Get Wi Wkc-9380 2017-2025

The WI WKC-9380 form is essential for individuals seeking dispute resolution regarding medical treatment necessity under workers' compensation. This guide will assist you in navigating and completing the form effectively online.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to obtain the form and access it in your preferred editor.
2. Begin by selecting either Section 1 or Section 2 based on your situation. If you are the respondent challenging a treatment denial, fill out Section 1. For a default order request due to late notice, complete Section 2.
3. In Section 1, clearly indicate the date you received notice from the insurer regarding the refusal to pay for treatment. Note the insurer's name specified in Section 3 and list the reasons for denial you received.
4. Provide documentation supporting your claim, including the organization and credentials of any experts who supported the insurer's denial. You must state your right to submit the dispute to the Worker’s Compensation Division within nine months of the notice.
5. If applicable, confirm that you provided the insurer with a written explanation at least 30 days prior to this dispute filling and indicate the date you sent this explanation.
6. In Section 2, if chosen, indicate the date you submitted your bill for treatment. Confirm that you were not notified of a dispute within the required 60 days.
7. Fill out Section 3 with accurate information about the individual health care practitioner, the insurer or self-insurer, and the employee-patient involved. Ensure that the injury date is correctly noted.
8. Complete Section 4 by detailing the specific treatments that are being disputed, including the treatment dates and amounts charged.
9. In Section 5, summarize the total amount charged, paid, and disputed for clarity.
10. Attach all required documents, including copies of communication with the insurer regarding the refusal to pay and your written explanation, before submitting the form.
11. After completing all sections, review your form for accuracy and clarity. Save your changes, and choose to download, print, or share the form as needed.

Start filling out the WI WKC-9380 online today to ensure your dispute is processed efficiently.