Maryland > Workers Compensation > Vocational Rehabilitation
Claim For Medical Services C-51 - Maryland
|Claim For Medical Services Form. This is a Maryland form and can be used in Vocational Rehabilitation Workers Compensation .||
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WORKERS COMPENSATION COMMISSION 10 EAST BALTIMORE STREET BALTIMORE, MD 21202-1641 http://www.wcc.state.md.us Claim No: Social Security No: Case of: Employer: INSTRUCTIONS: Before a bill is presented to the Commission for consideration, it must be presented to the employer and/or insurer for payment. If payment is refused, then an itemized bill must be submitted with this form and any correspondence pertinent the subject. For additional information, see the reverse (Additional Information) of this form. Bill of Name of Physician or Hospital Street Suite # or addtional address Telephone # City State Zip Code For$ , for services rendered Name of Injured Employee Street Suite # or addtional address Telephone # City State Zip Code While in the employ of Name of Employer Street Suite # or addtional address Telephone # City State Zip Code For accident which happened on the day of , . In compliance with COMAR 14.09.03.01(10), the bill was presented to: Name of Insurer Street Suite # or addtional address Telephone # City State Zip Code Date mailed to Insurer: Payment was refused as per attached correspondence. Request is hereby made of the Commission to approve this bill, which is as follows: ATTACH ITEM IZED BILL(S) WITH THIS FORM Name of Physician or Representative completing this form (Contact) Contact Telephone Number Contact Email Address ACTION OF MEDICAL DEPARTMENT ON THE ABOVE CLAIM. Form C-51 (Rev. OCT. 2004) <<<<<<<<<********>>>>>>>>>>>>> 2 ADDITIONAL INFORMATION 1. Claim for Medical Services must be provided to Employer/Insurer for payment. 2. If payment is refused, then an itemized bill prepared in compliance with COMAR.14.09.03.01(10) must be submitted with this form and any correspondence on the subject. * Form C-51 must be completed in entirety. * If any required information is not complete, all documents will be returned with a cover letter stating what is needed. * Social Security Number must be provided. * Dates of service will be checked against Claim Forms and/or First Reports of Injury f iled. 3. CPT codes will b e validated using the Medical Fee Guide for the year of service. Some CPT codes which are not "specific" may require a detailed description. 4. The Commission will i ssue an Order NISI forallow the Medical Fed medical claims per ee Guide. * To controvert the Order NISI complete the Workers Compensation Commission form H-24M (09/05/2003) "Controversion of Medical Claim". * The "Controversion of Medical Claim" form must be filed w ith the Workers Compensation Commission wi thin 21 days of the Order NISI and c opies must be mailed to the Health Care Provider and other appropriate parties. * If the medical claim is controverted, it will be scheduled for a hearing before a Commissioner. 5. If the medical claim is not controverted, the Workers Compensation Commission will i ssue a F inal Order of Payment. * A provider may request a hearing before the Commission if an insurer refuses payment of the Medical Claim after the Final Order of Payment. *The Commission may impose penalties, fines and interest or may deny the Employer and Insurer the right to object to reimbursement if the Insurerfails without good cause to timely reimburse the provider for treatment or services. (LE9-664); COMAR 14.09.03.01(10)(c) and (e). Note: The Medical Fee Guide referred to is the "Official Maryland Workers Compensation Medical Fee Schedule".