Form 198 A INSURER REQUEST FOR EXTENSION OF TIME TO OBTAIN 2ND DENTAL OPINION PLEASE PRINT OR TYPE Name of Claimant ____________________________ Address ____________________________________ ____________________________________ Phone Number _______________________________ Name of Insurer ______________________________ Address ____________________________________ ____________________________________ Phone Number ______________________________ Fax Number ________________________________ Date of Birth ___________________________ Social Security Number __________________ Date of Injury __________________________ Employer _____________________________ Name of Person Requesting Extension ______________________________________________________ Date of Initial Dental Evaluation ___________________________________________________________ Anticipated Date to Locate Dentist for 2nd Opinion ____________________________________________ (Up to 10 additional days will be considered reasonable) Is Injury or Treatment a Medical Emergency _________________________________________________ Extension of Time Granted ______ Yes ______ No _____________________________________________ Signature of Industrial Accidents Staff Person ______________________________________ Date Official Form 198 Revised 10/14 State of Utah * Labor Commission * Division of Industrial Accidents 160 East 300 South * P.O. Box 146610 Salt Lake City, UT 84114-6610 * Telephone: 801-530-6800 Fax: 801-530-6804 * Toll Free: (800) 530-5090 * www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com Labor Commission. Industrial Accidents. R612-300. Workers' Compensation Rules ­ Medical Care. R612-300-5 (H). Dental Injuries. 1. Initial Treatment. a. If an employer maintains a medical staff or designates a company doctor, an employee requiring treatment for a workplace dental injury shall report to such medical staff or doctor and follow their directions for obtaining the necessary dental treatment. b. If an employer does not maintain a medical staff or designate a company doctor, or if such medical staff or doctor is unavailable, the injured workers may obtain the necessary dental care from a dentist of his or her choice. The payor shall pay the dentist at 70% of UCR for services rendered. 2. Subsequent treatment. a. If additional dental care is necessary, the dentist who provided initial treatment may submit to the payor a request for authorization to continue treatment. The transmission date of the request must be verifiable. The request itself must include a description of the injury, the additional treatment required, and the fee to be charged for the additional treatment. i. The payor shall respond to the request for authorization within 10 working days of the request's transmission. This 10-day period can be extended with written approval of the Director of the Industrial Accidents Division. ii. If the payor does not respond to the dentist's request for authorization within 10 working days, the dentist may proceed with treatment and the payor shall pay the cost of treatment as contained in the request for authorization. iii. If the payor approves the proposed treatment, the payor shall send written authorization to the dentist and injured worker. This authorization shall include the amount the payor agrees to pay for the treatment. If the dentist accepts the payor's payment offer, the dentist may proceed to provide the approved services and shall be paid the agreed upon amount. iv. If the dentist proceeds with treatment without authorization, the dentist's fee is limited to 70% of UCR. b. If the dentist who provided initial treatment is unwilling to provide subsequent treatment under the terms outlined in subsection 1.a., above, the payor shall within 20 calendar days direct the injured worker to a dentist located within a reasonable travel distance who will accept the payor's payment offer. i. If, after receiving notice that the payor has arranged for the services of a dentist, the injured worker chooses to obtain treatment from a different dentist, the payor shall only be liable for payment at 70% UCE. The treating dentist may bill the injured worker for the difference between the dentist's charges and the amount paid by the insurer. c. If the payor is unable to locate another dentist to provide the necessary services, the payor shall attempt to negotiate a satisfactory reimbursement with the dentist who provided initial treatment. American LegalNet, Inc. www.FormsWorkFlow.com