Section 6 Alternative Dispute Resolution Services

The department offers an alternative to formal litigation in resolving workers’ compensation disputes. Parties may choose to be represented by an attorney in alternative dispute resolution or can participate without representation.

Assistance and Early Intervention
Department staff answer questions from employees, employers, insurers, medical providers, rehabilitation consultants, attorneys, and others interested in obtaining information about workers’ compensation. Staff also help parties resolve issues that arise in specific claims. Minnesota Statutes §176.261 requires the department to “...make efforts to settle problems of employees and employers by contacting third parties, including attorneys, insurers and health care providers, on behalf of employers and employees and using the department’s persuasion to settle issues quickly and cooperatively.” Mediators are available between 8:00 a.m. and 4:30 p.m., Monday through Friday, by calling 1-800-DIAL-DLI (the local Twin Cities number to access the mediators directly is 651-284-5005), and pressing “2” then “1”.

Certification of Disputes – Medical and Rehabilitation Issues
The department is required by Minnesota Statutes §176.081, Subd. 1(c) to attempt to resolve disputes involving medical and rehabilitation issues as early as possible in the dispute process. Before a Medical and Rehabilitation Request can be scheduled for an administrative conference, a mediator will determine whether a genuine dispute exists, and attempt to resolve the dispute. If it is not possible to resolve the issue, the dispute is certified. This process is known as “dispute certification”. Attorney fees may not be charged, subject to one exception, until the department has had an opportunity to attempt to resolve the issue. Typically, an employee or the employee’s attorney will file a Request for Certification of a dispute with the department before filing a Medical and Rehabilitation Request. The request can also be made by telephone. A mediator will then contact the insurer to determine whether the dispute can be resolved. If the dispute is not resolved informally, the department issues a Certification of Dispute. Certification is not required if an attorney is already representing the employee in other pending litigation. For example, if a claim petition is pending when a medical issue arises, the attorney may charge for representing the employee in the medical dispute without first getting the dispute certified by the department.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 6-1

Alternative Dispute Resolution Services

July 2007 6-2

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Department of Labor and Industry Workers’ Compensation Division Customer Assistance 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Fax: (651) 284-5727

Request for Certification of Dispute
Please PRINT or TYPE Enter dates in MM/DD/YYYY format.
C A 0 0 2 2

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

EMPLOYER NAME

INSURER/SELF-INSURER/TPA

INSURER ADDRESS

CITY

STATE

ZIP CODE

CLAIM REPRESENTATIVE NAME

INSURER CLAIM #

INSURER PHONE #

EXT.

INSURER FAX #

Part(s) of body injured:

Have more than 3 days of work been missed because of this injury? If medical services are disputed, are they being provided or managed by a certified managed care plan?

YES YES

NO NO

If Yes, attach information showing that the dispute procedure of the managed care plan has already been exhausted (per 176.1351, subd. 3). Nature of the rehabilitation or medical dispute (if there are unpaid medical bills, itemize below):

HEALTH CARE PROVIDER NAME

SERVICE DATE(S) -

$ AMOUNT

DATE BILL SUBMITTED TO INSURER

Reason insurer has denied (if known):

PRINTED NAME AND TITLE ADDRESS CITY STATE ZIP

PHONE # FAX # DATE SUBMITTED

EXT.

CA0022 (3/05)

Alternative Dispute Resolution Services

Administrative Conferences – Medical and Rehabilitation Issues
Minnesota Statutes §176.106 provides that administrative conferences be conducted by the department to resolve medical and rehabilitation disputes. The administrative conference is designed as an informal proceeding where parties can receive assistance in resolving disputes without resorting to more formal litigation. The goal of an administrative conference is to resolve certified disputes involving medical and rehabilitation services. The mediator conducting the conference will help the parties discuss and resolve their differences. If an agreement is not possible, the mediator will issue a Decision and Order. This decision can be appealed by means of a Request for Formal Hearing, which will result in a formal hearing at the Office of Administrative Hearings (OAH). When a party desires an administrative conference a Medical and Rehabilitation Request form is filed.

Medical Request
Medical Requests are usually filed by employees or healthcare providers to get approval for payment of a medical service which was denied by the insurer. An insurer may also file such a request to resolve a dispute over treatment. Medical Responses are filed within 20 days after the Medical Request is filed. If the dispute involves surgery or medical services exceeding $7,500.00, the request is automatically referred to OAH for a formal hearing. Otherwise, the matter will be set for an administrative conference with a mediator at the department.

Rehabilitation Request
Rehabilitation Requests are filed by employees, QRCs, and insurers. Although a Rehabilitation Response is not required by statute or rule, it is recommended that a response be filed within twenty days after receipt of a request. Rehabilitation Requests are used to resolve issues ranging from the direction of the rehabilitation plan, to requests for approval of a specific retraining plan, to disputed bills for rehabilitation services. A party may also request an order allowing an Independent Vocational Evaluation, where the requesting party believes that would assist in determining7 the direction of the rehabilitation plan. If a request is for the termination of a rehabilitation plan (usually filed by the insurer), the department will send a letter to the employee and QRC advising them that the plan will be automatically terminated if no response is filed. If a response contests the termination of the plan, an administrative conference is scheduled.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 6-3

Alternative Dispute Resolution Services

Non-Conference Decisions and Orders – Medical and Rehabilitation Issues
In some instances, if the parties supply sufficient information on the request and response forms, the department may elect to issue a Decision and Order without holding an administrative conference.

Dispute Resolution at the Office of Administrative Hearings (OAH)
Disputes that require a more formal process for resolution are directed to the Office of Administrative Hearings. This includes hearings involving a denial of primary liability, discontinuances of indemnity benefits, medical disputes involving bills that exceed $7,500.00, medical and rehabilitation disputes that are consolidated with other OAH matters, and appeals of administrative orders. When OAH handles appeals of orders provided by the department, the matter is considered de novo. A workers’ compensation judge makes an independent decision without regard to what was decided in the informal process at the department.

July 2007 6-4

Basic Adjusters’ Training Guide MN Department of Labor and Industry

CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST SOCIAL SECURITY NUMBER

Medical Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution at (651) 284-5032 (or 1-800-342-5354).

M

Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

Health Care Provider

2. 3.

Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE

b. FROM: TO: c. d. e.

a change of treating doctor: NAME NAME ADDRESS ADDRESS SPECIALTY SPECIALTY

that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. a second opinion or consultation with NAME SPECIALTY

f.

other (explain):

MN MQ03 (12/05)

(over)

IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS’ COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: Medicare NAME employee Veterans Administration Dept. of Human Services (Welfare) other POLICY NUMBER

Social Security Administration ADDRESS

private health insurance

In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.

5.

Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

6.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #6 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Medical Response
Enter dates in MM/DD/YYYY format.

THIS FORM RESPONDS TO ISSUES RAISED ON THE MEDICAL REQUEST FORM THAT WAS SIGNED ON

M

R 0 3

(date)

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. • This form must be filled out completely. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • You must complete this response form and send it to the address on the back of this form within 20 days of the date you received the Medical Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. YES NO

2.

THIS RESPONSE IS BEING COMPLETED BY: Employee’s Insurer/TPA Insurer’s Health Care Employee Employer Attorney Self-insured Attorney Provider The employee has not exhausted the dispute resolution process of the certified managed care plan. The employee may contact at Name of the Certified Managed Care Plan (phone) to initiate this process.

3.

RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I respond to the request for payment of medical or chiropractic bills as follows: (List the health care providers and your response to the specific bill amounts listed on the Request form. Attach extra sheets if needed). HEALTH CARE PROVIDER ALREADY PAID AGREE TO PAY REFUSE TO PAY

b. c. d. e. f.

I I I I

agree agree agree agree

disagree refuse refuse disagree

with the request to change treating doctors. to pay for the requested treatment, surgery or equipment. to reimburse the employee for medical expenses. with the request for a second opinion or consultation.

Response to “Other”:

MN MR03 (12/05)

(over)

YOU MUST COMPLETE # 4 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 4. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers’ Compensation Division file, and the Medical Request form. Specify any applicable treatment parameter(s): Minn. Rule 5221.

5.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #5 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

CHECK BOX IF THIS REQUEST ADDS REHABILITATION ISSUES TO A PENDING REHABILITATION REQUEST SOCIAL SECURITY NUMBER

Rehabilitation Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution Unit at (651) 284-5032 (or 1-800-342-5354).

R Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, medical, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

QRC/ Vendor

2.

REHABILITATION ISSUES (check only those that apply) I request: a. b. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions. a change of QRC (qualified rehabilitation consultant): NAME FIRM NAME T O ADDRESS PHONE # (include area code)

NAME F FIRM NAME R O ADDRESS M PHONE # (include area code) c. d. e. f. g. h. i. that the rehabilitation plan be changed. retraining or exploration of retraining. that the rehabilitation plan be terminated. that the rehabilitation plan be suspended.

that the employee’s rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills. other (explain)

MN RQ03 (11/05)

(over)

3.

Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Rehabilitation Response
Enter dates in MM/DD/YYYY format.

THIS FORM RESPONDS TO ISSUES RAISED ON THE REHABILITATION REQUEST FORM WHICH WAS SIGNED ON

R R 0 3

(date)

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. • This form must be filled out completely. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after service of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all parties, within 20 days after service of the Rehabilitation Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS RESPONSE IS BEING COMPLETED BY: Employee’s Insurer/TPA Employee Employer Attorney Self-insured RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. YES NO

Insurer’s Attorney

QRC/ Vendor

2.

IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY

b. c. d. e. f. g. h. i.

I I I I I I I

agree agree agree agree agree agree agree

disagree disagree disagree disagree disagree refuse refuse

with the request to change QRCs. that the rehabilitation plan should be changed. with the request for retraining/exploration of retraining. that the rehabilitation plan should be terminated. that the rehabilitation plan should be suspended. to reimburse the employee for rehabilitation expenses. to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for dispute.

Response to “Other”:

MN RR03 (11/05)

(over)

YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers’ Compensation Division file, and the Rehabilitation Request form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

SOCIAL SECURITY NUMBER

DATE(S) OF CLAIMED INJURY

Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 1-800-342-5354 (DIAL-DLI)

R F 0 3

DO NOT USE THIS SPACE

EMPLOYEE VS. EMPLOYER AND INSURER AND ADDITIONAL PARTIES (INCLUDING INTERVENORS)
Please PRINT or TYPE. Enter dates in MM/DD/YYYY format.

Request for Formal Hearing
(under M.S. 176.106 or 176.305)

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

TO THE ABOVE NAMED PARTIES AND THEIR ATTORNEYS: The above-named party, a formal hearing. An administrative decision on the issues was previously issued by: (Name) The decision was served and filed on: specific reason(s) for disputing the decision are as follows: . (date). The specific issues in dispute and the , requests

MN RF03 (10/04)

(over)

Copies of this request have been served on all parties and their attorneys who are listed with addresses and attorney registration numbers as follows: (attach additional sheet if necessary) Employee: Employee Attorney:

Employer:

Employer/Insurer Attorney:

Insurer:

Other Party (Specify):

REQUESTOR SIGNATURE

ATTORNEY FOR PARTY SIGNATURE

REQUESTOR PRINTED NAME

ADDRESS

DATE

CITY

STATE

ZIP CODE

ATTORNEY REGISTRATION #

PHONE # (include area code)

INSTRUCTIONS This form must be served on each party and each party’s attorney, and received by the Department within 30 days after the date the decision was served and filed. Issues and reasons for the request must be specifically listed. For example, a general statement that the prior decision is not in conformity with the Workers’ Compensation Act is not a specific statement of the disputed issues. All requests will be referred to the Office of Administrative Hearings for a formal hearing before a workers’ compensation judge. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Alternative Dispute Resolution Services

Mediation
The department provides free mediation services to all parties to any workers’ compensation dispute. Mediation is voluntary. Like an administrative conference, the mediation session is designed to be informal. A mediator assists the parties in resolving their workers’ compensation issues. If an agreement is reached, the mediator arranges for the Mediation Resolution/Award to be signed, awarded, and served and filed. Mediation services are available to resolve disputes ranging from pressing rehabilitation or medical disputes to a full, final, and complete settlement of an employee’s claim. Parties use mediation services to assist in negotiating a settlement or to memorialize an agreement they have already reached. Sometimes insurers use mediation to negotiate amongst multiple insurers in order to arrive at a mutually acceptable apportionment of liability. Attorneys may find mediation useful in assisting their client (or the opposing party) to understand the strengths and weaknesses of the case, as seen through the eyes of an impartial third party (the mediator). This independent assessment can often assist the parties in reaching a settlement, even in particularly difficult cases. The parties save litigation costs by using the department’s voluntary mediation services. The Mediation Award is binding on the parties. The agreement will only be approved by the mediator if, in the judgment of the mediator, the agreement is fair, reasonable, and in conformity with the workers’ compensation law. Where both parties are represented by counsel, the agreement is conclusively presumed to be fair, reasonable, and in conformity with the law, and will be approved, unless it purports to close out claims for medical or rehabilitation benefits on a full, final, and complete basis. Those agreements require a discretionary review. When involved in workers’ compensation disputes, it can be difficult to see how the parties may actually be able to resolve their differences. The parties’ positions may be in such opposition to one another that common ground is difficult to even imagine. Still, all parties want to retain some control over the situation and achieve a resolution. The department’s program can assist in achieving those results. Participation in a mediation session is risk-free. If the dispute is not resolved through mediation, the parties have not lost their right to litigate or pursue other options.

Dispute Resolution Time Line
This dispute resolution time line is an effort to describe the costs and dynamics involved as a potential dispute proceeds along a continuum from an “issue” which may simply need clarification, to a litigated dispute in the Minnesota workers’ compensation system. As the dispute moves along the continuum from facilitated agreement through other forms of alternative dispute resolution, and then into the litigation phase, it becomes readily apparent that more time, money and other resources are needed to achieve resolution with finality. The costs to the parties and to the system are therefore reduced by early resolution.
Basic Adjusters’ Training Guide MN Department of Labor and Industry July 2007 6-5

Alternative Dispute Resolution Services

The department is responsible, by statute, for facilitating early resolutions of disputes. The cost estimates for this time line were based on staff research and experience. The following categories list in chronological order of their occurrence, the opportunities for resolution that can exist along this time line. They begin with the least costly, agreement at the outset, and end with the most costly, Supreme Court decision after appeals of remanded proceedings. Each category along the time line reveals its own set of cost-drivers, in addition to the increased time required to resolve the dispute. These cost-drivers have a cumulative quality, in that they add to the costs of the lost opportunities that preceded each step. A. Resolved by discussion between the parties without involvement of any facilitation. The parties are involved in some debate before reaching agreement, but are able to resolve the dispute without the assistance of other people. The only increase in cost here is in time and expense of file administration. COST DRIVER: (less than $500.00) B. 1. Adjusting expense.

Resolved by discussion between the parties with involvement of some facilitation. The parties require limited outside facilitation to reach resolution. This could include consultation with attorneys or the department’s workers’ compensation hotline or dispute certification process. COST DRIVERS: 1. 2. 3. (less than $800.00) Adjusting expense. Department expense. Insurer attorney fees

C.

Resolved by the department’s mediation or administrative conference process. The parties request assistance from the department to resolve a dispute with the facilitation of a mediator or an informal administrative conference under Minnesota Statutes §176.106 which can result in an agreement or a Decision and Order when agreement is not reached. COST DRIVERS: 1. 2. 3. (less than $1,000.00) Adjusting expense. Department expense. Possible attorney fees and costs for the parties

D.

Resolved by agreement of the parties after a Decision and Order and the filing of a Request for Formal Hearing.

July 2007 6-6

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Alternative Dispute Resolution Services

Following an adverse decision by the department, either party files a Request for Formal Hearing to get a de novo hearing before a compensation judge, but are able to reach agreement before trial. COST DRIVERS: 1. 2. 3. 4. 5. ($1,000.00 - $2,000.00) E. Adjusting expense. Department expense. OAH expense. Attorney fees for the parties. Other nominal litigation costs.

Resolved by hearing at OAH . The parties, having completed discovery and hearing preparation, require a compensation judge to conduct a hearing and render a Findings and Order. COST DRIVERS: 1. 2. 3. 4. 5. Adjusting expense. Department expense. OAH expense. Attorney fees for the parties. Litigation costs, including fees for expert witnesses (e.g., IME, IVE, vocational expert), lay witnesses, court reporters, expenses for deposition transcripts, medical records, rehabilitation records, wage and employment records, surveillance and investigation, and travel.

($7,500.00 - $15,000.00) F. Resolved by the Workers’ Compensation Court of Appeals. The parties require an appellate review of the Findings and Order. COST DRIVERS: 1. 2. 3. 4. 5. Adjusting expense. Department expense. OAH expense. Attorney fees for the parties. Litigation costs, including fees for expert witnesses (e.g., IME, IVE, vocational expert), lay witnesses, court reporters, expenses for deposition transcripts, medical records, rehabilitation records, wage and employment records, surveillance and investigation, and travel. Filing fees. Hearing transcript. Legal research and briefing expense. Costs associated with possible remands to OAH.

6. 7. 8. 9. ($10,500.00 - $20,000.00)

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 6-7

Alternative Dispute Resolution Services

G. Resolved by Supreme Court. The parties require appellate review of the Workers’ Compensation Court of Appeals. COST DRIVERS: 1. 2. 3. 4. 5. Adjusting expense. Department expense. OAH expense. Attorney fees for the parties. Litigation costs, including fees for expert witnesses (e.g., IME, IVE, vocational expert), lay witnesses, court reporters, expenses for deposition transcripts, medical records, rehabilitation records, wage and employment records, surveillance and investigation, and travel. Filing fees. Hearing transcript. Legal research and briefing expense. Costs associated with possible remands to OAH.

6. 7. 8. 9. ($13,000.00 - $23,000.00)

July 2007 6-8

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Alternative Dispute Resolution Services

Alternative Dispute Resolution Services – Exercise 6A
Pat Williams received chiropractic care from Dr. C. Crunch, D.C., from March 29, 2005 through July 14, 2005. The insurer, Insurance Mutual, paid for some of these services but is refusing to pay for the last thirteen visits. Pat Williams hired an attorney, Lyle Litigator, to help get the bill paid by the insurer. After having the dispute certified, he filed a Medical Request. Your supervisor gave the file to you asking that you prepare a Medical Response. The memo directs you to deny payment using all possible defenses to the claim.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 6-9

Alternative Dispute Resolution Services

July 2007 6-10

Basic Adjusters’ Training Guide MN Department of Labor and Industry

CHECK BOX IF THIS REQUEST ADDS MEDICAL ISSUES TO A PENDING MEDICAL REQUEST SOCIAL SECURITY NUMBER

Medical Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution at (651) 284-5032 (or 1-800-342-5354).

M

Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

999-99-9999
EMPLOYEE NAME

03/23/2005
PHONE # (include area code)

PAT WILLIAMS
EMPLOYEE ADDRESS

(651) 888-8800
INSURER/SELF-INSURER/TPA

411 MAIN ST
CITY STATE ZIP CODE

INSURANCE MUTUAL
INSURER ADDRESS

PEACEFUL VALLEY
EMPLOYER NAME

MN

55800

PO BOX 007
CITY STATE ZIP CODE

CHURCH OF HEALTH & WEALTH
EMPLOYER ADDRESS

MINNEAPOLIS
CLAIM REPRESENTATIVE NAME

MN

55100

5500 CRIMSON AVE NW
CITY STATE ZIP CODE

PAULA PERFECT
INSURER CLAIM # INSURER PHONE # EXT

PEACEFUL VALLEY

MN

55800

WC 0001-0404

(612) 111-0011

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, vocational rehabilitation, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

Health Care Provider

2. 3.

Are medical services being provided or managed by a certified managed care plan? YES NO If yes, attach information showing that the dispute resolution process of the certified managed care plan has already been exhausted. MEDICAL ISSUES (check only those that apply) I request: a. that health care provider bills be paid. (List all health care providers whose bills or services are in dispute. Attach extra sheets if needed. Itemized bills and supporting medical reports must be attached.) NAME ADDRESS UNPAID BALANCE

Dr C Crunch

123 Main St Peaceful Valley MN 55800

$520.00

b. FROM: TO: c. d. e.

a change of treating doctor: NAME NAME ADDRESS ADDRESS SPECIALTY SPECIALTY

that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting medical reports.) that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports. a second opinion or consultation with NAME SPECIALTY

f.

other (explain):

MN MQ03 (12/05)

(over)

IF YOU DO NOT COMPLETE SECTION 4 ENTIRELY, WE WILL NOT BE ABLE TO PROCESS YOUR REQUEST. 4. HAS ANYONE OTHER THAN THE WORKERS’ COMPENSATION INSURER PAID HEALTH CARE PROVIDER BILLS RELATED TO THIS DISPUTE? YES NO If yes, bills were paid by: Medicare NAME employee Veterans Administration Dept. of Human Services (Welfare) other POLICY NUMBER

Social Security Administration ADDRESS

private health insurance

In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.

5.

Explain the details of your request. Attach all documents, such as medical reports and bills, and also identify any applicable treatment parameter or other rule that support(s) your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

6.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, health care provider, attorneys, and any party named in #4 above who has paid medical expenses. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

Pat Williams
NAME

411 Main St
ADDRESS

Peaceful Valley MN 55800
CITY, STATE, ZIP CODE

Church of Health & Wealth
NAME

5500 Crimson Ave NW
ADDRESS

Peaceful Valley MN 55800
CITY, STATE, ZIP CODE

Insurance Mutual
NAME

PO Box 007
ADDRESS

Minneapolis MN 55100
CITY, STATE, ZIP CODE

Dr C Crunch

123 Main St

Peaceful Valley MN 55800
(date)

I sent a copy of this form and all attachments to the parties listed in #6 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

LYLE LITIGATOR
ADDRESS ATTORNEY REGISTRATION #

8001 SKYLINE DR
CITY STATE ZIP CODE

X12345
PHONE # (include area code) EXT DATE SIGNED

CITRUS

MN

55911

(651) 998-9988

09/07/2005

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Statement

Crunch Chiropractic Center 123 Main St. Peaceful Valley MN 55800

Date 3/29/2005 4/1/2005 4/6/2005 4/11/2005 4/15/2005 4/18/2005 4/20/2005 4/25/2005 4/26/2005 4/29/2005 5/3/2005 5/9/2005 5/20/2005 5/28/2005

Service Initial visit, Exam, Manipulation Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back

Amount $ 134.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00 $ 40.00

Balance of $654.00 was reduced by the fee schedule and paid by insurer on 6/23/2005 5/31/2005 6/3/2005 6/6/2005 6/11/2005 6/14/2005 6/17/2005 6/21/2005 6/28/2005 6/30/2005 7/5/2005 7/7/2005 7/12/2005 7/14/2005 Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back Manipulation - low back $ $ $ $ $ $ $ $ $ $ $ $ $ 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00 40.00

Balance currently outstanding: $ 520.00