Workers' Compensation Division Medical Fee Dispute Resolution Request and Worksheet Notice When a dispute about fees exists between a medical provider and an insurer, the insurer, medical provider, or worker may request review by the director of the Department of Consumer and Business Services. The request for review must be submitted to the division within 90 days of the time the aggrieved party knew or should have known about the dispute. The insurer or medical provider should use both Forms 2842 and 2842a to request review of fee disputes. An injured worker may elect to use these forms, or may call the Medical Resolution Team at 503-947-7606 for assistance. If you are aggrieved because of nonpayment or reduction of payment, you should do the following before submitting this form: 1. Contact the insurer to determine why payment has not been made or why payment has been reduced. Please provide the insurer's explanation. 2. Wait at least 45 days from the date the insurer received your billing, unless you have received a denial of payment or reduced payment. In all cases of an accepted compensable injury or illness under workers' compensation law, the injured worker is not liable for payment for any services for the treatment of that injury or illness, except as provided in OAR 436-009-0010. Worker information Worker name: Provider name: Provider phone: Phone: Claim no.: Attention providers: List specific CPT codes and dates of services in dispute Service dates CPT code Amount billed Amount paid 440-2842a (12/15/DCBS/WCD/WEB) Attach copies of this sheet if more lines are needed 2842a American LegalNet, Inc. www.FormsWorkFlow.com