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Form 198 6/2005 State Of Utah – Labor Commission Division of Industrial Accidents 160 East 300 South – 3rd Floor – P. O. Box 146610 Salt Lake City, UT 84114-6610 (801) 530-6800 – FAX (801) 530-6804 INSURER REQUEST FOR EXTENSION OF TIME TO OBTAIN 2 ND DENTAL OPINION Name of Claimant _____________________________ Date of Birth ________________________ Address _____________________________________ Social Security Number _______________ ____________________________________________ Date of Injury _______________________ Phone Number ________________________________ Employer ___________________________ Name of Insurer ___________________________________________ Address _________________________________________________ ________________________________________________________ Phone Number ____________________________________________ Fax Number ______________________________________________ Name of Person Requesting Extension _____________________________________________________ _____________________________________________________________________________________ Date of Initial Dental Evaluation __________________________________________________________ _____________________________________________________________________________________ Anticipated Date to Locate Dentist for 2 nd Opinion ___________________ (Up to 10 additional days will be considered reasonable.) Is Injury or Treatment a Medical Emergency _________________________________________ Extension of Time Granted _______ Yes ______ No _________________________________________ ___________________________________ Signature of Industrial Accide nts Staff Person Date Copy to Insurer and Claimant R612. Labor Commission. Industrial Accidents. R612-2. Workers’ Compensation Rules-Health Care Providers. R612-2-18. Dental Injuries. A. This rules establishes procedures to obtain dental care for work-related dental injuries and sets fees for such dental care. B. Initial Treatment. 1. If an employer maintains a medical staff or designates a company doctor, an injured worker seeking dental treatment for work-rela ted injuries shall report to such medical staff or doctor and follow their instructions. 2. If an employer does not maintain a medical sta ff or designate a company doctor, or if such staff or doctor are not available, an injured worker may consult a dentist to obtain immediate care dental for injuries caused by a work-related accident. The in surer shall pay the dentist providing this initial treatment at 70% of UCR for the services rendered. C. Subsequent care by ini tial treatment providers. 1. If additional treatment is necessary, the dent ist who provided initial treatment my submit to the insurer a request for authorization to continue treatmen t. The transmission date of the request must be verifiable. The request its elf must include a description of the injury, the additional treatment required, and the cost of the additional treatment. If the den tist proceeds with treatment without authorization, the dentist must accept 70% UCR as payment in full and may not charge any additional sum to the injured worker. 2. The insurer shall respond to the request fo r authorization within 10 working days of the request’s transmission. This 10-day period can be exte nded only with written approval of the Industrial Division. If the insurer does not re spond to the dentist’s request for authorization within 10 working days, the insurer shall pay the cost of treatment as contained in the request for authorization. 3. If the insurer approves the proposed treatment, the insurer shall send written authorization to the dentist and injured worker. This authorizat ion shall include the anticipated payment amount. 4. On receipt of the insurer’s written author ization, and if the dentist accepts the payment provisions therein, the dentist may proceed to provide the approved services. The dentist must accept the amount to be paid by the insurer as full payment for t hose services and may not bill the injured worker for any additional amount. D. Subsequent care by other providers. 1. If the dentist who provided initial treatm ent does not agree to the payment offered by the insurer, the insurer shall within 20 calendar days direct the injured work er to a dentist located within a reasonable travel distance who will accept the insurer’ payment offer. 2. If the insurer cannot locate another dentist to provide the necessary services, the insurer shall attempt to negotiate a satisfactory reimbursement w ith the dentist who provided initial treatment. The negotiated reimbursement may not include any balance billing to the claimant. 3. If the insurer is successful in arranging treatment with another dentist, the insurer shall notify the injured worker. 4. If, after having received notice that the insurer has arranged the services of another dentist, the injured worker chooses to obtain treatment from a diffe rent dentist, the insurer shall only be responsible for payment at 70% of UCR. Under the circumstances of this subsection (4), the treating dentist may bill the injured worker for the differenc e between the dentist’s charges and the amount paid by the insurer. E. Payment or treatment disputes that cannot be resolved by the parties may be submitted to the Labor Commission’s Adjudication Division for decision, pursuant to the Adjudication Division’s established forms and procedures.