Get Texas Department Of Insurance, Division Of Workers' Compensation Medical Fee Dispute Resolution

Filing a medical fee dispute is an essential process for those involved in workers' compensation in Texas. This guide provides clear and detailed instructions on how to effectively complete the Medical Fee Dispute Resolution form online, ensuring that you can advocate for your rights and seek the reimbursement you deserve.

Follow the steps to complete your dispute resolution form online.

1. Press the 'Get Form' button to access the Medical Fee Dispute Resolution form and open it for editing.
2. Fill in your requestor's name and address. Ensure to include the proper contact details, as errors may delay the dispute process.
3. Provide the MFDR tracking number and DWC claim number associated with this dispute. Accurate tracking is crucial for processing your case.
4. Input the injured employee's name and details accurately to ensure that the case is correctly identified.
5. Include the respondent's name and box number. This information identifies the insurance carrier responding to your dispute.
6. List the date of injury and the employer's name to provide full context to your case.
7. In Part II, summarize your position regarding the dispute and include any principal documentation that supports your claim, such as medical records or authorization letters.
8. In Part III, the respondent will provide their position summary and supporting documents. Ensure you review these carefully.
9. In Part IV, clearly list the eligible dates of service and CPT codes relevant to your claim with their corresponding amounts in dispute.
10. Review Part V, which includes findings and the methodology used for the dispute. This section may provide key insights into the ruling.
11. In Part VII, acknowledge the division's order, including any amounts awarded, and follow up as necessary.
12. If you wish to appeal the decision, refer to Part VIII for instructions on how to submit your appeal in writing.
13. Once all sections are completed, ensure to save changes, download a copy, print it, or share the form as needed for your records.

Complete your documents online today to ensure your rights are protected.