Fillable REQUEST FOR HEARING TO CONTEST FEE REVIEW DETERMINATION (Pennsylvania)

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REQUEST FOR HEARING TO CONTEST FEE REVIEW DETERMINATION (Pennsylvania)

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DEPARTMENT OF LABOR & INDUSTRY
WORKERS’ COMPENSATION OFFICE OF ADJUDICATION
REQUEST FOR HEARING TO
CONTEST FEE REVIEW
DETERMINATION
PATIENT/EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER
- -
PROVIDER
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Specialty
Contact
PATIENT/EMPLOYEE
First name
Last name
Date of birth
Address
Address
City/Town State ZIP
DATE OF INJURY WCAIS CLAIM NUMBER
- -
MM DD YYYY
INSURER or THIRD PARTY ADMINISTRATOR (if self-insured)
Name
Address
Address
City/Town State ZIP
County
Telephone FEIN
Contact
NAIC code or Insurer code
Insurer/TPA claim #
EMPLOYER
Name
Address
Address
City/Town
Telephone
State
FEIN
ZIP
THIS REQUEST IS BEING FILED BY: HEALTH CARE PROVIDER INSURER/EMPLOYER
FEE REVIEW APPLICATION NUMBER(S) AND DATE OF FEE REVIEW DETERMINATIONS(S):
Application number: Determination date:
Application number: Determination date:
Application number: Determination date:
TO THE FEE REVIEW HEARING OFFICE:
I hereby request a de novo hearing by a fee review hearing ocer under 34 Pa. Code §127.257 in the above-referenced Fee
Review Application(s).
a. The following bills are disputed:
BILLING FORM DATE OF BILL SERVICE DATE PROC/SVC CODE AMOUNT BILLED
LIBC-606 REV 06-21 (Page 1)
b. The following factual issues relative to the medical payment matter are in dispute. Concisely state all factual issues.
Do Not attach supplemental pages.
c. The following legal issues are in dispute. Concisely cite the specic statutory and regulatory authority asserted to be
relevant and/or applicable in this matter. Do Not attach supplemental pages.
Requesting Party or Representative’s signature Requesting Party or Representative’s name (typed/printed)
Attorney ID (if representative is counsel)
E-mail Address
Telephone
Address
Address
City/Town State ZIP
If you are an attorney, or if you wish to be represented by an attorney, said
attorney must formally enter their appearance through WCAIS. Until then, all
notices will go to the current parties of record.
Notice: This petition must be lled out as fully as possible. If not ling electronically, the original must be sent to the Workers’ Compensation Oce of Adjudication,
1010 N. Seventh St, Suite 202, Harrisburg, PA, 17102-1400. A copy must be sent to the prevailing party in the fee review determination that you are appealing. A Proof
of Service must be attached. A Proof of Service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if
known.
All requests for a hearing will be returned if not signed and dated. Do not attach documents to this request. The Workers’ Compensation Oce of Adjudication will
destroy all attachments and will NOT process them or return them to you.
Any individual ling misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
Employer Information Claims Information Services Hearing Impaired Email
Services toll-free inside PA: 800.482.2383 PA Relay 7-1-1 ra-li-bwc-helpline@pa.gov
717.772.3702 local & outside PA: 717.772.4447
*606*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-606 REV 06-21 (Page 2)
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REQUEST FOR HEARING TO CONTEST FEE REVIEW DETERMINATION (Pennsylvania)

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Completed 9 December 2021

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