Voicemail:

I left voice mail to Adjuster: Martin King at Phone #: (951) 808-3877 for the resolution of
providers bills. I will be calling ADJ again in the morning time to resolve this matter.
Sending a fax request:
Send the demand packet along with Total Itemized bill, proof of service, Doctor Request
Form, copy of the lien if Available, & reports to the ADJ: ______ on this fax no
_____________, Also mention on the Top of the sheet "Best counter offer & I will
highly appreciate a quick and positive response from you.
Reconsideration a fax request:
Send the demand packet along with Total Itemized bill (reconsideration stamp), proof of
service, Doctor Request Form, copy of the lien if Available, & reports to the ADJ:
______ on this fax no _____________, Also mention on the Top of the sheet "Best
counter offer & I will highly appreciate a quick and positive response from you.
Counter Offer Comment:
File settled $_____ FNF For all DOS, please send confirmation letter of $_______ at
Fax # ________ In ATTN:: ________
Waiting for payment:
Left voice mail to adjuster ____________________ at ________________ regarding
the Provider ___________________________ for the confirmation letter & payment
status... and I requested her to give me call back for further assistance at 951-808-
3877...
ACTING IN BAD FAITH LETTER:
Send Response to refuse to negotiate a letter to Michael at fax no (603) 427-1890, Also
mention on the Top of the sheet reply with "Best offer"
Bills send to the Hartford INS billing Department:
Kindly send the itemized bills to California claims Dept: a fax: (859) 258-2239
Kindly send itemized bills, demand & bills & reports on domestic claims, Claim
no_________ at fax no (866) 739-6983
Fill the Request for Lien Information/Documents Received, send it to California claims
Dept: at fax: (859) 258-2239



Informal letter:
Send an informal letter to Adjuster: Miki Miriam, phone #: (951) 808-3877 Fax: (123)
456-789. Kindly fax the informal letter stating that 3 consecutive voice mails were left in
continuous days but no reply was received.
Request form outline:
As part of the treatment plan, authorization for the designated diagnostic test(s) is being
requested under the Labor Code Section 4610.
As the Primary Treating Physician defined by Title 8, Calif. Code of Regs. Sect. 9785
the undersigned physician is submitting the Request via facsimile within 5 days after the
injured worker's exam. If no response is received after 5 working days of a Decision "to
modify, deny, or delay" the treatment under the "Utilization Review" statute, Labor Code
Sect. 4610(e) the PTP will have the testing completed.
The treatment is reasonably necessary for the care of the injured worker pursuant to
Labor Code Sect. 4600 and the evidence based guidelines promulgated by the A.D. in
the MTUS. Further, under Sandhagen v. WCAB (2004) 69CCC1452 the PTP should be
notified if any dispute about the treatment is being referred to the AME/QME process
pursuant to Labor Code Sect. 4062. If no Notification is sent the treatment will be
considered approved and reimbursement for the test under the OMFS should be
issued..


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Title 8 California Code of Regulations, section 10250 requires a moving party state
under penalty of perjury that the moving party has made a genuine good faith effort to
resolve the dispute before filing the Declaration of Readiness (DOR). Forcing a provider
to file a lien and pay the filing or activation fee before the payer will discuss informal
resolution of their billing amount prevents the provider from complying with this
mandate. Such conduct could expose the payer to the imposition of sanctions,
attorneys fees and costs under Labor Code section 5813. This practice also exposes
the payer to audit penalties for violation of Title 8, California Code of Regulations,
section 10109(e). As is the Audit Units existing practice, the Audit Unit will review all
complaints received about this practice during the next random or targeted audit of any
payer about whom such a complaint has been received.




INTERPRETING LAW:
As per new law, SB 863 amended Labor Code section 4600(g) to state that an injured
worker is entitled to the services of a qualified interpreter at medical appointments if
the injured worker is not proficient in English. These regulations define the qualified
interpreter for purposes of medical treatment appointments as an interpreter who
has a documented and demonstrated proficiency in both English and the other
language; a fundamental knowledge in both languages of health care terminology and
concepts relevant to health care delivery systems; and education and training in
interpreting ethics, conduct and confidentiality so that employers can furnish, and
non-English-speaking injured employees can receive, interpreter services at medical
treatment in accordance with the statute.
Labor Code SB863: section 4603.2 Defendant must object within 30 days or pay within
45 days of receipt of Itemization, else 15% increases and 10% interest attach (payment
within 60 days and 7% interest for government entities),
AIM Report
Medical examinations are scheduled to obtain information which will enable the CE to
evaluate and resolve medical questions regarding the extent of anatomical impairment.
Whenever the CE or other party schedules an examination to evaluate anatomical
impairment, the CE will request the physician to submit a detailed narrative report
containing the following basic information:
(1) An evaluation of impairment in accordance with the AMA Guides, and a percentage
rating of the impairment of the injured member, or of impairment of the individual as a
whole, as in back or head injuries or retiree occupational disease cases.
(2) A description of any impairment not measured by the AMA Guides (except in retiree
claims under section 8(c) (23).
(3) A description of the physical limitations imposed by the injury with respect to lifting,
bending, sitting, walking, standing, stooping, or other activities, and the extent to which
such limitations preclude the claimant from performing usual and customary duties. A
description of the work limitations would not be necessary in the majority of scheduled
injuries, particularly when the claimant has returned to regular full-time work.
(4) Date of maximum medical improvement and/or date employee was able to return to
work.