Use when the patient received a medical bill for an injury that arose out of and in the course of employment. Under every state's workers'-compensation statute, work-related medical care is the financial responsibility of the employer's WC carrier, not the patient or the patient's health insurance. The provider's correct billing path is to bill the WC carrier directly under the carrier's approved fee schedule; balance-billing the patient is generally prohibited by state WC statute.
Common scenarios where this letter applies:
- The provider billed the patient's health insurance (or self-pay) when the patient told them the injury was work-related.
- The provider billed the WC carrier, the carrier denied or under-paid, and the provider rebilled the patient instead of pursuing the carrier through the WC dispute process.
- The WC claim is still pending acceptance/denial and the provider is collecting from the patient in the meantime.
This letter redirects the bill to the WC carrier, asserts the state's WC anti-balance-billing rule, and gives the provider a defined window to rebill correctly. If the WC claim has already been denied, use this template in parallel with letter_initial_dispute.md or letter_no_surprises_violation.md rather than as a substitute.
[PATIENT FULL NAME]
[STREET ADDRESS]
[CITY, STATE ZIP]
Phone: [PATIENT PHONE]
Email: [PATIENT EMAIL]
[DATE]
[BILLING DEPARTMENT MANAGER / PATIENT FINANCIAL SERVICES]
[PROVIDER NAME]
[PROVIDER MAILING ADDRESS]
VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED
USPS Tracking: [CERTIFIED MAIL TRACKING NUMBER]
cc by certified mail with full enclosure set:
[EMPLOYER NAME], Human Resources or WC contact
[WC CARRIER NAME], Claims department
[STATE] Workers' Compensation Commission or Board
RE: Redirect to workers'-compensation carrier, work-related injury,
Patient: [PATIENT FULL NAME]
Account #[ACCOUNT NUMBER]
Date of service: [DATE OF SERVICE]
Date of injury: [DATE OF INJURY]
Employer at time of injury: [EMPLOYER NAME]
WC carrier: [WC CARRIER NAME]
WC claim number (if assigned): [WC CLAIM NUMBER]
Amount asserted by your office: $[CURRENT BALANCE]
To Billing / Patient Financial Services:
I am the patient identified above. The medical care reflected in your bill was for an injury that arose out of and in the course of my employment with [EMPLOYER NAME] on [DATE OF INJURY]. Under [STATE STATUTE, e.g., Tennessee Code Title 50 Chapter 6, Workers' Compensation Law], the financial responsibility for work-related medical care is the employer's workers'-compensation carrier, not me. I am writing to redirect this bill to the WC carrier and to demand that your office withdraw any further collection activity against me on this account.
I. Notice and identifying information
The work-relatedness of the injury was disclosed at the time of service. The relevant identifiers are:
- Date of injury: [DATE OF INJURY]
- Employer at time of injury: [EMPLOYER NAME], [EMPLOYER ADDRESS], FEIN [if known]
- Workers'-compensation carrier: [WC CARRIER NAME], [WC CARRIER MAILING ADDRESS], [WC CARRIER PHONE], [WC CARRIER CLAIMS EMAIL OR FAX]
- WC claim number (if assigned): [WC CLAIM NUMBER]
- WC adjuster (if assigned): [ADJUSTER NAME], [ADJUSTER PHONE], [ADJUSTER EMAIL]
If your office has not previously billed the WC carrier, please submit the bill now to the carrier using the identifiers above. Your office is on notice from the date of this letter that the WC carrier is the correct payer.
II. State workers'-compensation balance-billing protection
[STATE STATUTE, e.g., Tennessee Code § 50-6-204(a)(3)(D); or Georgia O.C.G.A. § 34-9-204; or California Labor Code § 4600(c); the drafter resolves the citation from references/laws_state_<code>.md] prohibits a provider from billing or attempting to collect from an employee for work-related medical care that should be billed to the WC carrier. A provider who balance-bills an employee for work-related care is subject to administrative action from the state WC commission and, depending on the state, may forfeit the right to collect the disputed amount from any party.
The provider's remedy for a denied or under-paid WC claim is the state's WC fee-dispute process, not collection against the patient.
III. Demand
I demand, within fifteen (15) calendar days of the date of this letter:
1. Withdrawal of the current bill and any collection activity against me on account [ACCOUNT NUMBER].
2. Re-submission of the bill to [WC CARRIER NAME] under WC claim number [WC CLAIM NUMBER] (if assigned; otherwise under a new claim filed with the carrier using the information in Section I).
3. If the carrier denies or under-pays, your office will pursue the carrier through the state WC fee-dispute process and will not re-bill me.
4. Written confirmation that no further statements, collection contacts, or credit-bureau reporting will occur on this account.
IV. If your office has previously refunded or credited insurance payments
[Render this block only when health insurance previously paid on the same DOS and the provider has not yet refunded.]
If your office has previously accepted payment from my health insurance plan for this date of service and the care was in fact work-related, please refund the plan and pursue the WC carrier instead. [Health insurance contracts typically include a "primary-payer" rule under which work-related care is not a covered benefit; the plan's payment was a subrogation-eligible accident-related payment, which the plan is entitled to recover from the WC carrier through the WC claim, not from me.]
V. WC claim status (render the applicable block)
[BLOCK A, Accepted]
The WC claim has been accepted by [WC CARRIER NAME] under claim number [WC CLAIM NUMBER]. The carrier is the responsible payer. Bill the carrier.
[BLOCK B, Pending acceptance]
The WC claim is pending acceptance. Under [STATE STATUTE, e.g., Tennessee Code § 50-6-204(a)(3)(A)], the carrier has [N] days to accept or deny. During pendency, your office may not collect from me. Bill the carrier and await the determination.
[BLOCK C, Denied]
The WC claim was denied on [DENIAL DATE]. I have appealed the denial and the appeal is pending under [STATE WC APPEAL PROCESS, e.g., Tennessee Court of Workers' Compensation Claims, docket [DOCKET NUMBER]]. While the appeal is pending, your office should hold collection activity. If the appeal succeeds, the carrier will be the responsible payer. If the appeal fails and the matter is finally determined non-work-related, I will reopen this account with my health insurance and your office will be billed through the appropriate non-WC channel.
VI. Reservation of rights
If your office continues to balance-bill me for work-related care after this notice, I will:
1. File a complaint with the [STATE] Workers' Compensation Commission (or Board) alleging unlawful provider billing of an injured worker.
2. File a complaint with the [STATE] Department of Insurance and the [STATE] Attorney General's Division of Consumer Affairs.
3. Forward this letter and the bill to [EMPLOYER NAME]'s HR / WC contact and to [WC CARRIER NAME]'s claims department, both of whom have a financial interest in the correct billing path and may also pursue your office directly through the WC fee-dispute process.
4. If escalation to court becomes necessary, seek declaratory relief and (where the state authorizes) statutory damages for unlawful balance billing.
VII. Privilege
This letter is sent as a courtesy notice and an offer to resolve the billing dispute administratively. No statement is an admission of liability for any amount, and the case is not in compromise; rather, your office is directed to the correct payer.
Please direct your response to the address above.
Sincerely,
[PATIENT FULL NAME]
Account number: [ACCOUNT NUMBER]
Date of service: [DATE OF SERVICE]
Date of injury: [DATE OF INJURY]
WC claim number: [WC CLAIM NUMBER]
Enclosures:
A, Copy of the bill in question
B, Copy of the WC claim acknowledgment / acceptance / denial letter from [WC CARRIER NAME]
C, Copy of any First Report of Injury filed with the employer
D, Copy of any prior correspondence between me and your office on this account
[WC CLAIM NUMBER]may not be assigned if the WC claim is brand new or the patient declined to file. If the patient declined to file a WC claim (some patients do this for personal reasons), this template is the wrong tool, the bill is then properly handled through health insurance or self-pay, and the patient should use the regular dispute flow.[STATE STATUTE]resolves fromreferences/laws_state_<code>.md. Every state has a WC statute with an anti-balance-billing provision; the citation is state-specific.- The CC list is critical. The employer's HR / WC contact has a strong incentive to pressure the provider into rebilling correctly because incorrect billing complicates the employer's loss-experience modifier. The WC carrier wants the bill on its desk to control the fee-schedule adjudication.
The drafter confirms:
- The bill is in fact for a work-related injury. The kit detects this via the bill's
findingsfield (work_related_injury) or via sidecar text keywords. If neither matches and the user has not manually flagged it, this template does not apply. - The patient has actually filed (or intends to file) a WC claim. If the patient declined to file, do not use this template.
- The WC claim status is known: accepted, pending, or denied. The drafter selects the matching V.A/B/C block.
- File a state WC commission complaint if the provider's balance-billing pattern is established (multiple statements after notice).
- Forward the letter to the employer's HR contact directly, even if the formal CC was to a generic address. HR contacts often resolve provider-billing missteps in days.
- Update the action log with
--action wc_carrier_redirect_sent.
- 15 days from postmark, no withdrawal → file state WC commission complaint.
- WC carrier acknowledges and accepts the bill → confirm in writing and update tracker
statustoclosed(resolved through redirect). - WC carrier denies but appeal pending → keep tracker
statusasdisputedand watch the WC appeal deadline. - WC denial becomes final and care is determined non-work-related → reopen with health insurance and run the regular dispute flow.
templates/letter_auto_med_pay.md, analogous redirect for auto-accident med-pay (PIP coverage).templates/letter_challenge_hospital_lien.md, when the provider has filed a hospital lien against the WC recovery.references/laws_state_<code>.md, state WC anti-balance-billing citation.