Provider Request For Medical Fee Dispute Resolution {MFDR Form 19} | Pdf Fpdf Docx | Oklahoma

 Oklahoma   Workers Comp 
Provider Request For Medical Fee Dispute Resolution {MFDR Form 19} | Pdf Fpdf Docx | Oklahoma

Last updated: 10/17/2024

Provider Request For Medical Fee Dispute Resolution {MFDR Form 19}

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Description

MFDR FORM 19 - PROVIDER REQUEST FOR MEDICAL FEE DISPUTE RESOLUTION. This form is used in Oklahoma workers' compensation cases to request Medical Fee Dispute Resolution (MFDR). This form is filed by a healthcare provider (claimant) when there is a dispute regarding the payment of charges for health or rehabilitation services provided to an injured worker. The form outlines the services in dispute, the amount billed, and the amount paid by the workers' compensation payor (insurance carrier or employer). The Workers’ Compensation Commission will NOT set this MFDR Form 19 for hearing unless it is attached to a CC Form 9, Request for Hearing. Send a copy of the CC Form 9, MFDR Form 19 and the following to the workers’ Compensation PAYOR: (1) a paper copy of all medical bills related to the dispute, as originally submitted to the payor (2) a paper copy of each explanation of benefits (EOB) related to the dispute as originally submitted to the health care provider (3) a copy of all applicable medical records related to the date(s) of service in the dispute and (4) any other documentation that the provider deems applicable to the medical fee dispute. DO NOT ATTACH ANY SUCH RECORDS OR DOCUMENTATION TO THE MFDR FORM 19 WHEN THE FORM IS FILED WITH THE COMMISSION. www.FormsWorkflow.com

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