Authorization Number : 845-0505
Agency Series No. : IC-MED-08
Status : Active
Agency Web Link :
Agency : OIC
Confidential Description : Contains provider numbers, injured worker names, and claim information
Division : OIC0017
Vital Description :
Section : OIC00170017
Record Title : Fee Bill Inquiries
Revision : 1
Record Description : A form created when an IC specialist examiner or their representative inquire about non-payment of a fee bill. The form contains the date, claim number, the specialist information,name, provider numbers, date of service, and amount of the bill. This form is used as receipt of inquiry and documentation of action for reconciliation of payment.