|
Appropriate
billing forms:
CMS 1500
UB 04 - hospital
ADA - dental
NCPDP - pharmacy
|
| Questions?
Ask
MRT |
Reviewer
of the day:
503-934-6049, option 3
E-mail MRT |
|
| |
| |
|
Chart
notes or documentation to support services provided
|
| |
| |
|
The
employer’s workers’ compensation insurer for the injured
worker
|
| If
you do not have the insurer’s address, or know who the insurer
is for an employer, you can submit
a request on-line or call WCD Employer Index 503-947-7814. |
|
| |
|
| |
|
| Medical
Fee Dispute Request |
|
| When
a dispute about fees exists between a provider and an insurer, a provider,
insurer, or injured worker may request review by the director. A request
for review must be submitted to the director within 90 days of the
date the aggrieved party knew or should have known that the dispute
existed. |
|
Use
these forms to request review:
Medical
Fee Dispute Resolution Request (Form
2842)
Medical
Fee Dispute Resolution Worksheet (Form
2842a) |
|
