Medical Services Dispute Resolution Request { SFN 19605}

MEDICAL SERVICES DISPUTE RESOLUTION REQUEST CLAIMS DIVISION SFN 19605 (07/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com PLEASE PRINT OR TYPE USING BLACK OR BLUE INK NOTICE PAGE 1 OF 2 The requirements of NDAC 92-01-02-46 must be met before this form may be appropriately submitted to the Director. If the requirements are not met, your request will be dismissed. If an injured worker or provider raises a bona-fide dispute concerning WSI's determination that a worker is receiving, or is proposed to receive, medical treatment for a compensable condition that is excessive, inappropriate, ineffectual or in violation of the medical rules, binding dispute resolution may be requested. An employer who disputes an award for medical services may also request binding dispute resolution for a bona-fide dispute as defined under NDAC 92-01-02-46. In all cases of accepted compensable injury or illness under the jurisdiction of ND workers compensation law, the injured worker is not liable for payment of any services for the treatment of that injury or illness except as provided in NDAC 92-01-02-45.1(7a-e). INJURED WORKER INFORMATION Injured Worker Address City Type of Injury Injured Worker's Attorney Claim Number Social Security Number* Telephone Number State Zip Code Employer Date of Injury Attorney's Telephone Number PROVIDER INFORMATION Medical Provider Address City Contact Person Are you the attending doctor? State Zip Code Federal ID Tax ID Number Telephone Number Attending Doctor's Address (if different from above) Yes No If no, list name of Attending Doctor: City Attending Doctor's Telephone Number State Zip Code TREATMENT INFORMATION Type of treatment in dispute (be as speci c as possible. For example, "proposed fusion L5 "chiropractic treatment past medically stationary state", etc.) -S1, left" or "lumbar MRI" or Time Period of Treatment in Dispute Treatment disputed is: Proposed Already Provided * In compliance with the Federal Privacy Act of 1974, disclosure of the social security number on this form is mandatory pursuant to N.D.C.C. 65-05-02. The social security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. American LegalNet, Inc. www.FormsWorkFlow.com M2 MEDICAL SERVICES DISPUTE RESOLUTION REQUEST (con't) Injured Worker Claim Number PAGE 2 OF 2 TO BE COMPLETED BY REQUESTING PARTY You must respond to the questions listed below. Please provide narrative information on a separate sheet, numbered to correspond to each item listed. Yes No 1. Is the disputed treatment the result of the managed care program? 2. If you answered "Yes" to question #1, has the managed care vendor's internal dispute resolution process been completed? If "No", you must exhaust this process before requesting binding dispute resolution. If "Yes", please outline and submit documentation of the results of that process. 3. I have attached the following documentation and information: a. b. c. d. Statement summarizing my attempts to resolve this dispute informally with WSI or WSI's managed care vendor. Statement identifying the differences between the parties. Statement of the requested relief sought. Specified and/or attached all relevant and pertinent medical information regarding the dispute. Documentation to support the request for review. (Documentation includes, but is not limited to: Copies of the original HCFA bills, chart notes, remittance advice, operative reports, any correspondence between the parties regarding the dispute, copies of attending doctor's treatment plan or; palliative care treatment plan (if applicable), and any other documentation necessary to evaluate the dispute.) NOTE: You should be aware that the decision regarding the appropriateness of the request may be limited to information received from the requesting party. This form must be signed and dated by the provider or an authorized representation of the provider, or by the injured worker or an authorized representative of the injured worker, or by the employer or an authorized representation of the employer. Mailing instructions are listed below. CERTIFICATION STATEMENT This form was prepared by: Provider Injured Worker Injured Worker's Attorney Employer Other I have answered all questions to the best of my ability and have submitted sufficient documentation to support my review request. Signature Date MAIL COMPLETED FORM AND DOCUMENTATION TO: Workforce Safety & Insurance PO Box 5585 Bismarck, ND 58506-5585 American LegalNet, Inc. www.FormsWorkFlow.com M2