The application for mediation of the medical expenditure case requires the applicant to fill out the petition and the detailed list (see the attached list I and II) stating the following matters with his seal:
I. The name and code of the insurance contracted medical care institution and the person who is in charge of the institution.
II. Claims
III. Facts and reasons for mediation application
IV. The date of receiving or knowing the insurer's recheck notification (MM/DD/YY)
V. The medical record and other related certifications. The transcripts or copies of materials in written form are required.
VI. Transcripts or copies of the insurer's recheck notification document and the related documents or materials
VII. MM/DD/YY
The facts and reasons referred to in Subparagraph 3 of the preceding Paragraph shall be written to the columns specified by the format.
An applicant submitting an Attachment 2 (details of dispute mediation case) together with relevant documents and materials as prescribed in Paragraph 1 of this Article in electronic form through the system designated by the NHI Dispute Mediation Committee is exempted from providing those documents and materials in paper and physical form. However, the NHI Dispute Mediation Committee may, as it deems necessary, request the applicant to submit those documents and materials in paper and physical form.

• Attachment 1.pdf
• Attachment 1.odt
• Attachment 2.pdf
• Attachment 2.odt

The insurer shall present the position paper stating the following matters in accordance with Paragraph 2, Article 8:
I. The reasons not stated in the recheck notification documents.
II. Comments on all the arguments put forward by the applicant.
III. The evidence available for the recheck notification.
The evidence available for the recheck notification referred to preceding paragraph shall state the methods of review, analysis and sampling with related information enclosed in case of field audit, file analysis, purposive and random sampling examination.

The mediation approval of the medical expenditure case shall be carried out in accordance with Article 18 and 19 (excluding Subparagraph 4, Paragraph 1, Article 18).

The approved medical expenditure case requires the approval paper stating the following matters:
I. The name and code of the insurance contracted medical care institution.
II. Texts, facts and reasons, among which the facts and reasons not concerning the arguments may not be stated.
III. The agency and its leading officer.
IV. MM/DD/YY
If the same applicant applies for over two dispute mediations on the same agreement within the given time, only the disputed matters need to be stated as stipulated by Subparagraph 2 of the preceding Paragraph. The same process is also applied to case of the same type and same mediation result.
If the insurer re-evaluates the medical expenditure case in accordance with Paragraph 2, Article 8, the NHI Dispute Mediation Committee is allowed to close the case directly without the approval paper of Paragraph 1.
The approval paper shall have note specifying the relief measures for objection to items approved and the juridical court accepting the case.