieved party knew or should have known that the dispute existed. As an alternative to administrative review, your issue may be resolved by a less formal dispute-resolution process. This process allows the parties to work with a trained facilitator from the Medical Review Unit at an agreed-upon location to resolve the dispute. A medical reviewer may contact you about this process or, if you are interested in it, contact the Medical Review Unit at the phone number on the back of this form. If you are aggrieved because of nonpayment or reduction of payment, you must do the following before submitting this form: 1. Contact the insurer to determine why payment has not been made or why payment has been reduced. Please submit documentation. 2. Wait at least 45 days from the date the insurer received your billing. OAR 436-009-0030 In all cases of accepted compensable injury or illness under workers compensation law, the injured worker is not liable for payment for any services for the treatment of that injury or illness, except as provided in OAR 436-009-0015. Worker information Worker name: Phone: Address: City, State, ZIP: Social Security no.: Claim no.: Date of injury: Employer/insurer information Employer name: Employers workers compensation insurer: Insurer address: City, State, ZIP: Insurer phone: Provider information Medical provider name: Phone: Address: City, State, ZIP: Contact person: Are you the attending physician (AP) or authorized nurse practitioner (NP)? Yes No If no, name of AP or NP: Phone: Address: City, State, ZIP: 440-2330 (5/04/DCBS/WCD/WEB) (continued on back) 2330 <<<<<<<<<********>>>>>>>>>>>>> 2To be completed by requesting party Directions: You must respond to the questions below. Please provide additional narrative information on a separate sheet, numbered to correspond to each item listed: Yes No 1. Is the injured worker covered by an insurer/MCO contract? If yes, the MCO dispute-resolution process, if available, must be attempted prior to coming to the director; documentation of that process and the resulting decision must be attached to this form. OAR 436-015-0110 2. Has the insurer paid a portion of the bill and/or notified you of the reasons for reduced payment? If no, please explain and include copies of documents describing actions youve taken to determine why billing was not paid. If yes, attach the completed worksheet (Page 3 of this form) showing specific code(s) and dates of service in dispute. 3. Has the injured worker made payment for part or all of the services in dispute? If Yes, attach a sheet listing dates of service, amounts billed, and amounts paid by the injured worker. 4. Have you billed any other insurance company for the dates of service in dispute? If yes, attach a sheet listing the insurance company, the dates of service, the amount billed, and the amount paid. 5. I have attached the following: Statement identifying the grounds for questioning the disputed amount. Statement identifying the request for correction and relief. Documentation to support the request for review. (Documentation includes but is not limited to copies of original HCFA bills, chart notes, bill analysis from the insurer, operative reports, any correspondence between the parties regarding the dispute, copies of attending-physician treatment plan or palliative care treatment plan (if applicable), and any other documentation necessary to evaluate the dispute.) Be aware that the decision regarding the appropriateness of the request may be limited to information received from the medical provider and the insurer. This form must be signed and dated by the medical provider or an authorized representative of the medical provider or by the insurer/self-insured employer or an authorized representative of the insurer/self-insured employer. Mailing instructions are outlined below. Certification statement By signing below, I certify that: 1. I have answered all questions to the best of my ability. 2. Sufficient documentation to support the review request is attached. 3. The involved insurer or vendor (provider) has been provided a copy of the request for review and attached supporting documentation. 4. There is no issue of causation or compensability of the underlying claim or condition. Signature:________________________________________________________Date:___________________________________ Send the completed, signed original of this form and all accompanying documents to: Workers Compensation Division Medical Review Unit 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 For more information, please call the Medical Review Unit, (503) 947-7816 or (503) 947-7993 (TTY). 440-2330 (5/04/DCBS/WCD/WEB)
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