WORKERS’ COMPENSATION COMMISSION 10 EAST BALTIMORE STREET BALTIMORE, MD 21202-1641 CLAIM FOR MEDICAL SERVICES http://www.wcc.state.md.us Claim No: Social Security No: Case of: Employer: INSTRUCTIONS: Before a bill is presented to the Commission for consideration, it must be presented to the employer and/or insurer for payment. If payment is refused, then an itemized bill must be submitted with this form and any correspondence pertinent the subject. For detailed information, see "Additional Information" on page 2 of this form or "Medical/Fee Guide Info" via our web at the URL above. Bill of Name of Physician or Hospital Street State City For $ Telephone # Suite # or addtional address ZIP Code Provider NPI Number , for services rendered Name of Injured Employee Street Suite # or addtional address City Telephone # ZIP Code State While in the employ of Name of Employer Street Suite # or addtional address City Telephone # State For accident which happened on the day of , ZIP Code . In compliance with COMAR 14.09.03.01(06), the bill was presented to: Name of Insurer Street Suite # or addtional address City State Telephone # ZIP Code Date mailed to Insurer: Payment was refused as per attached correspondence. Request is hereby made of the Commission to approve this bill, which is as follows: ATTACH ITEMIZED BILL(S) WITH THIS FORM Name of Physician or Representative completing this form (Contact) Contact Email Address Contact Telephone Number ACTION OF MEDICAL DEPARTMENT ON THE ABOVE CLAIM. Form C-51 (Rev. 03/24/08) American LegalNet, Inc. www.FormsWorkflow.com ADDITIONAL INFORMATION (updated March 24, 2008) 1. A completed Claim for Medical Services must be prepared on a CMS 1500 Form in the manner provided by the Workers’ Compensation Commission and then submitted to the Employer/Insurer for payment. 2. If payment is refused, then an itemized bill prepared in compliance with COMAR 14.09.03.01(06) must be submitted with this form and any correspondence on the subject. *Form C-51 must be completed in entirety. *If any required information is not complete, all documents will be returned with a cover letter stating what is needed. *Social Security Number must be provided. *Dates of service will be checked against Claim Forms and/or First Reports of Injury file *If the CMS 1500 Form is not properly prepared, the C-51 Form will be returned to the Health Care Provider and the C-51 Form will not be processed by the Workers’ Compensation Commission. 3. CPT codes will be validated using the Medical Fee Guide for the year of service. Some CPT codes that are not "specific" may require a detailed description. 4. The Commission will issue an Order NISI for allowed medical claims per the Medical Fee Guide. *To controvert the Order NISI complete the Workers’ Compensation Commission form H-24M “Controversion of Medical Claim.” *The “Controversion of Medical Claim” form must be filed with the Workers’ Compensation Commission within 21 days of the Order NISI and copies must be mailed to the Health Care Provider and other appropriate parties. *If the medical claim is controverted, it will be scheduled for a hearing before a Commissioner. 5. If the medical claim is not controverted, the Workers’ Compensation Commission will issue a Final Order of Payment. *A provider may request a hearing before the Commission if an insurer refuses payment of the Medical Claim after the Final Order of Payment. *The Commission may impose penalties, fines and interest or may deny the Employer and Insurer the right to object to reimbursement if the Insurer fails without good cause to timely reimburse the provider for treatment or services. (LE §9-664); COMAR 14.09.03.01(06). Note: The Medical Fee Guide referred to is the “Official Maryland Workers’ Compensation Medical Fee Schedule.” American LegalNet, Inc. www.FormsWorkflow.com