Section 755.40  Procedures for Requesting Payment of Outstanding Costs

a)         Employees shall submit claims on forms provided by the Department. Employees shall provide documentation of:

1)         their policy's deductible amount and the amount of any payments applied toward it;

2)         the name, address, and telephone number of each provider for which outstanding costs are claimed;

3)         all outstanding costs claimed, including the date of service, patient account number, services provided and charges assessed;

4)         all payments made to providers or collection agencies against outstanding costs and the source of those payments; for example, the employee, secondary insurers, the Districts, other persons, etc.; and

5)         the amount of eligible costs, if any, which have been forgiven by the provider.

b)         Documentation acceptable to the Department shall include, but is not limited to, original provider bills, canceled checks, payment receipts, balance due statements, statements of benefits from Mid-Continent, and correspondence from providers, Mid-Continent or other relevant sources.