Request For Independent Bill Review {IBR-1}

DWC Form IBR-1 - REQUEST FOR INDEPENDANT BILL REVIEW. This form is used in California workers’ compensation cases when a medical provider disputes the amount paid on a bill after completing the required second bill review with the claims administrator. Issued by the Division of Workers’ Compensation (DWC) under California Code of Regulations, title 8, section 9792.5.8, this form allows providers to request review by an independent, conflict-free bill review organization (IBRO). The form collects detailed provider, employee, claims administrator, and billing information, including fee schedule selection, billing codes, and amounts in dispute. Required supporting documents must be indexed and submitted with the request, along with the applicable filing fee. Requests must be filed within 30 days of the second bill review determination. www.FormsWorkflow.com