- The RFA-2 form has been modified to better align with the process for resolving payer PAR denials. The updated version of Form RFA-2 is available as of today (12/4/2023). The prior version will continue to be accepted for 30 calendar days until 1/3/2024.
- If the provider escalates a PAR denial for Level 3 review, any determination issued is final and not subject medical necessity review. Also, the payer may not dispute payment based on medical necessity.?
- In instances where the claim administrator has raised the issue regarding condition or unestablished body part, payment for any services provided in relation to this condition or body part are not guaranteed by the Notice of Resolution.
- Additionally, any dispute for payment related to the issue of causal relationship raised by the payer (Form C-8.1B) after the treatment is rendered may be resolved in favor of the payer.
The Board periodically releases new versions of forms. As such, the Board will only accept older versions of the forms listed below until January 31, 2024.
- C-32 (4/21) - Waiver Agreement - Section 32 WCL
- C-32AF (12-21) - Carrier's/Self-Insured Employer's Affirmation
- C-32E (7/19) - Section 32 - Electronic Signature
- C-32-I (6/20) - Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement
- C-300.5 (10/16) - Stipulation
- C-312.5 (12/10) - Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only)
- DB-451 (5/19) - Notice of Total or Partial Rejection of Claim for Disability Benefits
- OC-400.5 (6-13) - Attorney/Representative's Certification of Form C-3 or Notice of Controversy
- OC-400.17 (8/20) - Attorney/Licensed Representative Request to Withdraw from Representation
- OC-406 (1/18) - Notice of Retainer and Appearance on Behalf of Employer
If you submit an older version of one of these forms after January 31, 2024, Conduent will send you a letter advising that you submitted an older version until the end of February (30 days after the deadline).?
