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11:51:05 PM CDT
Sunday, April 20, 2014

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Treating an Injured Worker

Topics ICD-9 Forms & Publications Medical Provider's Guide
Treating An Injured Worker Treatment Guidelines First Report of Injury (FROI) Form  
Claim Information Claim Number Lookup Capability Assessment form (C3)  
Medical Treatment Medical Provider Appeal Process Medical Services Dispute Resolution Request (M2)  
Subsequent Treatment   Provider Request for Adjustment (M6) form  

A medical provider, is a vital member of the Claims Management Team. When the Claims Management Team works together, everyone benefits. A productive work force contributes to the economic health of a company, shortens the injured workers’ recovery period, and establishes common goals to strengthen ties between the employer, injured worker, medical provider, and WSI. When stay-at-work and return-to-work options are utilized, the injured worker is more likely to be happier and healthier by staying an active worker and employee.

During treatment of the injured worker, if any concerns arise (such as the injured worker not attending physical therapy, symptoms not consistent with the injury, cancellation of medical appointments, or noncompliance with treatment plan), please contact us promptly at (701) 328-3800 or 1-800-777-5033. This information is critical in the management of a claim.

Claim Information
It is required a claim be filed by one of the three methods:

WSI will inform the injured worker of their claim number in writing upon registering the claim. If the claim is filed online, a claim number will immediately be assigned. The assigned claim number is only a confirmation of the claim being registered. All pertinent information relating to the injury will need to be received and applied to North Dakota statutes for a decision of either acceptance or denial.

A claims adjuster is assigned to the claim and starts to review the information within 24 hours of receiving a completed claim form. There are two types of claims:

  • Medical only claim – If the injured worker is off work for fewer than five calendar days in a row; or if there is no loss of earning, the claim is a medical only claim.
  • Time-loss claim – If the injured worker is off work five or more consecutive calendar days and there is a loss of earnings, the claim is a time-loss claim.

Medical Treatment
Treatment with more than one doctor is not allowed except in emergency situations or when the services require a consulting doctor, surgeon, or anesthetist. In this case, one doctor must be designated as the primary treating doctor. The primary treating doctor establishes the work restrictions. Note: “Doctor” means a licensed medical doctor, surgeon, chiropractor, osteopath, podiatrist, psychologist, dentist or optometrist.

If the doctor refers patients to another doctor, authorization from WSI is not needed; however, if the patient is choosing to seek treatment from a different doctor or wishes to change their primary treating doctor without obtaining a referral, they must complete and submit a Change of Doctor form to WSI for prior approval.

Subsequent Treatment
For subsequent medical treatment the Capability Assessment form (C3) form must be completed. This information will assist employers in determining appropriate accommodations. Keeping a worker on the job in transitional duty reduces the worker’s likelihood of long-term disability. Please return the original form to WSI, provide a copy for the injured worker to give to their employer, and retain a copy for your records.

Completion of the C3 is not a substitute for chart notes. Notes (e.g., SOAP format) are needed for continued management of the claim as well as for payment of services. All medical documentation, including the C3 forms, should continue to be faxed to 1-888-786-8695 or 1-701-328-3820. Providers may call WSI Customer Service at 1-800-777-5033 to obtain a supply of the C3 forms. The C3 form cannot be used to file a claim.

International Classification of Diseases, 9th Revision (ICD-9)
For WSI to process claims in a timely manner the ICD-9 diagnosis code(s) must be submitted on the First Report of Injury (FROI) or C3 forms.

WSI sends the injured worker, employer and primary treating doctor a letter notifying them of claim acceptance which includes the specific ICD-9 code(s) and body part(s).

Treatment Guidelines
WSI use reference materials to review for “best practices”. Reference material utilized includes:

  • Official Disability Guidelines (ODG)
  • American College of Occupational and Environmental Medicine’s Practice Guidelines
  • Guide to Physical Therapy Practice
  • Medical Disability Advisor
  • Diagnosis and Treatment of Physicians and Therapist Upper Extremity Rehabilitation
  • Treatment Guidelines of the American Society of Hand Therapists

Claim Number Lookup
WSI has an online feature which allows providers to look up claim numbers.

This feature can be accessed by following these steps:

  • Visit the website at www.WorkforceSafety.com
  • Click on the “Medical Provider” section on the left side of home page
  • Click on the “Claim Lookup” link
  • Type in the Social Security number (no dashes)
  • Type in the date of injury (DOI) using the following format: mm/dd/yyyy
  • Click on “lookup”

Medical Provider Appeal Process
There are several different appeal processes available to medical providers in the event medical charges or services have been denied by WSI.

For services denied by the Utilization Review Department (UR):

  • Submit the appeal in writing, along with additional information to support the necessity to overturn the decision
  • Submit within 30 days of the denial
  • Submitted by the injured worker or the medical provider

Should the denial be upheld during the appeal, providers can submit a Medical Services Dispute Resolution Request (M2) form for Binding Dispute Resolution. This form must be submitted within 30 days of receiving notification of the appeal outcome.

For bills denied or paid incorrectly:

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