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 July 2007

MN Department of Labor and Industry 6-1
Alternative Dispute Resolution Services

July 2007 Basic Adjusters’ Training Guide

6-2 MN Department of Labor and Industry
Department of Labor and Industry
Workers’ Compensation Division
Customer Assistance
443 Lafayette Road North
Request for Certification of Dispute
Please PRINT or TYPE C A 0 0 2 2
St. Paul, MN 55155
(651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Enter dates in MM/DD/YYYY format.
DO NOT USE THIS SPACE
Fax: (651) 284-5727

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? YES NO
If medical services are disputed, are they being provided or managed by a certified managed care plan? YES 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):

DATE BILL
HEALTH CARE PROVIDER NAME SERVICE DATE(S) $ AMOUNT SUBMITTED TO
INSURER
-

Reason insurer has denied (if known):

PRINTED NAME AND TITLE PHONE # EXT.

ADDRESS FAX #

CITY STATE ZIP DATE SUBMITTED

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 July 2007

MN Department of Labor and Industry 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 Basic Adjusters’ Training Guide

6-4 MN Department of Labor and Industry
CHECK BOX IF THIS
REQUEST ADDS
Medical Request
Enter dates in MM/DD/YYYY format.
MEDICAL ISSUES TO NOTE: Before filing this form, call the workers’ compensation insurer. M Q 0 3
A PENDING If that does not resolve the issue, call Workers’ Compensation Benefit
MEDICAL REQUEST Management and Resolution at (651) 284-5032 (or 1-800-342-5354). 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:
• 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. YES NO

1. THIS REQUEST IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s Health Care
Employee Employer
Attorney Self-insured Attorney Provider
2. 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.
3. 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. a change of treating doctor:

NAME ADDRESS SPECIALTY
FROM:

NAME ADDRESS SPECIALTY

TO:

c. that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting
medical reports.)
d. that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports.
e. 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: employee Veterans Administration Dept. of Human Services (Welfare)
Medicare Social Security Administration private health insurance other
In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.
NAME ADDRESS POLICY NUMBER

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.
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 #6 on (date)

PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

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
M R 0 3
THIS FORM RESPONDS TO ISSUES
RAISED ON THE MEDICAL REQUEST
Enter dates in MM/DD/YYYY format. DO NOT USE THIS SPACE
FORM THAT WAS SIGNED ON (date)

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. YES NO

1. THIS RESPONSE IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s Health Care
Employee Employer
Attorney Self-insured Attorney Provider
2. The employee has not exhausted the dispute resolution process of the certified managed care plan. The employee may contact

at (phone) to initiate this process.

Name of the Certified Managed Care Plan
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. I agree disagree with the request to change treating doctors.

c. I agree refuse to pay for the requested treatment, surgery or equipment.
d. I agree refuse to reimburse the employee for medical expenses.
e. I agree disagree with the request for a second opinion or consultation.

f. 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.
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

NAME ADDRESS CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #5 on (date)

PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

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 Request
Enter dates in MM/DD/YYYY format.
REHABILITATION NOTE: Before filing this form, call the workers’ compensation insurer. If R Q 0 3
ISSUES TO A PENDING that does not resolve the issue, call Workers’ Compensation Benefit
REHABILITATION Management and Resolution Unit at (651) 284-5032 (or 1-800-342-5354). DO NOT USE THIS SPACE
REQUEST
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:
• 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. YES NO

1. THIS REQUEST IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s QRC/
Employee Employer
Attorney Self-insured Attorney Vendor
2. REHABILITATION ISSUES (check only those that apply)
I request:
a. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions.
b. a change of QRC (qualified rehabilitation consultant):

NAME NAME

F FIRM NAME FIRM NAME

R T
O ADDRESS O ADDRESS
M
PHONE # (include area code) PHONE # (include area code)

c. that the rehabilitation plan be changed.

d. retraining or exploration of retraining.
e. that the rehabilitation plan be terminated.
f. that the rehabilitation plan be suspended.
g. that the employee’s rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation.
h. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills.

i. 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.
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 (date)

PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

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
THIS FORM RESPONDS TO ISSUES R R 0 3
RAISED ON THE REHABILITATION
Enter dates in MM/DD/YYYY format. DO NOT USE THIS SPACE
REQUEST FORM WHICH WAS SIGNED ON (date)

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. YES NO

1. THIS RESPONSE IS BEING COMPLETED BY:

Employee’s Insurer/TPA Insurer’s QRC/
Employee Employer
Attorney Self-insured Attorney Vendor
2. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply)
a. I agree disagree with the request for rehabilitation consultation/services.
IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC.

NAME FIRM NAME ADDRESS SELECTED BY

b. I agree disagree with the request to change QRCs.

c. I agree disagree that the rehabilitation plan should be changed.
d. I agree disagree with the request for retraining/exploration of retraining.
e. I agree disagree that the rehabilitation plan should be terminated.
f. I agree disagree that the rehabilitation plan should be suspended.
g. I agree refuse to reimburse the employee for rehabilitation expenses.
to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for
h. I agree refuse
dispute.

i. 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.
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

NAME ADDRESS CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on (date)

PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

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 Minnesota Department of Labor and Industry
Workers’ Compensation Division
443 Lafayette Road North
St. Paul, MN 55155 R F 0 3
DATE(S) OF CLAIMED INJURY
(651) 284-5030
1-800-342-5354 (DIAL-DLI) DO NOT USE THIS SPACE

EMPLOYEE

VS.
EMPLOYER

AND
INSURER
Request for Formal Hearing
(under M.S. 176.106 or 176.305)
AND
ADDITIONAL PARTIES (INCLUDING INTERVENORS)
Please PRINT or TYPE.
Enter dates in MM/DD/YYYY format.

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, , requests

a formal hearing. An administrative decision on the issues was previously issued by:

(Name) .

The decision was served and filed on: (date). The specific issues in dispute and the

specific reason(s) for disputing the decision are as follows:

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 July 2007

MN Department of Labor and Industry 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: 1. Adjusting expense.

(less than $500.00)

B. 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. Adjusting expense.

2. Department expense.
3. Insurer attorney fees
(less than $800.00)

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. Adjusting expense.

2. Department expense.
3. Possible attorney fees and costs for the parties
(less than $1,000.00)

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

July 2007 Basic Adjusters’ Training Guide

6-6 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. Adjusting expense.

2. Department expense.
3. OAH expense.
4. Attorney fees for the parties.
5. Other nominal litigation costs.
($1,000.00 - $2,000.00)

E. 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. Adjusting expense.

2. Department expense.
3. OAH expense.
4. Attorney fees for the parties.
5. 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. Adjusting expense.

2. Department expense.
3. OAH expense.
4. Attorney fees for the parties.
5. 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.
6. Filing fees.
7. Hearing transcript.
8. Legal research and briefing expense.
9. Costs associated with possible remands to OAH.
($10,500.00 - $20,000.00)

Basic Adjusters’ Training Guide July 2007

MN Department of Labor and Industry 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. Adjusting expense.

2. Department expense.
3. OAH expense.
4. Attorney fees for the parties.
5. 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.
6. Filing fees.
7. Hearing transcript.
8. Legal research and briefing expense.
9. Costs associated with possible remands to OAH.
($13,000.00 - $23,000.00)

July 2007 Basic Adjusters’ Training Guide

6-8 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 July 2007

MN Department of Labor and Industry 6-9
Alternative Dispute Resolution Services

July 2007 Basic Adjusters’ Training Guide

6-10 MN Department of Labor and Industry
CHECK BOX IF THIS
REQUEST ADDS
Medical Request
Enter dates in MM/DD/YYYY format.
MEDICAL ISSUES TO NOTE: Before filing this form, call the workers’ compensation insurer. M Q 0 3
A PENDING If that does not resolve the issue, call Workers’ Compensation Benefit
MEDICAL REQUEST Management and Resolution at (651) 284-5032 (or 1-800-342-5354). DO NOT USE THIS SPACE
SOCIAL SECURITY NUMBER DATE OF INJURY
999-99-9999 03/23/2005
EMPLOYEE NAME PHONE # (include area code)
PAT WILLIAMS (651) 888-8800
EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA
411 MAIN ST INSURANCE MUTUAL
CITY STATE ZIP CODE INSURER ADDRESS
PEACEFUL VALLEY MN 55800 PO BOX 007
EMPLOYER NAME CITY STATE ZIP CODE
CHURCH OF HEALTH & WEALTH MINNEAPOLIS MN 55100
EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME
5500 CRIMSON AVE NW PAULA PERFECT
CITY STATE ZIP CODE 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.

✔ YES NO
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 Insurer/TPA Insurer’s Health Care
Employee ✔ Employer
Attorney Self-insured Attorney Provider
2. 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.
3. 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. a change of treating doctor:

NAME ADDRESS SPECIALTY
FROM:

NAME ADDRESS SPECIALTY

TO:

c. that prescribed treatment, surgery or equipment be provided. (Specify the requested surgery or equipment & attach supporting
medical reports.)
d. that the employee’s medical expenses be reimbursed (e.g., mileage, prescription drugs). Attach supporting medical reports.
e. 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: employee Veterans Administration Dept. of Human Services (Welfare)
Medicare Social Security Administration private health insurance other
In the space below, provide the name(s) of the person(s) or organization(s) checked above. Attach extra sheets if necessary.
NAME ADDRESS POLICY NUMBER

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.
NAME ADDRESS CITY, STATE, ZIP CODE
Pat Williams 411 Main St Peaceful Valley MN 55800
NAME ADDRESS CITY, STATE, ZIP CODE
Church of Health & Wealth 5500 Crimson Ave NW Peaceful Valley MN 55800
NAME ADDRESS CITY, STATE, ZIP CODE
Insurance Mutual PO Box 007 Minneapolis MN 55100
NAME ADDRESS CITY, STATE, ZIP CODE
Dr C Crunch 123 Main St Peaceful Valley MN 55800

I sent a copy of this form and all attachments to the parties listed in #6 on (date)

PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

LYLE LITIGATOR
ADDRESS ATTORNEY REGISTRATION #
8001 SKYLINE DR X12345
CITY STATE ZIP CODE 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 Service Amount

3/29/2005 Initial visit, Exam, Manipulation $ 134.00

4/1/2005 Manipulation - low back $ 40.00
4/6/2005 Manipulation - low back $ 40.00
4/11/2005 Manipulation - low back $ 40.00
4/15/2005 Manipulation - low back $ 40.00
4/18/2005 Manipulation - low back $ 40.00
4/20/2005 Manipulation - low back $ 40.00
4/25/2005 Manipulation - low back $ 40.00
4/26/2005 Manipulation - low back $ 40.00
4/29/2005 Manipulation - low back $ 40.00
5/3/2005 Manipulation - low back $ 40.00
5/9/2005 Manipulation - low back $ 40.00
5/20/2005 Manipulation - low back $ 40.00
5/28/2005 Manipulation - low back $ 40.00

Balance of $654.00 was reduced by the fee schedule and paid by insurer on 6/23/2005

5/31/2005 Manipulation - low back $ 40.00

6/3/2005 Manipulation - low back $ 40.00
6/6/2005 Manipulation - low back $ 40.00
6/11/2005 Manipulation - low back $ 40.00
6/14/2005 Manipulation - low back $ 40.00
6/17/2005 Manipulation - low back $ 40.00
6/21/2005 Manipulation - low back $ 40.00
6/28/2005 Manipulation - low back $ 40.00
6/30/2005 Manipulation - low back $ 40.00
7/5/2005 Manipulation - low back $ 40.00
7/7/2005 Manipulation - low back $ 40.00
7/12/2005 Manipulation - low back $ 40.00
7/14/2005 Manipulation - low back $ 40.00

Balance currently outstanding: $ 520.00