Necessity Of Treatment Dispute Resolution Request {WKC 9380}

WKC-9380-E - NECESSITY OF TREATMENT DISPUTE RESOLUTION REQUEST. This form is used in Wisconsin's Workers’ Compensation system to resolve disputes between health care providers and insurers or self-insured employers regarding payment for medical treatment. Specifically, it applies in cases where payment for treatment related to a conceded work injury is denied on the grounds that the treatment was unnecessary, or when there has been no response from the insurer or self-insurer within 60 days of billing. The form provides two resolution pathways: Section 1 allows a provider to request an independent review if a treatment denial was received within 60 days, and Section 2 allows a provider to request a default order if no response was received within that time frame. To process the request, the form requires supporting documentation such as the insurer’s denial, the provider’s rebuttal, medical records, and billing information. Submission of this form, while voluntary, may be necessary to avoid delays in the administration of a claim under Chapter 102 of the Wisconsin Statutes. www.FormsWorkflow.com