Medical Provider

WC 164 Form

• Fees Rule 18-6(G)(2)

• Fees Rule 16-7(E)

  • Billing Codes Rule 18-6(G)(2)(e)

  • Closing Report Rule 18-6(G)(2)(b)

  • Closing Report  Rule 16-7(E)(1)(b)

  • Initial Report Rule 18-6(G)(2)(a)

  • Initial Report Rule 16-7(E)(1)(a)

  • Maximum Allowance Rule 18-6(G)(2)(e)

  • Payer Requested Rule 18-6(G)(2)(c)

  • Provider Initiated Rule 18-6(G)(2)(d)

   

• Timeline for filing initial Rule 16-7(E)(3)

• Supporting Documentation Rule 16-7(E)(4)

• Hospital Documentation Rule 16-7(E)(5)

• Contest of Payment Rule 16-7(E)(6)

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