The Indiana Provider Fee Request for Assistance — SF 52875 is a form used by Medicaid providers in Indiana to request additional funding when the cost of providing services exceeds the amount of money the provider receives from the state. The form can be used to request assistance for additional funding for costs related to the delivery of Medicaid services, such as medical supplies, equipment, and personnel. There are two types of Indiana Provider Fee Request for Assistance — SF 52875: the original form and the renewal form. The original form is used to request assistance for the first time, while the renewal form is used to request additional funding after the initial request.
Indiana Provider Fee Request for Assistance - SF 52875
State:
Indiana
Control #:
IN-52875-WC
Format:
PDF
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Description
Provider Fee Request for Assistance - SF 52875
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FAQ
You must be an employee. Your employer must carry workers' comp insurance. You must have a work-related injury or illness. You must meet your state's deadlines for reporting the injury and filing a workers' comp claim.
How to File a Workers' Compensation Claim in Indiana Step-by-step process for filing a workers' comp claim. Step #1: Seek medical attention. Step #2: Notify your employer. Step #3: Make certain your employer files the necessary form. Step #4: Wait to receive a decision from the insurance company.
In Indiana employers are required to purchase workers' compensation coverage if they employ one or more workers. Sole Proprietors, Partners and LLC Members are all excluded from coverage, but have the option to be included. Corporate Officers are included in coverage, but may elect to included.
In Indiana employers are required to purchase workers' compensation coverage if they employ one or more workers. Sole Proprietors, Partners and LLC Members are all excluded from coverage, but have the option to be included. Corporate Officers are included in coverage, but may elect to included.
If you are injured while working at your job, you may be entitled to workers' compensation benefits. Q: When should I report an accident that happened on the job? A: You should report any accident to your employer (boss, foreman, or supervisor) immediately. If you wait more then 30 days your claim may be denied.
Form 29109: Application for Adjustment of Claim The form may be filed by an injured worker who believes that he is entitled to compensation or medical benefits. An employer who believes that compensation should be terminated may also file the form. This form is also used to attempt to re-open a settled claim.
In Indiana, the maximum average weekly wage for determining benefits is $1,170 (as of 2020). That equates to a maximum TTD benefit of $780 per week. TTD benefits last for a maximum of 500 weeks or until the worker reaches maximum medical improvement.