Get State Office Of Risk Management Medical Dispute Resolution Form

Filling out the State Office Of Risk Management Medical Dispute Resolution Form online can seem daunting, but with a clear understanding of each section, it becomes a manageable task. This guide provides step-by-step instructions to ensure your form is completed accurately and effectively.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the general information in Part I. This includes selecting the type of requestor: Health Care Provider, Injured Employee, or Insurance Carrier. Fill in the Medical Dispute Resolution (MDR) Tracking Number, Claim Number, and the Requestor's Name and Address.
3. Fill in the Injured Employee's Name, Date of Injury, Employer's Name, and the Respondent's Name and Address in the relevant fields of Part I.
4. In Part II, you will need to provide the Requestor's Principal Documentation and Position Summary. Attach any relevant documents, such as the DWC 60 package, and explain the basis of your request for medical bill payment.
5. Proceed to Part III, where you will detail the Respondent's Principal Documentation and Position Summary. Summarize the Respondent's position regarding the dispute and any documentation they have submitted.
6. In Part IV, summarize the dispute and findings. List the dates of service, CPT codes or descriptions, whether the services were medically necessary, and any additional amounts due.
7. In Part V, outline the Medical Dispute Resolution Review Summary, Methodology, and/or Explanation based on the provided information. Explain the decision making process and conclusions reached.
8. Review the General Payment Policies/References impacting the decision in Part VI. Provide any pertinent references that are applicable to your case.
9. Complete Part VII with the Division's Decision. Summarize the outcomes including the amount the requestor is entitled to receive.
10. Finally, in Part VIII, inform the user of their right to request judicial review. Include details about the appeal process if they choose to contest the decision.
11. Once you have filled out the form thoroughly and accurately, you can save any changes made, download the document, print it, or share it as needed.

Complete your forms online today to streamline your dispute resolution process.