To facilitate the claim process, ensure the Provider Initial Report (PIR) is:
Filled out completely, leaving areas blank may delay processing of the claim and interrupt the processing of your bills for payment. If the condition is a disease, enter “N/A” for “not applicable” in both of the following boxes:
- Date of injury
- Time of injury
Be as specific as possible.
- Include a complete diagnosis and the appropriate Common Diagnostic Codes (ICD-10 codes). Be clear about the specific body site and the definition of the injury.
- If your patient is unable to perform any work due to the injury or disease, estimate how much time the injured worker will lose due to the injury.
- Must be signed by both you and your patient.
Submit promptly with copies of the:
- History and Physical
- Emergency room evaluation or your office notes
Helpful Links:
- Additional information is available on the Labor & Industry website here.
- The PIR form can be downloaded from the Labor & Industry website.
- Labor & Industry also provides additional guidance for billing Self-Insured Employers.
