As the sole insurer of workers' compensation in North Dakota, WSI manages all elements of billing and payment for a medical service provided to an injured employee covered by WSI. This model differs from most other state workers' compensation structures, which often include independent insurance companies and/or third-party administrators. A medical provider interested in rendering service to an injured employee covered by WSI should be aware of the following information regarding billing and payment.
Medical documentation must accompany each bill sent to WSI. For a list of common services and the corresponding documentation necessary for reimbursement, a medical provider should refer to WSI's Quick Reference for Medical Documentation. To ensure all documentation requirements are met, a medical provider should also be familiar with WSI's Documentation Policies and Fee Schedule Guidelines. WSI may deny payment if the required documentation does not accompany the bill, or the level/type of service documented does not support the procedure code billed.
Effective July 1st, 2021, WSI accepts medical bills solely through Electronic Data Interchange (EDI). A medical provider will need to work through WSI’s exclusive vendor, Carisk Intelligent Clearinghouse, for EDI submission. Carisk is a specialized clearinghouse that allows electronic medical bill submission with simultaneous attachment of medical documentation. A medical provider should refer to WSI's Quick Reference for Medical Documentation for a list of common services and their corresponding documentation requirements.
Unique benefits of submitting a medical bill through Carisk include:
- Error-proof submissions with a 97% first-pass clean claims rate
- Automatic notification of WSI’s receipt of a medical bill
- Ability to track and manage e-claims
- Unlimited attachments
- Free storage of all bills and medical records
EDI also allows a medical provider to combine multiple dates of service into 1 bill and combine notes into 1 PDF attachment, if the billing provider is the same for all services. This is not to exceed 50 service lines or 12 diagnosis codes.
WSI covers the transaction fee, so there is no cost to a medical provider for submitting a medical bill directly through Carisk. To establish a direct EDI connection, contact Carisk by email at email@example.com or by phone at 888-238-4792.
If a medical provider currently uses a clearinghouse other than Carisk, an indirect EDI connection may be possible, depending on that clearinghouse’s ability to meet certain technical requirements. To establish an indirect connection, contact that clearinghouse to check if an indirect connection with Carisk can be established.
To assist medical providers in the transition to electronic billing, WSI has developed the following crosswalks detailing the required data in the 837 transactions compared to the CMS-1500 and UB-04 forms.
Effective July 1, 2021, WSI no longer accepts submission of a billed charge in paper format except from a medical provider submitting less than 50 bills per year to WSI. See the Electronic Billing section for full details.
For a medical provider billing less than 50 bills per year, WSI accepts submission of a billed charge on the most current versions of the CMS-1500, UB-04, or ADA Dental forms. A medical provider must mail the applicable bill form with supporting documentation to:
Workforce Safety & Insurance
PO Box 5585
Bismarck, ND 58506-5585
WSI reimburses for a medical service in accordance with the WSI Fee Schedule for both an in-state and out-of-state provider. WSI utilizes the most current CPT® and HCPC code sets and does not accept out-of-state specific codes. The presence of a code and an associated amount in a fee schedule is not a guarantee of payment.
WSI has established Fee Schedules for the following services:
- Ambulatory Surgery Center
- Clinical Laboratory
- Durable Medical Equipment
- Home Health Care
- Inpatient Hospital
- Long-Term Care Hospital
- Medical Provider
- Outpatient Hospital
- Physician-Administered Drugs
A medical provider should access the applicable Fee Schedule Guideline for complete information on the following: pricing methodology, payment parameters, billing requirements, and reimbursement procedures.
A medical provider may choose to use the WSI Advance Beneficiary Notice of Non-Coverage (ABN) when recommending a service WSI may not allow. The ABN informs the injured employee of the estimated cost and allows them to decide whether to receive the service and accept financial responsibility if WSI denies payment.
The following are examples of when a medical provider may choose to complete an ABN form:
- WSI statutorily excludes the service from coverage, e.g. hot/cold packs, Biofreeze, dry needling
- WSI does not cover the service, e.g. massage therapy performed by a massage therapist
- WSI's Utilization Review department deems the service not medically necessary to treat the work injury
In contrast, the following are examples of when a medical provider does not need to use an ABN form:
- Routine service related to the treatment of a compensable work injury, e.g. office visit, therapy
- Treatment of a condition for which WSI has not determined liability or has denied liability
A medical provider choosing to submit an ABN to WSI must ensure the following:
- ABN is specific to the date of service
- Injured employee's signature is present
- Corresponding bill includes modifier -GA on the applicable service line item(s)
A medical provider must submit the bill, ABN and the supporting medical documentation to WSI. WSI will make an appropriate payment determination and specify whether the medical provider may bill an injured employee or other insurance on the remittance advice.
WSI's Bill Audit department seeks to detect and prevent fraud, waste, and abuse by completing a pre-payment audit of medical bills submitted for reimbursement. An audit includes a review of the following:
- Service/treatment is related to the work injury
- Medical documentation supports the level of service billed
- Service or supply is accurately coded
- Service or supply is appropriate and cost-effective
- Service provided meets professionally recognized standards/level of care
- Charge is not duplicate or redundant
- Receipt of the bill is within one year from date of service or within one year from date WSI accepted liability
WSI encourages a medical provider who suspects fraud, waste, or abuse to anonymously report it. Suspicion of fraud does not indicate fraud has occurred, but WSI may undertake a closer review of the claim or medical information. Click here to view WSI's fraud resources.
WSI issues remittance advices on a weekly basis for processed medical bills. To assist in the interpretation of the remittance advice, a medical provider should refer to the How to Read the WSI Remittance Advice document. This reference includes a sample remittance advice, along with definitions for significant fields within the remittance advice.
The remittance advice includes important information about how WSI processed a medical bill and includes remittance advice reason codes. Each reason code provides a summary of the medical bill adjudication, information on whether a provider may bill an injured employee, and any action a medical provider may take. The WSI Remittance Advice Reason Codes document provides a comprehensive listing and description of the reason codes WSI utilizes.
A medical provider should review the remittance advice reason code(s) used to deny or reduce a charge to determine if the bill is eligible for an appeal. To initiate an appeal, a medical provider must complete the Medical Bill Appeal (M6) form and submit with additional supporting documentation to WSI.
Mail: Workforce Safety & Insurance
PO Box 5585
Bismarck, ND 58506-5585
Fax: 701-328-3765 or 888-786-8695
WSI will not process an appeal received without an M6 form.