Fill and Sign the Wisconsin Fee Workers Compensation Form

REASONABLENESS OF FEE DISPUTE RESOLUTION REQUEST Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901 Personal information you provide may be used for secondary purposes, (Privacy law, s. 15.04(l)(m).Madison, Wl 53707-7901 Telephone: (608) 266-1340 Direct all inquiries to: Medical Cost Dispute Unit, telephone (608) 266-1340. Please read the following information carefully before filling out this form. 1 . This form should be used ONLY for fee disputes related to treatment provided on or after July 1, 1992. 2. Once a health care provider has been notified that the fee for treatment is in dispute, the provider may not collect or bring an action for collection of the disputed fee against the person who received the treatment, (1 02.16(2)(b), Stats.). 3. Generally, in denying payment, the insurer or self-insurer will use a data base certified by the Department of Workforce Development to determine the ''formula amount''. The formula amount is the arithmetic mean of all fees in the data base, plus 1.5 standard deviations from the mean, in a particular region of the state, for a specific CPT code. If the fee is less than the formula amount shown in the certified data base for that procedure, the fee is presumed to be reasonable. If the fee is more than the formula amount, the insurer or self-insurer must pay only for the formula amount unless the provider demonstrates that the service provided in this case was more difficult or more complicated to provide than in the usual case. 4. In denying payment, the insurer or self-insurer must also specify, among other things: A. The CPT code (or other code from a certified data base) in dispute-, B. The formula amount for the coded procedure and the certified data base from which that formula amount was obtained-, C. The steps a provider must take prior to submitting this dispute to the department. SECTION 1. DATES OF CORRESPONDENCE PRIOR TO SUBMITTING DISPUTE Please provide the dates requested in paragraphs A & B in the column at right. DAT E A. Date Health care provider first billed insurer or self-insurer. NOTE: The provider has 6 months to file a dispute resolution request with the department from the date the insurer or self-insurer first refuses to pay the bill. B. Date insurer or self-insurer first refused to pay the fee. NOTE: If this date is not within 30 days of the billing date shown in Section 1A, the insurer shall compute and pay interest from this date if the provider prevails. SECTION 2. ISSUES IN DISPUTE YES NO A. In refusing to pay the disputed fees (listed in Section 4), did the insurer state it was using a data base certified by the department? B. Did the insurer state that the disputed fees are higher than the formula amount in a certified data base? C. Is the provider alleging that a fee greater than the formula amount from a certified data base is justified because the service for each disputed fee was more difficult or complicated to provide than the usual care? D. If the answer to C is yes, at least 20 days prior to filing this dispute, did the provider explain to the insurer the reason why the higher fee was justified? E. If the answer to D is yes, did the insurer respond to the explanation? F. Is there a dispute about whether the fee for service was properly coded? G. Are there other matters in dispute? (If yes, attach a narrative explanation.) -PLEASE CONTINUE TO PROVIDE INFORMATION ON THE REVERSE SIDE- WKC-9498 (R. 2/00)                                                                                                                                                                                                                                                                                                                                                                                                            Yes No Yes No Yes No                                                              Name:                        Lic. No. to Practice in WI:            Signature:             Date Signed:                        - - SECTION 3. NAM E ADDRESS SECTION 5. As required by law, I am enclosing copies of all correspondence relating to this dispute including: Health Care Provider 1. The insurer's or self-insurer's initial notice refusing to pay. Insurer or Self-Insurer 2. My written response explaining to the insurer why the fee was justified. Employer (at time of injury) 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 same time I filed this request with the Division. Employee - Patient The health care provide whose fee is the subject of this dispute: Injury Date Social Security No. Certified Data Base Used by Insurer The provider's fee is based upon the zip code at which the service was provided. If the zip code indicated for the health care provider in section 3 of this form is not the zip code location at which the service was provided, please indicate the correct zip code for each service listed in section 4. SECTION 4. SPECIFIC TREATMENT IN DISPUTE TREATMENT NUMBER OF NUMBER CPT CPT DATE S AMOUNT ZIP CODE TREATMENTS OF UNITS BILLING MODIFIER FROM TO CHARGED PAID DISPUTED CODE TOTALS