NAME OF CARRIER OR SELF-INSURER NOTICE TO HEALTH CARE PROVIDER AND INJURED WORKER OF A CARRIER'S REFUSAL TO PAY ALL (OR A PORTION OF) A MEDICAL BILL DUE TO VALUATION OBJECTION(S) 1. WCB Case Number 2. Carrier Case Number 3. Carrier Code 4. Date of Injury 5. Social Security Number Name 6. Injured Person 7. Employer* 8. Carrier 9. Volunteer Fire or Ambulance Company, if applicable 10. Injured Person's Doctor Address to which notices should be sent (give Number and Street, City, State and Zip Code) Apt. No. * In volunteer firefighters' and volunteer ambulance workers' benefit cases, the liable political subdivisions (or unaffiliated ambulance service as defined in Sec. 30 VAWBL) is deemed to be the "EMPLOYER." 11. Date of Medical Bill 12. Date Bill Received 13. Treatment Date(s) MEDICAL BILL INFORMATION: 14. Amount of Medical Bill 15. Amount Paid 16. Amount in Dispute $ $ $ REASON(S) FOR OBJECTION TO MEDICAL BILL: Please check all that apply. Amount of Bill: is excessive or not in accordance with pertinent NYS Medical Fee Schedule has not been properly pro-rated or apportioned between providers uses improper CPT codes is not in accordance with Ground Rules limitation Treatment: is inappropriate involves concurrent or overlapping services is duplicative, excessive or rendered too frequently involves unnecessary or excessive hospitalization involves a provider treating outside scope of practice FAILURE TO PAY UNDISPUTED PORTION OF BILL WITH THIS NOTIFICATION SHALL NOT BE CONSIDERED A TIMELY NOTIFICATION. IT IS HEREWITH CERTIFIED THAT A COPY OF THIS FORM WAS SENT THIS DATE TO THE HEALTH CARE PROVIDER AND THE WORKERS' COMPENSATION BOARD. Dated Prepared By Tel. No. & Ext. Official Title THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. C-8.4 (1-11) SEE REVERSE SIDE American LegalNet, Inc. www.FormsWorkFlow.com Information Concerning Medical Treatment and Bills For Injured Workers, 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. 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. Objection to Payment - 12 NYCRR Rule 325-1.24(c) and 325-1.25(c) provide that the carrier shall, within 45 days after a bill has been submitted, pay the bill; or notify the health provider or hospital in writing that the bill is not being paid and explain in detail the reasons for nonpayment. The carrier must file the appropriate objection form, unless the amount billed for a particular CPT code is in excess of the amount specified by the appropriate fee schedule. If this is not done, the carrier may be mandated to pay for the medical services along with interest and penalty. 3. Form C-8.4 - This form was designed specifically to provide carriers with a useful format for notification of valuation objections. This form must be used for valuation objections except when the amount billed for the particular CPT code is in excess of the amount designed by the workers' compensation fee schedule, and the carrier pays the bill at the appropriate fee schedule amount. 4. Valuation Objection Issues - Valuation issues relate to the dollar amount of the medical bill or the medical appropriateness of the treatment provided. Valuation issues are listed on the front of this form. This form cannot be used for objections relating to Forms C-7 or C-8.1 legal issues. 5. Valuation Objection Received - When a health provider or hospital receives an objection from a carrier specifically for valuation objection issues, the health provider has the right to submit a Form HP-1, Health Provider's Request For Decision On Unpaid Medical Bill(s), requesting Arbitration of the issue(s) in dispute before a Committee of peers, unless there are outstanding legal issues pending that relate to the medical treatments in question. If the employer or carrier has provided a copy of Form C-7 or C-8.1 to the health provider or hospital or sent a detailed written explanation raising legal objections, any legal issue must be resolved prior to the submission of a Form HP-1 for arbitration. 6. Form HP-1, Health Provider's Request For Decision On Unpaid Medical Bill(s) - If no legal issues relating to the medical bill are pending, and the health provider or hospital has received a valuation issue objection, the provider may request arbitration by proper submission of Form HP-1. Details of the HP-1 process and the HP-1 form can be obtained from the NYS Workers' Compensation Board's website at www.wcb.state.ny.us or by calling 1-800-781-2362. Fraud Section 114 of the Workers' Compensation Law provides, in part, that any employer or carrier, or any employee, agent, or person acting on behalf of an employer or carrier, who knowingly makes a false statement or representation as to a material fact in the course of, or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or benefit shall be guilty of a felony. C-8.4 (1-11) Reverse American LegalNet, Inc. www.FormsWorkFlow.com