Request to Resolve a Medical Fee Dispute Instructions
This form contains 203 fields organized into 33 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Claim Information | ||
| Injured Employee's Name | Text |
Please provide the full name of the injured employee.
|
| Date of Injury | Date |
Please provide the date when the injury occurred.
|
| Claim Numbers | ||
| DWC Claim | Text | |
| Carrier Claim Number | Text |
Provide the claim number assigned by the carrier.
|
| DWC Claim Number | Text |
Provide the DWC (Division of Workers' Compensation) claim number.
|
| Eighteenth Disputed Service | ||
| Eighteenth Disputed Service - Dates | Text |
Enter the dates of service for the eighteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighteenth Disputed Service - Treatment/Service Codes | Text |
Enter the treatment or service codes for the eighteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighteenth Disputed Service - Amount Billed | Number |
Enter the amount billed for the eighteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighteenth Disputed Service - Amount Paid | Number |
Enter the amount paid for the eighteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighteenth Disputed Service - Amount in Dispute | Number |
Enter the amount that is in dispute for the eighteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Service | ||
| Eighth Service Dates in Dispute | Text |
Enter the specific dates of service for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Service Treatment Codes | Text |
Enter the treatment or service codes for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Service Amount Billed | Number |
Enter the total amount billed for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Service Amount Paid | Number |
Enter the total amount paid for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Service Amount in Dispute | Number |
Enter the total amount in dispute for the eighth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Service Dates | Date |
Enter the specific dates of the eighth service that is in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Treatment/Service Codes | Text |
Enter the treatment or service codes for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Amount Billed | Number |
Enter the total amount billed for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Amount Paid | Number |
Enter the total amount paid for the eighth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eighth Disputed Amount in Dispute | Number |
Enter the total amount that is currently in dispute for the eighth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eleventh Disputed Service | ||
| Eleventh Disputed Service Dates | Date |
Provide the dates of the eleventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eleventh Disputed Service Codes | Text |
Enter the treatment or service codes for the eleventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eleventh Disputed Service Amount Billed | Number |
Specify the amount billed for the eleventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eleventh Disputed Service Amount Paid | Number |
Indicate the amount paid for the eleventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Eleventh Disputed Service Amount in Dispute | Number |
State the amount that is currently in dispute for the eleventh service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifteenth Disputed Service | ||
| Fifteenth Dates of Service in Dispute | Date |
Enter the dates of the fifteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifteenth Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes for the fifteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifteenth Amount Billed | Number |
Enter the amount billed for the fifteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifteenth Amount Paid | Number |
Enter the amount paid for the fifteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifteenth Amount in Dispute | Number |
Enter the amount currently in dispute for the fifteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifth Disputed Service | ||
| Fifth Dates of Service in Dispute | Date |
Enter the date of the fifth service that is in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifth Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes for the fifth service that is in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifth Amount Billed | Number |
Enter the billed amount for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifth Amount Paid | Number |
Enter the amount paid for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fifth Amount in Dispute | Number |
Enter the amount currently in dispute for the fifth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Disputed Service Dates | Date |
Enter the date or date range of the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Disputed Service Codes | Text |
Enter the treatment or service codes for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the total amount that was billed for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the total amount that was paid for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the specific amount that is currently in dispute for the fifth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| First Disputed Service | ||
| Date of Service | Date |
Enter the date of the first disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment/Service Codes | Text |
Enter the treatment or service codes for the first disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount billed for the first disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount paid for the first disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the amount currently in dispute for the first disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Dates of Service in Dispute | Date |
Enter the specific dates when the disputed service was provided. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes in Dispute | Text |
Provide the relevant treatment or service codes for the disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the total amount that was originally billed for this service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the total amount that was paid towards this service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the portion of the amount for this service that is currently under dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourteenth Disputed Service | ||
| Fourteenth Service Dates | Text |
Enter the dates of service for the fourteenth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourteenth Service Codes | Text |
Enter the treatment or service codes for the fourteenth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourteenth Amount Billed | Number |
Enter the amount billed for the fourteenth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourteenth Amount Paid | Number |
Enter the amount paid for the fourteenth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourteenth Amount in Dispute | Number |
Enter the amount in dispute for the fourteenth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Disputed Service | ||
| Fourth Disputed Service Dates | Date |
Provide the date or date range for the fourth service being disputed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Disputed Service Codes | Text |
Enter the treatment or service codes relevant to the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Disputed Service Amount Billed | Number |
Enter the total amount billed for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Disputed Service Amount Paid | Number |
Enter the total amount paid for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Disputed Service Amount in Dispute | Number |
Enter the total amount that is currently in dispute for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Service Date | Date |
Please enter the dates of the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Service Codes | Text |
Please enter the treatment or service codes for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Service Amount Billed | Number |
Please enter the total amount billed for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Service Amount Paid | Number |
Please enter the total amount paid for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Fourth Service Amount in Dispute | Number |
Please enter the total amount in dispute for the fourth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| General | ||
| Yes | Checkbox |
Check this box if the injured employee is a first responder who sustained a serious bodily injury. Fill only if 'Injured Employee' is 'Yes'.
Depends on:
Injured Employee
|
| No | Checkbox |
Check this box if the injured employee is not a first responder or did not sustain a serious bodily injury. Fill only if 'Injured Employee' is 'Yes'.
Depends on:
Injured Employee
|
| Grand Total | ||
| Grand Total Amount Billed | Number |
Please provide the grand total amount billed for all disputed services. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Grand Total Amount Paid | Number |
Please provide the grand total amount paid for all disputed services. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Grand Total Amount in Dispute | Number |
Please provide the grand total amount in dispute for all services listed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Nineteenth Disputed Service | ||
| Nineteenth Disputed Service Dates | Date |
Provide the dates when the nineteenth disputed service was rendered. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Nineteenth Disputed Service Treatment Codes | Text |
Enter the treatment or service codes associated with the nineteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Nineteenth Disputed Service Amount Billed | Number |
Enter the amount that was originally billed for the nineteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Nineteenth Disputed Service Amount Paid | Number |
Enter the amount that has been paid for the nineteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Nineteenth Disputed Service Amount in Dispute | Number |
Enter the specific amount that is currently in dispute for the nineteenth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Service | ||
| Dates of Service (9th Disputed) | Text |
Enter the dates of service for the ninth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment/Service Codes (9th Disputed) | Text |
Provide the treatment or service codes for the ninth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed (9th Disputed) | Number |
Enter the total amount billed for the ninth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid (9th Disputed) | Number |
Enter the total amount paid for the ninth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute (9th Disputed) | Number |
Enter the total amount that is in dispute for the ninth disputed item. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Service Dates | Date |
Provide the dates of the ninth service entry that is currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Service Codes | Text |
Enter the treatment or service codes for the ninth service entry that is currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Amount Billed | Number |
Enter the amount billed for the ninth service entry that is currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Amount Paid | Number |
Enter the amount paid for the ninth service entry that is currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Ninth Disputed Amount in Dispute | Number |
Enter the amount that is currently in dispute for the ninth service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Requestor Contact Information | ||
| Requestor's Contact Name | Text |
Provide the full name of the contact person for the requestor, if different from the requestor.
|
| Requestor's Phone Number | Text |
Enter the contact phone number for the requestor.
|
| Requestor's Fax Number | Text |
Enter the fax number for the requestor.
|
| Requestor's Email Address | Text |
Enter the email address for the requestor.
|
| Requestor Information | ||
| 3 Requestors Name | Text | |
| Requestor's Address | Text |
Provide the street address for the requestor.
|
| Requestor's City, State, ZIP | Text |
Provide the city, state, and ZIP code for the requestor's address.
|
| Requestor's Name | Text |
Provide the full name of the person or entity making this request.
|
| Second Disputed Service | ||
| Second Disputed Service Dates | Date |
Provide the dates for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Codes | Text |
Enter the treatment or service codes for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Amount Billed | Number |
Enter the total amount billed for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Amount Paid | Number |
Enter the total amount paid for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Amount in Dispute | Number |
Enter the total amount that is in dispute for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Dates | Date |
Enter the dates of service for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Service Codes | Text |
Enter the treatment or service codes for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Amount Billed | Number |
Enter the amount billed for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Amount Paid | Number |
Enter the amount paid for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Second Disputed Amount | Number |
Enter the amount currently in dispute for the second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventeenth Disputed Service | ||
| Seventeenth Disputed Service Dates | Date |
Enter the date(s) of the seventeenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventeenth Disputed Service Codes | Text |
Enter the treatment or service codes for the seventeenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventeenth Disputed Service Amount Billed | Number |
Enter the amount billed for the seventeenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventeenth Disputed Service Amount Paid | Number |
Enter the amount paid for the seventeenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventeenth Disputed Service Amount in Dispute | Number |
Enter the amount currently in dispute for the seventeenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service | ||
| Seventh Service Date | Date |
Provide the date(s) of service for the seventh disputed medical service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Service Treatment Code | Text |
Provide the treatment or service codes for the seventh disputed medical service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Service Amount Billed | Number |
Provide the total amount billed for the seventh disputed medical service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Service Amount Paid | Number |
Provide the total amount paid for the seventh disputed medical service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Service Amount in Dispute | Number |
Provide the total amount that is currently in dispute for the seventh medical service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service Dates | Date |
Provide the dates of service for the seventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service Treatment Codes | Text |
Enter the treatment or service codes for the seventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service Amount Billed | Number |
Enter the amount billed for the seventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service Amount Paid | Number |
Enter the amount paid for the seventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Seventh Disputed Service Amount in Dispute | Number |
Enter the amount in dispute for the seventh disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixteenth Disputed Service | ||
| Sixteenth Disputed Service Dates | Text |
Enter the dates of the sixteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixteenth Disputed Service Codes | Text |
Enter the treatment or service codes for the sixteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixteenth Disputed Service Amount Billed | Number |
Enter the amount billed for the sixteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixteenth Disputed Service Amount Paid | Number |
Enter the amount paid for the sixteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixteenth Disputed Service Amount in Dispute | Number |
Enter the amount that is currently in dispute for the sixteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixth Disputed Service | ||
| Sixth Service Dates in Dispute | Text |
Enter the dates for the sixth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixth Service Codes in Dispute | Text |
Enter the treatment or service codes for the sixth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixth Service Amount Billed | Number |
Enter the amount billed for the sixth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixth Service Amount Paid | Number |
Enter the amount paid for the sixth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Sixth Service Amount in Dispute | Number |
Enter the amount that is in dispute for the sixth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Dates of Service | Date |
Provide the dates of service that are currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes | Text |
Enter the treatment or service codes that are currently in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount that was billed for the service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount that was paid for the service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the specific amount that is currently in dispute for the service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service | ||
| Tenth Dates of Service in Dispute | Text |
Provide the dates of service for the tenth disputed service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Treatment or Service Codes in Dispute | Text |
Provide the treatment or service codes for the tenth disputed service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Amount Billed | Number |
Enter the amount billed for the tenth disputed service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Amount Paid | Number |
Enter the amount paid for the tenth disputed service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Amount in Dispute | Number |
Enter the amount currently in dispute for the tenth disputed service entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service Dates | Text |
Provide the dates of the tenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service Codes | Text |
Enter the treatment or service codes for the tenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service Amount Billed | Number |
Enter the amount that was billed for the tenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service Amount Paid | Number |
Enter the amount that was paid for the tenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Tenth Disputed Service Amount in Dispute | Number |
Enter the specific amount that is in dispute for the tenth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service | ||
| Third Disputed Service Dates | Text |
Enter the dates of service for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Treatment/Service Codes | Text |
Enter the treatment or service codes for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount Billed | Number |
Enter the amount billed for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount Paid | Number |
Enter the amount paid for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount in Dispute | Number |
Enter the amount currently in dispute for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Dates | Date |
Enter the date or date range for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Treatment/Service Codes | Text |
Enter the treatment or service codes for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount Billed | Number |
Enter the total amount billed for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount Paid | Number |
Enter the total amount paid for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Third Disputed Service Amount in Dispute | Number |
Enter the total amount currently in dispute for the third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Thirteenth Disputed Service | ||
| Dates of Service in Dispute | Date |
Enter the dates of the disputed service for the thirteenth entry. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes for the thirteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount billed for the thirteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount paid for the thirteenth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the amount that is in dispute for the thirteenth service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amounts | ||
| Amount Billed Total | Text | |
| Amount Paid Total | Text | |
| Amount in Dispute Total | Text | |
| Total Amount Billed | Number |
Enter the total amount billed for all disputed services. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amount Paid | Number |
Enter the total amount paid for all disputed services. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amount in Dispute | Number |
Enter the total amount in dispute for all disputed services. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twelfth Disputed Service | ||
| Dates of Service in Dispute | Date |
Enter the date or date range for the twelfth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes for the twelfth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the total amount billed for the twelfth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the total amount paid for the twelfth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the total amount that is in dispute for the twelfth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twentieth Disputed Service | ||
| Twentieth Disputed Service Dates | Text |
Enter the date or date range of the twentieth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twentieth Disputed Service Codes | Text |
Enter the treatment or service codes for the twentieth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twentieth Disputed Service Amount Billed | Number |
Enter the amount billed for the twentieth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twentieth Disputed Service Amount Paid | Number |
Enter the amount paid for the twentieth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twentieth Disputed Service Amount in Dispute | Number |
Enter the amount currently in dispute for the twentieth disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-fifth Disputed Service | ||
| Total Count of Disputed Service Dates (Page 1) | Number |
Enter the total count of disputed service date entries reported on Page 1. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Count of Disputed Service Codes (Page 1) | Number |
Enter the total count of disputed service code entries reported on Page 1. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amount Billed (Page 1) | Number |
Enter the total amount billed for all disputed services reported on Page 1. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amount Paid (Page 1) | Number |
Enter the total amount paid for all disputed services reported on Page 1. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Total Amount in Dispute (Page 1) | Number |
Enter the total monetary amount remaining in dispute for all services reported on Page 1. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-first Disputed Service | ||
| Twenty-first Disputed Service Dates | Date |
Enter the dates of the twenty-first service that is being disputed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-first Disputed Service Codes | Text |
Enter the treatment or service codes for the twenty-first service that is being disputed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-first Disputed Service Amount Billed | Number |
Enter the total amount that was billed for the twenty-first service being disputed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-first Disputed Service Amount Paid | Number |
Enter the total amount that was paid for the twenty-first service being disputed. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-first Disputed Service Amount in Dispute | Number |
Enter the specific amount that is currently in dispute for the twenty-first service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-fourth Disputed Service | ||
| Dates of Service in Dispute | Date |
Provide the date or date range of the service that is in dispute. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes related to the disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount that was originally billed for this service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount that has been paid for this service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the total amount of money that is currently in dispute for this service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-second Disputed Service | ||
| Dates of Service in Dispute | Text |
Enter the dates of service for the twenty-second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes in Dispute | Text |
Enter the treatment or service codes for the twenty-second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount billed for the twenty-second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount paid for the twenty-second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the amount in dispute for the twenty-second disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Twenty-third Disputed Service | ||
| Disputed Service Date | Date |
Enter the date of the twenty-third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Treatment or Service Codes | Text |
Enter the treatment or service codes for the twenty-third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Billed | Number |
Enter the amount billed for the twenty-third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount Paid | Number |
Enter the amount paid for the twenty-third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Amount in Dispute | Number |
Enter the total amount in dispute for the twenty-third disputed service. Fill only if 'Injured Employee' is 'No'.
Depends on:
Injured Employee
|
| Type of Requestor | ||
| Injured Employee | Checkbox |
Check this box if the requestor is an injured employee.
|
| Health Care Provider | Checkbox |
Check this box if the requestor is a health care provider.
|
| Pharmacy Processing Agent | Checkbox |
Check this box if the requestor is a pharmacy processing agent.
|
| Subclaimant | Checkbox |
Check this box if the requestor is a subclaimant.
|