Dispute Resolutions
Is a very complex system, A disputed issue arising under the claim
regarding compensability or eligibility for, or the amount of, income or death benefits
law firms can stand toe to toe for your rights.
Medical Fee Disputes; Medical Fee Disputes involve a dispute over the amount of payment for health
care rendered to an injured employee and determined to be medically necessary and appropriate for
treatment of that employee's compensable injury. The dispute is for reasons other than the medical
necessity of the care . The dispute is resolved by the commission pursuant to commission rules,
relating to Medical Dispute Resolution of a Medical Fee Dispute.
Employee Reimbursement Dispute. An employee who has paid for health care may request medical
dispute resolution of a denied reimbursement. The employee may only pursue reimbursement up to the
amount the employee paid the provider. Reimbursement shall be fair and reasonable in accordance with
commission rules, and shall not exceed the Maximum Allowable Reimbursement as established in
the appropriate fee guideline, or in the absence of a fee guideline, the amount determined to be fair and
reasonable for the health care.
An injured employee may choose to receive a brand name drug rather than a
generic drug or over-the-counter
alternative to a prescription medication that is prescribed by a health care provider. In such instances, the injured
employee shall pay the difference in cost between generic drugs and brand name drugs. The transaction between
the employee and the pharmacist is considered final and is not subject to medical dispute resolution by the
Commission. In addition, the employee is not entitled to reimbursement from the insurance carrier for the
difference in cost between generic and brand name drugs.
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