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Good Evening
6:46:17 PM CDT
Thursday, September 18, 2014

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Authorization Header Authorization Header

This information provides a summary of prior authorization requirements, including retrospective reviews, and referrals.

Authorization
Certain services, including DME, require approval from either the claims adjuster or the Utilization Review department as outlined in the Utilization Review Guide. Prior authorization approval is not a guarantee of payment; reimbursement is dependent upon the final liability determination of the claim.

Failure to obtain prior authorization may result in WSI not providing coverage for the service.

Submitting a Prior Authorization Request
  • Access Claim Lookup to obtain claim number or status
  • Review the Utilization Review Guide to determine if prior authorization is required
  • Complete the UR-C form
  • Fax UR-C form and supporting documentation to: 701-328-3765 or 866-356-6433

WSI developed the Post Injection Pain Response form as a tool for providers to utilize when requesting authorization for additional injections. The form contains pertinent information WSI requires for additional injections, which may not be included in the medical documentation. 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.

Submitting a Retrospective Review Request
  • Review the Utilization Review Guide to determine if prior authorization is required
    • Submit if the provider was not aware the condition was, or likely would be, covered by WSI
    • Injured worker's claim status on date of service included: denied, presumed closed, or a claim not filed
  • Complete the Provider Request for Adjustment (M6) form
  • Fax M6 form and supporting documentation to: 701-328-3765 or 866-356-6433
Referrals
Prior authorization is not required for referral to another healthcare provider, with the exceptions noted below:
  • Out of state providers
  • Mental Health providers

For more information about services requiring prior authorization, please contact WSI Utilization Review Department at 701-328-5990 or 888-777-5871.

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