HUMMEL CONSULTATION SERVICES

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Submitting a New Referral to Hummel Consultation Services:


What to Include With New Referrals:

For Workers' Compensation, Longshore & Harbor Workers, and Federal Employee Compensation Act Claims:

  •    Medical Records: At least for the past two years, detailing the injury, past and present treatment, and future physician recommendations. Please do not send originals. Documents from primary care physicians are more useful and should always be included.
  •    Medical Payment History: At least for the past two years, indicating at a minimum for each transaction the payee, the amount of the payment (preferred) or the amount billed, and the date of service (preferred) or the date paid. Service descriptions, CPT codes, and your own internal codes should be included if available. EOB and billing statements are acceptable if no organized payment history is available.
  •    Prescription Data: If no spreadsheet is available, then copies of current invoices may be used. For each prescription, the following must be provided: name of drug, dosage, pill count and refill frequency.
  •    Indemnity and Expense Data: At least for the past two years, indicating for each transaction the payee, amount paid, and date of payment.
  •    Contact Information: For returning clients, you only need to include your name on something prominent so we will notice it. For new clients, please include your name, company, mailing address, telephone number, facsimile number, and e-mail address.


For Third Party Liability and Jones Act Claims:

  •    Medical Records: At least for the past two years, detailing the injury, past and present treatment, and future physician recommendations. Please do not send originals. Documents from primary care physicians are more useful and should always be included.
  •    Future Medical Treatment Needs: Includes any data that addresses future medical treatment needs, such as deposition testimony, Life Care Plans, or treatment plans from the primary treating physicians.
  •    Cost Data: Any data outlining costs spent or billed for the injury or illness. Examples include Explanation of Billing statements (EOB's), billing invoices, medical lien notices, or payment ledgers from insurance providers.
  •    Prescription Data: If no spreadsheet is available, then copies of current invoices may be used. For each prescription, the following must be provided: name of drug, dosage, pill count and refill frequency.
  •    Settlement Information: The amount that the case either has or will settle for. If no settlement has been reached, then the insurance carrier policy limit data should be provided.
  •    Contact Information: For returning clients, you only need to include your name on something prominent so we will notice it. For new clients, please include your name, company, mailing address, telephone number, facsimile number, and e-mail address.


For Zero-Dollar Workers' Compensation Medicare Set-Asides: (As required per CMS guidelines)

  •    Medicare Release: To be signed and completed by the claimant. Please instruct them to check the "ongoing" box. A copy of the release may be foundhere.
  •    Claimant's Information: Name, address and phone number.
  •    Claimant's Attorney Information: Name, address, phone number and email address.
  •    Employer Information: Name, address and phone number. Include a personal contact if available.
  •    Workers' Compensation Carrier Information: Insurer name, address, name of the primary case manager, phone number, fax number, email address, and insurer claim number.
  •    No Indemnity or Medical Payment Letter: Letter from the Workers' Compensation insurance carrier on their letterhead stating no indemnity or medical payments have been paid on the claim. The letter must clearly state "No medical payments and no indemnity payments have been made." A statement of only "No benefits paid," is not acceptable by CMS.
  •    Settlement Amount: If settlement has not been reached, then either the most current amount offered by either party or an estimate of the likely settlement amount.
  •    Copy of the Settlement Agreement: Drafts are acceptable. If none is available, then a letter on the carrier's letterhead, signed and dated by an appropriate representative of the carrier, confirming that no settlement documents exist.
  •    Copy of the Pleadings: All pleadings filed must be included. If none are available, then a letter from both the carrier and the claimant's counsel, each on their respective letterheads, signed and dated, confirming that no pleadings exist.
  •    Medical, Expense and Indemnity Payment History: As provided by the carrier; all three must be provided, even if any are blank, and must encompass the entire history of the claim. The copies must indicate on which date the copies were printed and have appropriate identifying information. If the date of printing cannot be included on the actual payment histories, then a letter from the carrier, on letterhead, signed and dated, must be provided confirming that the date of printing cannot be included. All printouts must be dated within the last six months, otherwise they must be updated with current data.
  •    Medical Records: Copies of all records for the treatment of the alleged injury over the last two years, even if not paid by the carrier. Please do not send originals. If no medical records exist for the last two years, then a statement from the treating physician, signed and dated, must be provided verifying the last date of treatment, and two years of medical records preceding that date. IME records are not medical records for CMS purposes.
  •    Pharmacy History: A list of all medications for the past two years, which must include for each drug: name, dosage, pill count and refill frequency.
  •    All Letters: Any letter or statement indicated above must include: name of the claimant, date of injury, and a list of body parts involved in the claim. Furthermore, all letters must be dated within the last six months or must otherwise be updated.
  •    Contact Information: For returning clients, you only need to include your name on something prominent so we will notice it. For new clients, please include your name, company, primary contact, mailing address, telephone number, facsimile number, and e-mail address.


The following are not initially necessary for a new referral, but can be helpful for our analysis:

  •    Claim Submission Form: A blank form can be found here.
  •    Life Care Plan: Our firm does not produce Life Care Plans. Payment histories should still be included even if using a Life Care Plan. Life Care Plans can only be used if they are no more than a year old.
  •    Independent Medical Evaluations (IME): Please include all reports if available, although more current reports are more useful.
  •    Detailed Contact Information: Addresses, phone and facsimile numbers, and e-mail addresses for: the claimant, all involved employers, all involved attorneys, and all involved third-parties.
  •    Rated Ages: Our firm can assist you to obtain rated ages if you do not already have them.
  •    Legal Documents: If available, please include drafts or executed settlement agreements, depositions, state and federal filings, judicial rulings and opinions, and any other legal document with relevance to the claim.
  •    Medicare and Social Security Statements: Please note, due to federal privacy laws, a claimant cannot be compelled to surrender copies of these documents. Useful data includes Social Security Administration determinations and rulings, statements of benefits, and copies of Medicare cards.
  •    Claimant Statements: Declarations signed by the claimant regarding specific future treatment concerns.


How to Send New Referrals:

We welcome submission by any means you find to be the most convenient. If none of the following options are best suited for your individual needs, please contact us and we would be more than happy to discuss alternatives. You are welcome to combine types for the same referral.

  •    Paper Submissions via Mail, Delivery, or Facsimile: Hardcopies of any and all documents are always accepted. Please do not send originals of the medical records!
  •    Diskette, CD-ROM, or USB Data Device: File materials may be copied onto a diskette, CD-ROM or USB-based data device in any standard format. Our firm recognizes all major software formats, including graphic files (often used by scanning equipment, including .pdf, .gif, .jpeg, and .bmp), Adobe software files (.pdf), standard text files (.txt), and popular word processing and spreadsheet files (all versions of Word and Excel, XML formats, Unicode, dBase, Quattro, CSV, or DIF). We cannot accept Works files at this time.
  •    E-Mail: File materials may be included as e-mail attachments. Please use multiple e-mails if the sizes of the attachments are very large (greater than 1Mb), otherwise your e-mail may be forwarded to you as undeliverable.


Where to Send New Referrals:

All of the following options may be utilized for new referrals; the usage of multiple types is welcome.

  •    U.S. Postal Service: Post Office Box 180, Portsmouth, New Hampshire 03802-0180
  •    Delivery Services (UPS, FedEx, DHL, Airborne Express): 600 State Street, Suite 4, Portsmouth, New Hampshire 03801
  •    Facsimile: (603) 758-1411
  •    E-Mail: joseph@hummelcs.com


Questions and More Information:

Please contact Joseph Hummel for any questions you may have about submitting a new referral to Hummel Consultation Services. Thank you!

E-mail: joseph@hummelcs.com