Fill and Sign the Necessity of Treatment Dispute for Workers Compensation Wisconsin Form

Yes No On (mo/day/yr)      1. The reason that the insurer or self-insurer believes the treatment was unnecessary. 2. The organization and credentials of any person who provided supporting documentation to the insurer or 3. My right to submit this dispute to the Worker's Compensation Division within 9 months from the date 4. My obligation to provide the insurer or self-insurer at least 30 days prior to submitting this dispute to the On (mo/day/yr)       5. 1 may not collect the disputed fee from the employee-patient once I received notice from the insurer or 6. The Division will charge either the insurer or me for their cost of obtaining an independent, impartial, On (mo/day/yr)       Wisconsin Department of Workforce Development 199 2 NECESSITY OF TREATMENT DISPUTE RESOLUTION REQUEST Worker's Compensation Division 201 E. Washington Ave. Room 161 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)]. Direct all inquiries to: Medical Cost Dispute Unit, telephone (608) 266-1340. Mail requests to address above. - INSTRUCTIONS: Complete Section 1 or Section 2 and all sections (3, 4 & 5) on the reverse side. For default orders, skip Section 1 and complete Section 2 below and sections 3, 4 and 5 on the reverse side. SECTION 1. REQUEST FOR INDEPENDENT REVIEW I,I received notice within 60 days of submitting the bill for payment from the insurer or self-insurer (listed in Section 3) refusing to pay for treatment (specified in Section 4) because it was not necessary. The notice also informed me of the items I have checked below: self-insurer. (above) on which I received the notice denying payment. Division a written explanation stating why the treatment was reasonably required to cure and relieve the effects of the injury. I,I provided the insurer a written explanation mailed to the address which the insurer or self-insurer directed me to use regarding this dispute. self-insurer that the treatment was in dispute, per 102.16(2m)(b), Stats. expert medical opinion on the necessity of treatment; if this is the first necessity of treatment dispute resolution request I have submitted to the Division for treatment provided on or after January 1, 1992; the insurer will pay the full cost; but in all subsequent disputes which I file, the losing party will pay the full cost of obtaining the expert's opinion. This is the first dispute I have submitted to the Division regarding the necessity of treatment provided on or after January 1, 1992. SECTION 2. REQUEST FOR DEFAULT ORDER: LATE NOTICE - OVER 60 DAYS (May be requested only if review is not requested in Section 1 above. I,I submitted my bill for treatment to the insurer or self-insurer (listed in SECTION 3). 1 received notice more than 60 days after I submitted the bill that the treatment was in dispute. Because the insurer or self-insurer failed to pay the bill or to provide me with notice within 60 days of the date I submitted my initial bill explaining the reason why the treatment was not necessary, I am requesting that the Division issue a default order directing immediate payment in full. WKC-9380(R. 2/00) Yes Yes No No Yes No                                                                                                                                                                                                                                                                                                                            Date Signed:      ( ) SECTION 3. NAME ADDRESS Individual Health Care Practitioner Insurer or Self-InsurerEmploye r (at time of injury) Employee - Patient Injury Date Social Security Number SECTION 4. DATES AMOUNT SPECIFIC TREATMENT IN DISPUTE FROM TO CHARGED PAID DISPUTED TOTAL S SECTION 5. As required by law, I am enclosing copies of all correspondence and medical records relating to this dispute including: 1. The insurer's or self-insurer's initial notice refusing to pay (if any). 2. My written response explaining to the insurer why the treatment was necessary (if any). As required by law, I am sending one copy of this dispute resolution request with all attachments to the insurer or self-insurer at the time I filed this request with the Division. Individual health care practitioner (this must be a physician, podiatrist, chiropractor, dentist, or psychologist) whose treatment or order of treatment is the subject of this dispute per Ind. 80.73(2)(d) Wisc. Admin. Code. Practitioner Name (print or type) License Number to Practice in WI Telephone Number Practitioner Signature: