What is HP-1 Form?

A HP-1 request form is submitted when a health provider has been unsuccessful in obtaining payment from a carrier for services rendered to a patient who has a ‘Workers’ Compensation’ case.

There are two choices offered through the disputed bills process. The choice depends upon the carrier’s response (or lack of response) to submitted bill(s).

1. Request for Arbitration.
2. Request for Administrative Award

CureMD has integrated a ‘HP-1 Form’, allowing users to print the form with maximum data auto-populated from CureMD records. The information on HP-1 form is divided into the following sections:

1. Doctor’s Progress Report
2. Patient’s Information
3. Doctor’s Information
4. Billing Information
5. Examination
6. Treatment

User can enter information such as ‘Date of Accident’, ‘Claimant’s Social Security Number’, ‘Claimant’s Social Security Number’ , ‘Provider’s Telephone Number # ‘ ,’WCB Authorization #’ or ‘Provider’s WCB Rating Code’ etc.

Moreover, the fields such as ‘ Date You First Treated Claimant’, ‘WCB Case Number’ , ‘Carrier Case Number’, ‘WCB case number’ including patient demographics are auto-populated on this form.

An input date range field named ‘Date Span for Attached Bill’ has been added under the ‘Request for Administrative Award’ section.

The updated HP-1 can be seen below.

Once the form is completed, user can click ‘Save’ button or ‘Save & Print’ Button.

Clicking ‘Save and Print’  opens up HP-1 Form in Crystal Report.

All of these fields have been mapped on to the printed HP-1 form in a similar manner. However, the radio buttons under the Request for Arbitration section are mapped as checkboxes on the printed form.