Wi fee workers compensation 2026

1. Click ‘Get Form’ to open the wi fee workers compensation document in the editor.
2. In Section 1, enter the dates of correspondence. Fill in the date when the health care provider first billed the insurer and the date when payment was first refused.
3. Proceed to Section 2, where you will answer questions regarding the insurer's refusal. Indicate whether they used a certified data base and if they justified their fee dispute.
4. In Section 3, provide your personal information including name, address, and details about the health care provider involved in the dispute.
5. Complete Section 4 by listing specific treatments in dispute. Include CPT codes, zip codes, and amounts charged for each treatment.
6. Review all sections for accuracy before submitting your form. Ensure that all required attachments are included as specified.

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