COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Department of Workforce Development Index No. Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 REASONABLENESS OF FEE DISPUTE RESOLUTION REQUEST : : Plaintiff(s) Direct all inquiries to: Medical Cost Dispute Unit and mail to the : address above or telephone -against(608) 264-6819. P.O. Box Calendar No. 7901 Madison, WI 53707-7901 Telephone: (608) 264-6819 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.us JUDICIAL SUBPOENA : Please read the following information carefully before filling out this form. 1. This form should b e used ONLY for fee disputes related to treatment provided on or after July 1, 1992. 2. Once a health care provider has been notified that the fee for treatment is in dispute, the provider may not collect or bring an action for collection of the disputed fee against the person who received the treatment, (102.16(2)(b), Stats.). 3. . . . . . . . . . . . . . . . . . . . . . . . insurer . . . . . . . . . . . . . . a . . . . . Generally, in. denying payment, .the . . . . . . or.self-insurer .will use . .database certified by the Department of Workforce Development to determine the “formula amount”. The formula amount is the arithmetic mean of all fees in the database, plus 1.4 standard deviations from the mean, in a particular region of the state, for a specific CPT code. If the fee is less than the formula amount shown in the certified database for that procedure, the fee is presumed to be reasonable. If the fee is more THE PEOPLE OF THE STATE OF NEW YORK than the formula amount, the insurer or self-insurer must pay only for the formula amount unless the provider demonstrates that the service provided in this case was more difficult or more complicated to provide than in the usual case. 4. InTO denying payment, the insurer or self-insurer must also specify, among other things: : Defendant(s) : A. The CPT code (or other code from a certified data base) in dispute; B. The formula amount for the coded procedure and the certified data base from which that formula amount was obtained; C. The steps a provider must take prior to submitting this dispute to the department. GREETINGS: Personal information you provide may be used for secondary purposes [(Privacy Law, s. 15.04(1)(m)]. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before SECTION Honorable OF CORRESPONDENCE PRIOR TOat the SUBMITTING DISPUTE the 1. DATES Court , County of Please provide the dates requested in located at paragraphs A & B in the column at right. DATE in room , on the day of , 20 , at o'clock in the noon, and at any recessed A. Date Health care provider first billed insurer or self-insurer. or adjourned date, to testify and give evidence as a witness in this action on the part of the NOTE: The provider has 6 months to file a d ispute resolution request with the department from the date the insurer or self-insurer first refuses to pay the bill. B. Date insurer or self-insurer first refused to pay the fee. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to all damages sustained as a result of your failure to comply. NOTE: If this date is not within 30 days of the billing date shown in Section 1A, the insurer shall the party on whose behalf this subpoena was issued forprevails. a maximum penalty of $50 and compute and pay interest from this date if the provider SECTION 2. ISSUES IN DISPUTE YES Witness, Honorable , one of the Justices of the A. In Court in to pay the disputed fees (listed inof refusing Section 4), did,the insurer state it was using a data County, day 20 NO base certified by the department? B. Did the insurer state that the disputed fees are higher than the formula amount in a certified data base? (Attorney must sign above and type name below) C. Is the provider alleging that a fee greater than the formula amount from a certified data base is justified because the service for each disputed fee was more difficult or complicated to provide than the usual care? Attorney(s) for D. If the answer to C is yes, and at least 20 days prior to filing this dispute, did the provider explain to the insurer the reason why the higher fee was justified? E. If the answer to D is yes, did the insurer respond to the explanation? F. Is there a dispute about whether the fee for service was properly coded? and P.O. Address Office G. Are there other matters in dispute? (If yes, attach a narrative explanation.) H. Are you continuing to treat this patient for the injury? Telephone No.: Facsimile No.: PLEASE CONTINUE TO PROVIDE INFORMATION ON THE REVERSE SIDE E-Mail Address: Mobile Tel. No.: WKC-9498 (R. 04/2004) American LegalNet, Inc. www.USCourtForms.com Defendant(s) : ...................................................... NAME ADDRESS SECTION 5. As required by law, I am enclosing copies of all SECTION 3. THE PEOPLE OF THE STATE OF NEW YORK Health Care Provider correspondence and medical records relating to this dispute including: 1. The insurer’s or self-insurer’s initial notice refusing to pay. Yes No TO 2. My written response explaining to the insurer why the fee was justified. Yes No Insurer or Self-Insurer GREETINGS: As required by law, I am sending one copy of this dispute resolution request with all attachments to the insurer or selfWE COMMAND YOU, that all business and excuses at the sameaside, Iyou and each of you attend before insurer being laid time filed this request with the Division. Employer (at time of injury) --------------------------------- , the Honorable at the Court Yes No located at County of provider is the subject of this in room , on the day of , 20 The, health careo'clock inwhose feenoon, and at any recessed at the dispute: or adjourned ---------------------------------------------- date, to testify and give evidence as a witness in this action on the part of the Injury Date --------------------------------- ---------------------------------------------- Employee - Patient Social Security No. Name: Your social security number is mandatory _________________________________________ Lic. No. to Practice in WI: __________________________ Your failure to comply Statutes and will be used punishable as a contempt of court and will make you liable to under Wisconsin with this subpoena is to identify this subpoena was issued a maximum penalty of $50 and all damages sustained as a ________ - _____ - the party on whose behalf the claimant. Failure to comply forSignature: ___________ ______________________________________ may result in penalties or delayed payment result of your failure to comply. of benefits. Witness, Honorable Court in County, Certified Data Base Used by Insurer , one of the Justices of the ,Date Signed: 20 day of _____________________________________ The provider’s fee is based upon the zip code where the service was provided. If the zip code indicated for the health care provider in section 3 of this form is not the zip code location where the service was provided, please indicate the correct zip code for each service listed in section 4. (Attorney must sign above and type name below) SECTION 4. SPECIFIC TREATMENT IN DISPUTE TREATMENT ZIP CODE NUMBER OF TREATMENTS NUMBER OF UNITS CPT BILLING CODE CPT MODIFIER DATES FROM TO AMOUNT CHARGED PAID DISPUTED Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: TOTALS Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com