Copy 1 Carrier Copy 3 Carrier’s Explanation of Benefits Provider Copy 2 Employee Date processed Michigan Department of Energy, Labor & Economic Growth Workers’ Compensation Agency Health Care Services Division Page DIRECT ALL PAYMENT INQUIRIES AND REQUESTS FOR RECONSIDERATION TO THE CARRIER Carrier Name Service Company Street Address NAICS/Self-Insured City State Zip Code Employer Name Telephone Number Claim Number Provider Name Employee Name Street Address Street Address City State Zip Code City State National Provider Identification Number (NPI)/FEIN Number* Social Security Number * Patient Account Number Date of Injury Zip Code Date of the Date bill received by Carrier Provider Bill PROVIDER: EMPLOYEE: IF YOU INTEND TO SEEK RECONSIDERATION, PLEASE CONTACT THE CARRIER INDICATED ABOVE WITHIN 60 CALENDAR DAYS OF RECEIPT OF THIS NOTICE. IF ADDITIONAL INFORMATION IS REQUESTED, PLEASE FORWARD THE INFORMATION TO THE CARRIER. FOR INFORMATION ONLY. THIS IS NOT A BILL. IF YOU ARE BILLED FOR ANY SERVICES RELATED TO THIS WORKERS’ COMPENSATION CLAIM, DO NOT PAY. DO CALL THE CARRIER LISTED ABOVE. Date of Service Place of Procedure Code Service and Modifier Description--If Needed Diagnosis Days or Code Units Charge Payment Note THIS IS NOT A BILL Provider/Employee: R 418.10105 and R 418.101301(3) of the Workers’ Compensation Health Care Services Rules require that the carrier notify the employee and the provider that the rules prohibit a provider from billing an employee for any amount for health care services provided for the treatment of a covered work-related injury or illness when that amount is disputed by the carrier pursuant to its utilization review program or when the amount exceeds the maximum allowable payment established by these rules. The carrier shall request the employee to notify the carrier if the provider bills the employee. Total Charge Payment This form is required as set forth in Part 1, R 418.10117 (4), Part 10, R 418.101001 (4) and Part 13, R 418.101301 (1) of the Workers’ Compensation Health Care Services Rules. *PROTECTED INFORMATION TO BE USED FOR IDENTIFICATION PURPOSES DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-739 (Rev. 6-09) American LegalNet, Inc. www.FormsWorkFlow.com