Non-Payment Complaint Process

A non-payment issue arises when an accurately completed medical bill is submitted to a carrier for authorized medical treatment and/or service(s) and the carrier fails to adjudicate the bill and:

• Issue an Explanation of Bill Review (EOBR) in response to the health care provider's medical bill and pay reimbursement for the billed services that are not denied or disallowed within 45 days following the submission of the medical bill; or
• Issue a Notice of Denial.

If the preceding conditions are not met, a non-payment complaint can be filed with the Division and must include the following information and supportive documentation:

• Carrier/ adjuster name, telephone number(s) and WC claim number;
• Injured employee's name, SSN , date of injury; and
• Health care provider patient account/claim number, date(s) of service addressed in complaint and billed amount(s);
• A legible copy of the accurately completed medical bill;
• An itemized billing statement (hospital services only);
• An accurately completed DFS-F5-DWC-25 for each date of service (physician encounter);
• Proof of submission or mailing of the medical bill to the insurer, e.g. fax transmittal, email, courier or USPS postal tracking number; and
• A call log or any communication between the health care provider and the carrier regarding payment of the outstanding charges for medical service(s) or treatment.

Non-payment complaints may be filed with the Medical Services Section by: