Medical Fee Schedule Dispute Request Form

Download Medical Fee Schedule Dispute Request Form

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.

Please complete the MFS Dispute Request Form and forward directly to the Commission. This form may be filed electronically via the Commission’s website at http://workcomp.virginia.gov. To file electronically, the user must complete a PDF fillable form and submit supporting documentation. This form may also be filed by mail or in-person at 333 E. Franklin St., Richmond, Virginia 23219.

For questions or assistance with completing this form, please contact the Virginia Workers’ Compensation Commission toll-free at 1-877-664-2566.