UR-C Form Revised

January 2015

WSI recently revised the UR-C form and providers should use the revised form effective immediately.

The changes include:

  • General formatting changes
  • Added to Section 2: Preferred method of notification of recommendation
    • Please select only one of options: telephone call or fax
  • Added to Section 6: Non-implantable DME (e.g. shoulder sling, knee brace) related to the surgery and costing $500 or more. This will allow a provider the option to obtain DME approval when requesting the surgery
    • Please indicate the applicable DME required as a result of the requested surgery
    • The DME Guide has been updated to reflect this change
    • To be eligible for reimbursement, a provider must supply the approved DME within a week of the surgery

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