The Wisconsin Necessity of Treatment Dispute Resolution Request Form is used to initiate a dispute resolution process when a disagreement arises about the medical necessity of a requested medical treatment in Wisconsin. This form must be completed by the provider and the patient, and then submitted to the Wisconsin Department of Health Services for review. There are two types of forms: one for individuals who are enrolled in a Wisconsin Medicaid program, and one for individuals who are not enrolled in a Wisconsin Medicaid program. The form requests basic information about the dispute, including the patient's name, address, and date of birth; the provider's name, address, and license number; and the type of medical treatment in question. In addition, the form requires the patient and provider to provide detailed information about the proposed treatment, including the reason for the dispute, the medical evidence supporting the proposed treatment, and any other relevant information. After the form is submitted, the Wisconsin Department of Health Services will review the dispute and make a final determination about the medical necessity of the proposed treatment.
Wisconsin Necessity of Treatment Dispute Resolution Request Form
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How to fill out Wisconsin Necessity Of Treatment Dispute Resolution Request Form?
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