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8:04:18 AM CDT
Thursday, August 28, 2014

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The Claim Process

What You Can Expect From Us

  1. WSI will register a claim in response to one of the following actions: 1) receipt of a First Report of Injury (FROI) form; 2) receipt of a claim filed over the phone; 3) receipt of claims information filed online. A claim number will be assigned to your claim (generally within 24 hours).

  2. You will receive a letter informing you of the name of your claims analyst and your claim number. This letter informs you that your claim has been received and registered - at this point, a decision to accept or deny the claim has not yet been made. Please provide this claim number when contacting WSI, your medical facility, and your pharmacy. You will receive a guide to workers' compensation services along with this letter. Please carefully read and retain this guide as it outlines your benefits and rights.

  3. The claims analyst will review the facts and gather any additional information needed to make a decision to accept or deny the claim. As part of the claim investigation process, your claims analyst will start reviewing your claim within 24 hours after receiving a completed claim form from you or your employer. The decision whether to accept or deny a claim is based on North Dakota law. A notice informing you of claim acceptance or denial will be mailed to you and your employer.

  4. One of the following decisions will be made on your claim:
    • Accepted: You and your employer will receive a Notice of Decision Accepting Claim and Awarding Benefits stating that your claim is accepted. If you are eligible for wage-loss benefits, you will receive payments that are not taxable. We will periodically mail you an Injured Worker Status Report, which you must complete and return to WSI so there is no interruption in your wage-loss benefits. When visiting your doctor, take along a Capability Assessment form (C3) that you have received from us. After your doctor has completed the form, mail one copy to WSI, have your doctor keep one copy, and provide your employer a copy so they are aware of your medical status.
    • Denied: You and your employer are notified, in writing, that WSI is denying benefits. The decision is mailed to you and your employer, and it provides the reasons for the denial. See Disputing a Claim Decision.
    • Pending: More information is needed to determine whether to accept or deny your claim. If you have not received a response on your claim status, and it has been 60 days since WSI has received all the completed and signed forms from you, your employer, and your medical provider, please contact your assigned claims analyst. You also can contact the Decision Review Office at (701) 328-9900 or 1-800-701-4932.

  5. All claims are one of the following two types:
    Wage-loss claim - If you will be off work for five or more calendar days in a row or if you have a loss of earnings, the claim is a wage-loss claim. The claims analyst will contact you, your employer, and your medical provider to establish a working relationship and gather additional information to help with the processing of the claim.

    Medical only claim - If you will not be off work for five or more calendar days in a row, the claim is a medical only claim. The processing of medical bills will begin immediately once the claim has been accepted.

If You Experience a Problem With How Your Claim is Being Processed:

If you are having a problem with your claim, and your problem is not being resolved with the assistance of your claims analyst, please contact our Customer Service Unit at (701) 328-3800 or 1-800-777-5033 and ask to speak with the claims analyst's supervisor. The supervisor will assist you with your problem. If your problem has not been resolved with the assistance of the supervisor, request to speak with the staff member overseeing the Claims Department.

If a Benefit is Denied:

We can only pay for treatment of injuries or conditions caused by work. If, at any time, we do not pay a requested benefit, you will receive written notification along with instructions to follow if you disagree with the decision. For information about your rights in the event of a claim denial, please contact your assigned claims analyst or you may contact the Decision Review Office.

Important Steps You Must Take After Sustaining a Work-Related Injury:

  • Ask your doctor if you can return to work, even if you have some restrictions on your work duties. Follow all restrictions, both on and off the job.
  • Keep in touch with your employer and provide them with periodic updates on your condition. At the completion of your medical appointment, your doctor will complete a Doctor's Report of Injury form (C3) - (also called a workability assessment). After each medical appointment, provide your employer with a copy of this form.
  • Keep original, itemized, dated receipts for medicine, mileage, meals, and other items you buy that are necessary for your medical care. Complete a Request for Personal Reimbursement form (C40a), attach your receipts, and submit them to WSI.
  • Notify WSI immediately: 1) when you perform any type of work activity whether you receive pay for it or not; 2) if you change your address or telephone number; or 3) if you apply for either Social Security disability or retirement benefits or are found to be eligible for these benefits.
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