What if a required field is missing?

If a key field is omitted, the payor will usually issue a request for information. Missing claimant identifiers or TINs commonly cause routing delays and should be corrected promptly.

Can this form be signed electronically?

Yes, electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention are documented.

Is a notary required for the petition?

Notarization is typically not required for administrative provider petitions, but state or payor rules can vary; consult local board guidance when in doubt.

What attachments are most often requested?

Claims reviewers commonly request clinical notes, operative reports, imaging summaries, CPT/HCPCS line items, and prior authorization records if applicable.

How long should I keep copies?

Retain signed petitions and supporting records for at least the active claim period plus several years; HIPAA requires 6 years for many records (45 CFR §164.530(j)).

Who can sign the petition?

The authorized provider or an agent may sign. If using electronic signatures, ensure signer identity and authority are documented in the audit trail.

Electronic Signature
Templates
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WCB-190A Providers Petition for Payment of Medical

WCB-190A Providers Petition for Payment of Medical

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES

STATE OF MAINE

WORKERS' COMPENSATION BOARD

27 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0027

EMPLOYEE

NAME:

STREET/P.O. BOX:

CITY, STATE, ZIP:

TELEPHONE NUMBER:

DATE OF BIRTH:

SOCIAL SECURITY NUMBER: XXX-XX-

BOARD FILE NUMBER:

EMPLOYER

NAME:

STREET/P.O. BOX:

CITY, STATE, ZIP:

INSURER

NAME:

STREET/P.O. BOX:

CITY, STATE, ZIP:

NOTICE

When there is no ongoing dispute, if bills for medical or health care services are not paid within 30 days after the carrier has received notice of nonpayment by certified mail from the provider of the medical or health care services or, if the bill was paid by the employee, from the employee who paid for the medical or health care services, $50 or the amount of the bill due, whichever is less, must be added and paid to the provider of the medical or health care services or, if the bill was paid by the employee, to the employee who paid for the medical or health care services for each day over 30 days in which the bills for medical or health care services are not paid. Not more than $1,500 in total may be added pursuant to this subsection.

1. On sustained a work-related

injury while working for

2. The injury occurred

and the employee injured his/her

3. The charges related to the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of the employee's work-related injury or disease are as set forth on the attached bills (do not attach provider statements).

THEREFORE, the employee asks the board to order benefits pursuant to Title 39 or 39-A.

SIGNATURE OF PETITIONER

DATED:

FILING INSTRUCTIONS

Mail original petition to the Workers' Compensation Board at the above address by regular mail.
Mail one (1) copy by certified mail, return receipt requested, to each other party named in the petition.
Keep one (1) copy for yourself and keep the green certified mail cards when returned to you by the U.S. Post Office.

The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711.
WCB-190 (eff. 10/1/15)

What the WCB-190A Providers Petition for Payment of Medical Is

The WCB-190A Providers Petition for Payment of Medical is a workers' compensation petition used by medical providers to request payment for services rendered to an injured worker. It documents the provider's claim, the medical services or supplies billed, and the supporting treatment dates and records. The form is used within state workers' compensation systems to initiate administrative review, establish billing details, and notify responsible payors. Completing the WCB-190A accurately helps preserve billing rights and creates a clear administrative record for adjudication or settlement.

Why this petition matters for providers and payors

Filing a properly completed WCB-190A clarifies the amount due, documents medical necessity, and starts formal review for payment under the workers' compensation process. Accurate petitions reduce administrative delays and support timely resolution of billing disputes.

Who typically completes or receives the WCB-190A

The WCB-190A is completed primarily by treating medical providers, billing specialists, or their authorized representatives when seeking payment from an employer, insurer, or workers' compensation claims administrator.

Medical providers and clinics submitting charges for compensable work injuries.
Third-party billing agents or medical billing departments that prepare claims.
Claims administrators, payors, and defense counsel reviewing medical payments.

Step-by-step completion checklist

Follow these steps in order to prepare a complete WCB-190A and avoid common processing delays.

01

Gather records: Collect charts, dates of service, and billing codes before you start.
02

Complete form: Enter provider, claimant, and itemized charge information accurately.
03

Attach support: Add treatment notes, invoices, and prior authorization if available.
04

Send and retain: Submit to the claims administrator and keep a signed copy in records.

Digital workflow settings for eSubmission

Configure your electronic workflow to capture required fields, attachments, and signer authentication for the WCB-190A.

Field	Configuration
Patient Identifier	Required; autofill from claim database
Attachment Required	Set as mandatory for clinical notes and invoices
Signer Authentication	Email + SMS code or multi-factor for agent signers
Retention Policy	Store signed PDF with audit trail for required time

Digital signing and submission considerations

Use platforms that capture an auditable signing event and securely store attachments and metadata prior to sending to payors.

Authentication: Email + SMS or higher assurance
Document Formats: PDF and DOCX supported
Audit Trail: IP, timestamp, actions recorded

Typical submission flow for a provider petition

A standard four-step flow from preparation to adjudication shows where to attach evidence and how signatures are recorded.

Prepare petition: Provider completes WCB-190A with itemized charges
Attach records: Include treatment notes and invoices
Send to payor: Submit via claims portal or e-mail per rules
Payor review: Insurer reviews and issues payment decision

Key components to include on a professional petition

A complete WCB-190A clearly sets out the patient, provider, services billed, the legal basis for payment, and the provider's authority to bill.

Provider details

Legal name, address, NPI, and tax ID to ensure accurate payor matching and avoid billing rejections.

Claimant identity

Full injured worker name, date of birth, claim number, and employer to tie services to the compensable claim.

Service chronology

Itemized dates of service, CPT/HCPCS codes, and units so reviewers can verify treatment timing and billing accuracy.

Medical necessity

Brief clinical justification and diagnosis codes that support why the treatment was compensable under the claim.

Amount claimed

Clear line-item totals and a grand total that reconcile to attached invoices to prevent accounting discrepancies.

Authorization

Signature, provider representative name, and date establishing who submitted the claim and their authority to bill.

Attachments and supporting documents to include

Attach essential evidence to reduce follow-up requests and speed review of the petition.

Clinical Records

Include visit notes, progress reports, imaging reports, and any documentation demonstrating treatment provided and medical necessity for billed services.

Itemized Invoices

Provide invoices showing CPT/HCPCS codes, service dates, units, charges, and any prior payments or adjustments applied.

Authorizations

Attach prior authorizations, utilization review determinations, or referral documentation when payment depends on pre-approval.

Correspondence

Include prior communications with the payor, denials, or pre-billing notices to create a full administrative record.

Common pitfalls that cause delays or denials

Missing or inconsistent claimant identifiers between petition and claim file cause routing errors and payment delays.
Incomplete service detail or missing CPT/HCPCS codes often triggers requests for supplemental billing information.
Failure to attach medical records or authorization documents leads to denials for insufficient evidence of compensability.
Incorrect provider tax ID or mismatched payee name can result in backup withholding or rejected payment.

Consequences of an incorrect or incomplete petition

Claim Delay: Payment may be postponed

Denial Risk: Claim may be denied pending proof

Audit Exposure: Incomplete records increase audit likelihood

Financial Loss: Unpaid services reduce revenue

Regulatory Penalty: Potential sanctions for fraudulent claims

Backup Withholding: Incorrect TIN triggers 24% withholding

Timing expectations and common deadlines

Timing varies by jurisdiction and claims administrator; submit promptly and track response windows to preserve appeal rights.

Initial Submission:

Submit as soon as billing is compiled

Payor Acknowledgment:

Typically within 14–30 days of receipt

Request for More Info:

Often issued within 30 days if records missing

Appeal Window:

Varies; check state workers' comp timeline

Statute Consideration:

Timely filing preserves payment rights

Selected eSignature vendor comparison for petition workflows

Comparison focuses on typical price points and core capabilities relevant to providers submitting WCB-190A petitions; signNow is listed first per vendor comparison conventions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	30-day trial	30-day trial	Free limited plan	Free limited plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	No cap	No cap	No cap

Best practices to speed payment and reduce disputes

Adopt consistent internal processes and quality checks to minimize repetitive requests and maximize on-time payment.

Standardized intake

Use a consistent checklist for patient identity, claim number, TIN, CPT codes, and required attachments to reduce missing-data rejections.

Pre-submission QA

Run a quick reconciliation of invoices to ensure totals match attached statements and confirm provider tax identifiers before submission.

Secure eSubmission

Submit petitions using secure channels that preserve an audit trail; this reduces disputes about receipt and timing.

Track responses

Log acknowledgments and payor requests for additional info so deadlines and appeal windows are preserved and managed.

Real-world submission scenarios

Two concise examples show how providers and billers use the petition to resolve payment gaps.

Clinic billing resolution

A specialty clinic files WCB-190A after initial denial to reopen payment review

The clinic attached operative reports and billing reconciliation
The documented clinical notes and clear itemization supported reconsideration, shortening resolution from months to weeks and reducing administrative re-billing cycles.

Independent provider appeal

An independent physical therapist submitted an itemized petition after partial payment

The therapist included progress notes and prior authorizations
The added clinical documentation clarified medical necessity, leading to an adjusted payment and clearer guidance for future authorizations.

Key processing milestones after submission

These numbered milestones describe typical stages from submission to final decision in an administrative billing review.

01

Submission Received

Claims administrator records petition receipt and issues acknowledgment.

02

Initial Review

Reviewer checks completeness, coding, and attachments for compensability.

03

Information Request

Payor may request missing clinical records or clarification within a set window.

04

Final Decision

Payor issues payment, partial payment, or denial with appeal instructions.

Frequently asked questions about WCB-190A preparation and eSubmission

Practical answers to common questions about form completion, attachments, signatures, and retention for providers and billers.

Need help? Contact support

What if a required field is missing?
If a key field is omitted, the payor will usually issue a request for information. Missing claimant identifiers or TINs commonly cause routing delays and should be corrected promptly.
Can this form be signed electronically?
Yes, electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and retention are documented.
Is a notary required for the petition?
Notarization is typically not required for administrative provider petitions, but state or payor rules can vary; consult local board guidance when in doubt.
What attachments are most often requested?
Claims reviewers commonly request clinical notes, operative reports, imaging summaries, CPT/HCPCS line items, and prior authorization records if applicable.
How long should I keep copies?
Retain signed petitions and supporting records for at least the active claim period plus several years; HIPAA requires 6 years for many records (45 CFR §164.530(j)).
Who can sign the petition?
The authorized provider or an agent may sign. If using electronic signatures, ensure signer identity and authority are documented in the audit trail.

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