Changes to Retrospective Review Request Process

May 2016

Effective June 1, 2016, WSI will only accept a request to retrospectively review a rendered service that was not prior authorized after the provider has submitted a bill and received a denial for that service.  The Medical Bill Appeal (M6) form has been revised to incorporate this change.

If a provider does not obtain prior authorization before rendering a service, the provider should submit a bill for processing. The provider may then dispute a bill denied for services not pre-certified by submitting the Medical Bill Appeal (M6) form, formerly called the Medical Bill Appeal/Retrospective Review Request.

The M6 form previously included an option to request a retrospective review of a service not prior authorized and for which WSI did not receive a bill. In accordance with the new policy, WSI has removed this option from the revised M6 form. An excerpt of the revised M6 below displays the remaining options for a medical bill appeal:

WSI will allow retrospective authorization review if the provider can show one of the following criteria:

  • 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

If you have questions about this article, please send an email to wsipr@nd.gov. To receive provider news, subscribe to our Email Updates list.