Department of Labor and Industry

Board Minutes

Workers Comp Claims

Workers' Comp Claims Category

Proposed Montana Facility Fee Schedule

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Previous EDI Notices

NOTICE(S):

Intent to Adopt Claims Release 3:  On June 7, 2012, the Department of Labor and Industry announced its intention to adopt the IAIABC EDI Claims Release 3.0.  The Department plans to adopt the international reporting standards on a voluntary basis in the next three to five years.   This link contains the entire notice.

FROI/SROI Edit Matrix Change: In the near future, Montana will begin returning a TR (Transaction Rejected) for reports received with invalid Social Security Numbers (DN42), per SSA guidelines.  Communications will also be initiated with Trading Partners to correct invalid SSNs already submitted.   (Posted 11/17/11)

FROI Edit Matrix Change:  Effective 11/9/2011, Montana began returning a TR (Transaction Rejected) for FROI submissions containing ‘99’ in the Part of Body Injured Code (DN0036).  (Posted 11/9/2011.)

Medical Status Form - Hard Copy Request

 

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Medical Regulations Unit Forms

The forms listed below are those commonly used in the Medical Regulation Unit functions of the workers' compensation system.

Medical Forms

Medical Status Form

Independent Medical Review Form (pdf)

Subsequent Injury Fund Forms

SIF Application (pdf)

SIF Application (word)

SIF Release Form (pdf)

SIF Release Form (word)

Medical Status Form

The REVISED Medical Status Form is now available. Based on feedback from medical providers, the Department determined there was a need to revise the form. The revised form reflects this input from medical providers as well as feedback received from other stakeholders in the system.

If you use the online version of the form you may immediately begin using the revised fillable PDF form. If you use the triplicate hard copy of the form, please continue to use the forms you have on hand until your supplies are depleted. When you order new triplicate hard copy forms from the Department, they will be the revised Medical Status Form.

The revised form offers on-demand instructions. You will notice question marks in the black box on the left of each section. Clicking on the question mark will display specific instructions for that section. To close the instructions and return to the form, click the “X” on the right upper corner of the instruction window. The complete instructions may be found on page four.

If you have any questions about the use of the Medical Status Form and/or would like to schedule training, you may email Maralyn Lytle at Mlytle@mt.gov or call at (406) 444-6604.

Note: Effective July 1, 2011, 39-71-1036, MCA, requires the treating physician or a designee to complete the form following every office visit with the injured worker. The Legislature directed the Department to create the form to be used for injuries or occupational diseases. The form was originally finalized the first week of October 2011.

Download the Medical Status Form.

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