Liability/Auto No-Fault Referral Form

A Claims Settlement Allocation is indicated only in cases that are being settled and the claimant is not currently a Medicare beneficiary and there is no reasonable expectation of becoming a Medicare beneficiary within 30 months and where the settling parties are making a good faith effort to protect Medicare's intrests in a non-serious injury that does not require substantial lifetime medical care.

Fill in the required details and hit submit at the bottom of the page. Any fields that you do not have relevant information for can be filled out with "unknown". For print, please use the Manual Referral Form - Click Here

* indicates a required field

Insurer Information

*Insurer Name

This should be the insurer name not the TPA's name.
Request cannot be processed until this information is received.

Claim Information

*Claimant/Plaintiff
First Name

Claimant/Plaintiff
Middle Initial

*Claimant/Plaintiff
Last Name

*Date of Birth
(mm-dd-yyyy)

*Social Security Number

*Claimant/Plaintiff
Address

*Claimant/Plaintiff
City

*Claimant/Plaintiff
State

*Claimant/Plaintiff
Zip Code

Gender

*1st Date of Injury
(mm-dd-yyyy)

*1st Claim Number

2nd Date of Injury
(mm-dd-yyyy)

2nd Claim Number

3rd Date of Injury
(mm-dd-yyyy)

3rd Claim Number

*Employer/Defendant/
Insured Name

*Employer/Defendant/
Insured Address

*State Jurisdication

Insurance Type Selection

Liability Case
Auto/No-Fault Case

MSP Compliance Service Selection

Select one service only - call if uncertain.

CSA

Criteria:

General Orthopedic injuries
cervical neck strain/sprain or cervical disc problems
mid and or low back strain/ sprain
sciatica or lumbar disc problems
shoulder strain/sprain or rotator cuff injuries
elbow strain/sprain , epicondylitis
carpal tunnel syndrome or wrist strain/sprain
knee or hip strain/sprain
fracture or joint replacement
ankle sprain/strain or fracture
Zero Allocation without Cost Projections

Liability Settlement Allocation (LSA)

Criteria:

Complex Regional Pain Syndrome (CRPS)/Reflex Sympathetic Dystrophy (RSD)
Chronic or Failed Back Syndrome requiring Spinal Cord Stimulator/ Dorsal Column Stimulator or Intrathecal Pain Pump
Major psychiatric condition requiring long term monitoring, including major depression with suicidal ideation and Post Traumatic Stress Disorder (PTSD)
Immunodeficiency
Vision or Hearing loss requiring prosthesis or implant
Zero Allocation with cost projections

MSA

Criteria:

Total Settlement Value greater than $250,000
Catastrophic Claims: Spinal Cord Injury (SCI), Traumatic Brain Injury (TBI), Toxic Exposure, Multiple trauma with multiple organ/ orthopedic involvement, Amputation, Burns, Organ Transplants
Liability claims with coexisting WC injury

Additional MSP Compliance Services Selection

Prescription Drug Review (PDR)
Medicare Verification
Conditional Payment Research (CPR)
Conditional Payment Negotiation (CPN)

Key Contact and Billing Information

Please identify the referring party and any parties we should send copies of the allocation report to:

Adjuster/Carrier/TPA/Servicing Agent
Defense Attorney
Plaintiff Attorney
Structure Broker
Other

Party responsible for bill:

Insurance Carrier/TPA
Referring Party

Billing Address and Telephone Number
(If different from above)

General File Information

1. Is the claimant currently a Medicare Beneficiary? (If yes, please provide supporting documentation.)

Yes
No
Not Known

2. May we contact the plaintiff counsel/claimant to obtain releases? No contact will be made to plaintiff counsel, claimant or any medical providers without signed releases.

Yes
No
Not Known

3. Are there any denied/disputed/controverted/negligence issues? If yes, please fill out a Controverted Case Questionnaire Form.

Yes
No
Not Known

4. Has this claim been settled or a proposed settlement been reached?

Yes
No
Not Known

5. Are there any underlying workers' compensation claims involved?

Yes
No
Not Known

6. Do you want us to contact Medicare to determine if liens exist?

Yes
No
Not Known

7. What are the policy limits?

8. Amounts paid to date? ($) .00

9. List body part/injury that you are accepting?

Additional Questions if Denied/Disputed/Controverted/Negligence Issues

10. May we contact defense counsel on this claim?

Yes
No
Not Known

11. Has the entire claim been disputed based upon a "no liability defense"?

Yes
No
Not Known

12. Are monies included in the settlement for future medical care?

Yes
No
Not Known

13. Have any medical payments been made for denied/disputed/controverted services/treatment?

Yes
No
Not Known

14. Have you accepted liability for all alleged body parts connected to the accident?

Yes
No
Not Known

15. List body parts that you are denying/disputing.

16. What date was the case first disputed?
(mm-dd-yyyy)

17. Please list any prior injuries that pre-date this claim.

18. Please explain the specific condition or care that is being denied/disputed/controverted. Include all legal and medical reasons as well as supporting documents/records to support basis for denial of liability.

19. Is the claimant currently treating?

Yes
No

20. If currently treating, list treating physician, address and phone number.

21. What do you expect the allocation to provide?

Zero Dollar Allocation Only
Estimated Future Medical Expenses without a Zero Dollar Allocation
Zero Dollar Allocation with Estimated Future Medical Expenses

Notes/Special Handling

Please include controverted issues, deadlines, mediation/court dates, etc.

RSM/AAM Email
(Internal Use Only)

Gould and Lamb

Liability/Auto No-Fault Referral Form

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