443 Lafayette Road N. St. Paul, Minnesota 55155 www.doli.state.mn.us
(651) 284-5005 1-800-DIAL-DLI TTY: (651) 297-4198
Instructions for completing a Medical Request form
Use a Medical Request form if you want to resolve a dispute about a workers' compensation medical issue. Do not use a Medical Request form if you have a dispute about rehabilitation, wage loss or permanent partial disability issues. Do not use the Medical Request form if the insurer has denied primary liability for the entire claim (denial of primary liability). You must use an Employee's Claim Petition form in this case. Item 3 on the front of the Medical Request form lists the most common medical issues in dispute. The following are some guidelines to help you put your dispute in a category. a. I request the insurer pay medical or chiropractic bills. An injured worker may request the insurer pay medical or chiropractic bills if the insurer has accepted liability for the claim, but is denying payment for any reason. A health care provider may file a request on this issue if there is a dispute about the reasonableness and necessity of their services or about the amount that should be paid. A health care provider should not submit this form if the issue is whether the need for treatment is related to the work injury. Do not submit this form unless the insurer has had 30 days to review the bills or has already refused to pay. b. I request a change of treating doctor. The injured worker or the employer/insurer may request a change of doctor. Be sure to fill in the name of the current treating doctor and the name of the doctor you want as the primary health care provider. If the employee and insurer agree on a change of doctor, you do not need to file this form. c. I request prescribed treatment, surgery or equipment be provided. Check this issue if your doctor has prescribed treatment, surgery or equipment but the insurer has not agreed to pay for it. If a prescription expense is disputed, include a copy of the prescription. Examples: approval of rotator cuff surgery as recommended by Dr. Jones; three weeks of twice-a-week physical therapy as prescribed by Dr. Smith; purchase of an exercise bicycle as recommended by Dr. Anderson. d. I request the insurer reimburse my medical expenses. An injured worker may request expenses incurred in receiving medical care be reimbursed. This includes parking and mileage for medical appointments and any medication for which the injured worker paid. You should check this issue if you have submitted these expenses to your insurer and the insurer has not paid for them. Allow the insurer 30 days to consider the expenses before submitting a request. e. I request a second opinion or consultation with __________________. An injured worker may request to see another doctor or other health care provider for another opinion or for a consultation. This can either be as a referral from the primary health care provider or a request the injured worker makes on his or her own. This is usually done when the treating doctor recommends surgery and you are not sure you want to have the surgery and would like another opinion; you may also ask for a second medical opinion/consultation for other medical issues as well. f. Other. Check this item if you have a medical dispute that does not fit under the other categories. Briefly explain what you want.
This information can be provided to you in alternative formats (Braille, large print or audio tape). An Equal Opportunity Employer
Item 4 If the department orders the insurer to pay for disputed bills or other costs requested on this form, the insurer also has to reimburse any party who has paid some or all of these costs. The most common example of this is when an injured employee's private health insurance pays for treatment that should have been paid for by the workers' compensation insurer. Therefore, it is important you fill in item 4 so the department will know if there is anyone besides you whom the workers' compensation insurer should reimburse. Item 5 In item 5, you need to explain the basis for your request. At times, the department may issue a legally binding written decision based on the information and documentation you submit on or with a Medical Request form and from the opposing party's information on the Medical Response form. So it is important you make your request as complete as possible. You must attach documents that support your medical request. If you do not provide documentation that supports your request, the department may notify you that your Medical Request form is incomplete and that no further action will be taken on the request until supporting documentation is submitted. 1. If you are requesting payment of medical or chiropractic bills under item 3(a) you must submit supporting documentation with the Medical Request form. Examples of documents that could support your request include itemized bills and doctor reports or office notes. The standard for determining if the insurer is liable is whether the treatment was reasonable and necessary for the cure and relief of the work injury. There are "treatment parameter" rules (in Minnesota Rules, parts 5221.6010 to 5221.6600) that describe what diagnostic procedures, treatments and surgeries are considered reasonable and necessary to cure or relieve certain workers' compensation injuries. The treatment parameters also include exceptions to the parameters, which are called "departures." If you are aware of a treatment parameter or departure that supports your treatment claim, you may list it on the Medical Request form. If you have any questions about the treatment parameters, you may call the Benefit Management and Resolution hotline at the number below. The treatment parameters are on the Department of Labor and Industry Web site at www.doli.state.mn.us/pdf/treatparam.pdf. 2. If you are requesting approval of prescribed treatment, surgery or equipment under item 3(c), examples of supporting documentation include a report or office notes from a health care provider recommending the treatment. The standard for compensability is whether the treatment is reasonable and necessary for the cure and relief of the work injury. As noted above, on the Medical Request form you may include any treatment parameter that supports your request for treatment, surgery or equipment. 3. If you are requesting reimbursement of medical expenses under item 3(d), such as prescriptions or mileage expenses, you must submit supporting documentation. An example of supporting documentation for a prescription is a copy of the prescription. An example of supporting documentation for reimbursement of mileage or travel to obtain medical treatment of your injury is documentation of the mileage or receipts for other expenses. In addition, if the employer or insurer has denied the expense was necessary for treatment of your work injury, submit documentation that the expense was necessary, such as the examples described in number one above. 4. If you are requesting a change of doctor, a consultation with another doctor or a second opinion with another doctor, explain your reasons. A rule governing change of doctor can be viewed on the Office of the Revisor of Statutes Web site at www.revisor.leg.state.mn.us/arule/5221/0430.html.
5. In addition to the disputes described above, there can be a separate dispute about whether the need for treatment is due to the work injury. An example of supporting documentation for this could be a report or office notes from a doctor addressing this issue. The standard for compensability is whether the work injury is a substantial contributing factor to a need for medical treatment. If you have questions about what information to include, call the Benefit Management and Resolution hotline at 1-800-342-5354 or (651) 284-5032. Item 6 Please send a complete copy of all documents to everyone involved in the dispute and list their names and addresses under item 6 on the back of the Medical Request form. If you have a question about who should be considered involved, call the Benefit Management and Resolution hotline. Besides resolving your dispute through this process, the department can also provide you with trained mediators who may be able to help you resolve your dispute. The department requires the parties involved in the dispute to have agreed to having a mediation. If you are interested in this less formal process, call the Benefit Management and Resolution hotline for more information.