To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).

General billing information for those providers that bill the department.

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

A form for Providers to submit disputes to the department regarding payment of medical provider bills

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.

Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I's Provider Express Billing (PEB).

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.

This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.