Insurers

 This form may be used by legal counsel to request Full and Final Mediation by a Commission mediator as a means of reaching a compromise settlement. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

 This form may be used by injured workers, deceased worker claimants, medical provider claimants, employers, insurers, claim administrators, and legal counsel to request Issue Mediation by a Commission mediator as a means of resolving a claims dispute. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

The treating physician completes this form to provide information to support an injured worker’s claim which resulted in amputation to the foot, toes or metatarsal bones and/or hand, fingers or metacarpal bones.

The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial disability benefits.

Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.

Payment for services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. Whenever there is a disagreement on the application or interpretation of the MFS Rules between a provider and a payer, either party may submit a MFS Dispute Request Form along with supporting documentation to the Medical Fee Services Department for administrative review and determination.

 This form describes the mediation process and related Code of Virginia provisions. When one or more parties to a mediation does not have legal counsel to represent them at the mediation, Mediation Consent Form B is used, which requires a neutral facilitation style by the mediator (see paragraph 7).

 This form describes the mediation process and related Code of Virginia provisions. When all parties to a mediation have legal counsel to represent them at the mediation, Mediation Consent Form A is used, which allows the parties to choose a neutral evaluation style and/or a neutral facilitation style by the mediator (see paragraph 7).

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application

• is or will be accepted and paid;
• is under review for repricing, negotiation, or other reason; or
• is denied and for what reason; and
• whether the employer, insurer, or claims administrator consents to issue mediation with the medical provider to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

The Rejection of Coverage form may be filed by an executive officer or their agent should the officer elect to exclude himself or herself from coverage under the Act. An executive officer means (i) president, vice-president, secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii) the manager elected or appointed in accordance with the articles of organization or operating agreement of a limited liability company. It does not include persons with the title of director, LLC member or chairman.