Free WC-739 (6/09) Carrier's Explanation of Benefits - Michigan

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Provider Carrier Employee

Carrier's Explanation of Benefits
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency Health Care Services Division

Date processed Page

DIRECT ALL PAYMENT INQUIRIES AND REQUESTS FOR RECONSIDERATION TO THE CARRIER
Carrier Name Street Address Employer Name Provider Name Street Address Employee Name Street Address Service Company City State Zip Code NAICS/Self-Insured Telephone Number Claim Number

City

State

Zip Code

City

State

Zip Code

National Provider Identification Number (NPI)/FEIN Number*

Social Security Number *

Patient Account Number

Date of Injury

Date of the Provider Bill

Date bill received by Carrier

PROVIDER:
IF YOU INTEND TO SEEK RECONSIDERATION, PLEASE CONTACT THE CARRIER INDICATED ABOVE WITHIN 60 CALENDAR DAYS OF RECEIPT OF THIS NOTICE. IF ADDITIONAL INFORMATION IS REQUESTED, PLEASE FORWARD THE INFORMATION TO THE CARRIER.
Date of Service Place of Procedure Code Service and Modifier Description--If Needed

EMPLOYEE:
FOR INFORMATION ONLY. THIS IS NOT A BILL. IF YOU ARE BILLED FOR ANY SERVICES RELATED TO THIS WORKERS' COMPENSATION CLAIM, DO NOT PAY. DO CALL THE CARRIER LISTED ABOVE.
Diagnosis Code Days or Units Charge Payment Note

THIS IS NOT A BILL
Provider/Employee: R 418.10105 and R 418.101301(3) of the Workers' Compensation Health Care Services Rules require that the carrier notify the employee and the provider that the rules prohibit a provider from billing an employee for any amount for health care services provided for the treatment of a covered work-related injury or illness when that amount is disputed by the carrier pursuant to its utilization review program or when the amount exceeds the maximum allowable payment established by these rules. The carrier shall request the employee to notify the carrier if the provider bills the employee.
Total Charge Payment

This form is required as set forth in Part 1, R 418.10117 (4), Part 10, R 418.101001 (4) and Part 13, R 418.101301 (1) of the Workers' Compensation Health Care Services Rules. *PROTECTED INFORMATION TO BE USED FOR IDENTIFICATION PURPOSES DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
WC-739 (Rev. 6-09)