PRINT CARRIER NAME HERE NOTICE OF TREATMENT ISSUE(S)/DISPUTED BILL ISSUE(S) CHECK TYPE OF CASE: WORKERS' COMPENSATION VOLUNTEER FIREFIGHTER C-8.1 VOLUNTEER AMBULANCE WORKER ANSWER ALL QUESTIONS FULLY ALL COMMUNICATIONS SHOULD REFER TO THESE NUMBERS 1. W.C.B Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Social Security Number Name 6. Claimant Address to which notices should be sent Apt. No. 7. Employer 8. Carrier 9. Claimant's Medical Provider *In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivision (or unaffiliated ambulance service as defined in Sec. 30 VAWBL) is deemed to be the "EMPLOYER." PART A NOTICE OF OBJECTION REGARDING FURTHER OR FUTURE TREATMENT (Notice must be filed within 5 days of denial/termination/withdrawal) The carrier: , costing Denies authorization of more than $1,000 or requiring authorization under the Medical Treatment Guidelines, requested by Dr. on based upon the conflicting medical report* of Dr. dated . Withdraws authorization for granted on to Dr. upon conflicting medical report* of Dr. Terminates further medical treatment after base upon conflicting medical report* of Dr. dated . Objects to further treatment because claimant failed to attend a scheduled IME examination on Denies authorization of as the medical appliance or program is not covered under the WCL. Raises the medical necessity of the special medical service costing more than $1,000 of requested by Dr. on based upon conflicting medical report* of Dr. dated in that the claim was controverted by a denial dated and compensability has not been established. Requested treatment is not for an established site or condition. Explain Reason(s): . based . PART B NOTICE OF OBJECTION TO PAYMENT OF A BILL FOR TREATMENT PROVIDED (Notice must be properly completed and filed within 45 days of submission of bill. Failure to pay undisputed portion of bill may subject carrier to interest on that portion). dental Bill pertains to treatment: in New York State out of New York State Date of C-4/Bill WCB Document ID# of C-4/Bill (Note: If C-4/Bill is not in the Board's file, it must be submitted with this form.) Date of Treatment Amount of Bill $ Amount in Dispute $ The carrier raises the following legal objections to the above cited bill for treatment rendered: and Claim has been controverted by a denial dated liability has not been resolved. Prior authorization was not granted for treatment over $1,000. Request for treatment has been denied, withdrawn, or refused. Treatment provided was not causally related to the compensable injury. Treatment provided within 30 days of initial treatment was outside of preferred provider organization (PPO). Medical report for treatment was not timely filed or is legally defective. Medical appliance or program is not covered under the WCL. Provider is not authorized under the Workers' Compensation Law. Bill is not for treatment but for an evidentiary opinion. Amount of bill for dental treatment or treatment outside of NYS exceeds community standard. Diagnostic test was performed outside of network. Other (Specify): Compliance with Medical Treatment Guidelines: (ONLY applies to an injury and/or condition covered by Medical Treatment Guidelines) Treatment provided was not based on correct application of the Guidelines. Treatment deviates from the Guidelines without securing a Variance. Treatment not consistent with the approved Variance. Variance denied without claimant timely requesting review or Variance denied by Board Decision filed: Explain Reason(s)/MTG Reference: *Conflicting Medical Opinion: The medical report constituting the conflicting medical opinion required for Part A must be filed simultaneously. If the report has been previously filed with the Board, identify the WCB Document ID No.: and date received by the Board: IT IS HEREWITH CERTIFIED THAT A COPY OF THIS FORM WAS SENT THIS DATE TO THE HEALTH PROVIDER. Dated: Tel No. & Ext.: Prescribed by Chair Workers' Compensation Board State of New York Prepared By: Official Title: THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-8.1.0 (12-14) SEE REVERSE SIDE American LegalNet, Inc. www.FormsWorkFlow.com Information Concerning Medical Treatment and Bills For Claimants, Carriers*, and Health Care Providers 1. Medical Care: Workers' Compensation insurance provides medical, surgical, optometric or other attendance or treatment necessitated by the work-related injury or illness without cost to the injured worker. The cost is paid by the employer or its insurance carrier, and the health care provider may not collect a fee from the patient. Sometimes, the insurance carrier may object to the length or type of treatment or to the amount the provider has billed for treatment. Generally, the insurance carrier notifies the parties of its objection by filing this form (C-8.1). The injured worker should not pay the provider for services rendered until the Board rules that the services are not covered by workers' compensation. 2. Part A: Objection to Further or Future Treatment: Rule 300.23(d) provides that whenever a carrier terminates a claimant's medical care or refuses/denies authorization for special medical services, this form (C-8.1) shall be completed and filed with the Board within 5 days after termination or refusal/denial, together with: (1) a medical report by an authorized physician that need for medical care has ended; (2) a copy of notice to claimant's physician to discontinue medical care, or to refrain from commencing medical care, together with report of an authorized physician establishing a basis for discontinuance or refusal/denial; and (3) proof of mailing notice to claimant, his/her counsel, and his/her physician. 3. Part B: Objection to Payment of a Bill for Treatment Provided: 12 NYCRR 325-1.25(c)(1) provides that within 45 days after the bill has been submitted to the carrier, the carrier shall pay the bill or shall notify the provider and the Board on this form that the bill is not being paid and provide the legal reasons for nonpayment. 12NYCRR 325-1.25(c)(3) continues that if the carrier has not objected within forty-five days of submission of the bill, it shall be liable for payment of the full amount billed up to the maximum amount established in applicable fee schedule. The Board shall not review any objection made thereafter. 4. Part B: Objection to Payment of a Bill For Trea