Certain services, including Durable Medical Equipment, require approval from either the claims adjuster or the Utilization Review department as outlined in the Utilization Review Guide. Failure to obtain prior authorization may result in WSI not providing coverage for the service.  Prior authorization approval is not a guarantee of payment; reimbursement is dependent upon the final liability determination of the claim.

Submitting a Prior Authorization Request

The Post Injection Pain Response form is a tool for providers to utilize when requesting authorization for additional injections. The form contains pertinent information WSI requires for additional injections. 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 Medical Bill Appeal/Retrospective Review Request (M6) form
  • Fax the M6 form and supporting documentation to: 701-328-3765 or 866-356-6433