The Utilization Review Guide outlines services that require prior authorization from either the claims adjuster or the Utilization Review Department. Chiropractic AuthorizationDental Authorization, Durable Medical Equipment AuthorizationTherapy Authorization, and Ambulance Authorization contain additional pertinent information to the authorization of these services.

 Failure to obtain prior authorization may result in denial of payment for the service. Prior authorization approval is not a guarantee of payment; reimbursement is dependent upon the final liability determination of the claim.

Submitting a Prior Authorization Request

The Post Injection Pain Response form is a tool for providers to utilize when requesting authorization for additional injections. The form contains pertinent information WSI requires for additional injections. The intent of the Post Injection Pain Response form is to supplement the documentation. Its use is not mandatory and it does not replace the UR-C form.

Appealing a Decision on a Utilization Review Determination Letter

  • Review the Utilization Review Determination letter for specific information on how to appeal the decision
  • Complete the appropriate Utilization Review form
  • Fax the appropriate form and additional supporting medical documentation to: 701-328-3765 or 866-356-6433

Submitting a Retrospective Authorization Review Request

  • WSI will allow a retrospective authorization review if the provider has received a denied charge and can demonstrate one of the following:
    • The provider was not aware the condition was a work-related injury
    • The injured worker's claim status at time of service included: denied, presumed closed, or a claim not filed
  • Complete the Medical Bill Appeal (M6) form to initiate the retrospective authorization review process
  • Fax the M6 form and supporting medical documentation to 701-328-3765 or 866-356-6433