Get Medical Fee Dispute Resolution Findings And Decision - Tdi Texas

Filing a medical fee dispute resolution request can seem daunting, but with the right guidance, it becomes manageable. This comprehensive guide will help users understand how to fill out the MEDICAL FEE DISPUTE RESOLUTION FINDINGS AND DECISION form online, ensuring that all necessary information is accurately provided.

Follow the steps to complete your form effectively.

1. Press the ‘Get Form’ button to access the MEDICAL FEE DISPUTE RESOLUTION FINDINGS AND DECISION form and open it in the provided editor.
2. Enter the requestor's name and address in Part I, ensuring all details are correct, including the MFDR Tracking Number and DWC Claim Number as applicable.
3. Fill in the injured employee's information and the respondent's details, including the name of the insurance carrier and the representative's address.
4. In Part II, summarize the requestor's position. Clearly state why the amount in dispute is justified, including comparative charges and support documents.
5. Complete Part III, providing the respondent’s position summary if applicable. Include information about the amount determined to be fair by the respondent.
6. In Part IV, review the summary of findings and ensure all denied codes and services are correctly outlined, as this section impacts the final decision.
7. Part V requires careful review of the methodology and explanation. Ensure all provided documentation justifying the requested reimbursement is accurately referenced.
8. In Part VII, understand the decision made by the Division clearly, including the authorized signature.
9. Complete Part VIII carefully, noting your right to request an appeal if necessary. Ensure to follow all guidelines for submission.
10. After finishing the form, save your changes. You can choose to download, print, or share the completed MEDICAL FEE DISPUTE RESOLUTION FINDINGS AND DECISION as required.

Take the next step toward resolving your medical fee dispute by completing the form online today.