Provider's Report of Claim & Request for Medical Payment Form

DATE: August 22, 2002

TO: All Workers' Compensation Carriers and Providers

FROM: Craig R. Petersen, Director
Saundra Ford, Administrator, Health Care Services Division

On May 29, 2002, the bureau notified workers' compensation carriers and health care providers of their approval to allow providers to submit Form BWC-117 as the notice of injury to the carrier. This procedure has caused problems and concerns to the carriers, providers, and the bureau. As a result, the bureau has created a new form and developed a detailed set of instructions to be used in certain situations.

Health care providers should no longer use Form BWC-117. The bureau has developed a new form, Provider's Report of Claim & Request for Medical Payment ( BWC-117H), for providers to use when treating occupational injuries or diseases. Below are the instructions for completion and submission of this form to the carrier.

Instructions for Completion of Form BWC-117H

  1. The injured worker should complete section one and the provider should complete section two.
  2. The name of the person on the employer's authorization form or telephone referral should be provided in the box titled "employer's representative authorizing treatment". A telephone number should be included on the form for future reference by the provider and carrier.
  3. The completed form should be retained in the patient's file for possible future submission to the carrier on the injured worker's behalf. This form should not be sent to the Bureau.
  4. The provider should initially bill the carrier for their medical services without attaching the Form BWC-117H.
  5. If the carrier rejects payment because there is no report of injury on file with the carrier, or if the carrier fails to respond to a medical bill within 30 days, the provider may then send the Form BWC-117H to the carrier. Copies of this form should not be sent to the bureau under any circumstances.

Employee's Report of Claim forms (BWC-117) currently contained within an injured worker's file may be submitted to the carriers. However, please do not send a copy of this form to the bureau.

Please print the Provider's Report of Claim & Request for Medical Payment BWC-117H for your use. You may print and/or duplicate as many copies of this form as you need, as the bureau will not be maintaining a supply. This form is also available on this website under the Health Care Services link in the Featured Forms and Publications box, or the Forms button located on the left side of the page.