As the sole insurer for workers' compensation in North Dakota, WSI manages all elements of billing and payment for a medical service provided to an injured worker covered by WSI. This model contrasts with the majority of other state workers' compensation structures, which often include the operation of independent insurance companies and/or third-party administrators. A provider interested in rendering a medical service to an injured worker covered by WSI should be aware of the following information pertaining to billing and payment.
Medical documentation must accompany each bill sent to WSI. A provider should refer to WSI's Medical Policies and Fee Schedule Guidelines to ensure proper documentation and billing requirements are met. WSI may deny or reduce payment if the required documentation is not provided or the level/type of service documented does not match the procedure code billed.
WSI accepts 837P and 837I EDI transactions through one of the following options:
- Carisk Intelligent Clearinghouse (formerly iHCFA): WSI's preferred clearinghouse vendor is Carisk. Carisk offers electronic medical bill submission with electronic medical documentation attachment. In addition, users receive automated notification of WSI's receipt of a medical bill. Submission through Carisk is available at no cost to the provider. Contact Carisk EDI Support Services at 973-795-1641 (option 2) for additional information.
- Noridian: Noridian offers electronic medical bill submission without documentation attachment. A provider must submit all supporting medical documentation to WSI. Users do not receive notification of WSI's receipt of a medical bill. Cost for bill submission is negotiated through Noridian directly. Contact Noridian EDI Support Services at 800-967-7902 for additional information.
WSI reimburses for a medical service in accordance with 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
- Medical Provider
- Outpatient Hospital
- Physician-Administered Drugs
A provider should access the applicable Fee Schedule Guideline for complete information including the following: pricing methodology, payment parameters, billing requirements, and reimbursement procedures.
A provider may choose to use the WSI Advance Beneficiary Notice of Non-Coverage (ABN) when recommending a medical service that WSI may not allow. The ABN informs the injured worker 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 circumstances and examples for which a provider may choose to complete an ABN form:
- Service is statutorily excluded from coverage, e.g. hot/cold packs, Biofreeze, dry needling
- Service is statutorily limited in quantity, e.g. trigger point injections (maximum of 20 injections per claim)
- Service may not be covered by WSI, e.g. massage therapy performed by a massage therapist
- Service is deemed by WSI's Utilization Review department as not medically necessary to treat the work injury
In contrast, the following are circumstances and examples for which a provider does not need to use the 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
To identify a charge accompanied by a signed ABN, which must be specific to the date of service, a provider should append modifier GA to the applicable bill line(s). Submit the medical bill, ABN, and supporting documentation to WSI. WSI will review for the most appropriate payment determination and specify whether a provider may bill an injured worker 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
- Services or supplies are accurately coded
- Services provided meet professionally recognized standards/level of care
- The most appropriate and cost-effective supplies are being utilized
- Duplicate or redundant charges are not paid
- Timely filing within one year from date of service or within one year from date liability was accepted
WSI encourages a provider who suspects fraud, waste, or abuse to anonymously report it. Suspicion of fraud does not indicate fraud has occurred, but a closer review of the claim or medical information may be warranted. 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 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 a patient, and any action a provider may be required to take. The WSI Remittance Advice Reason Codes document provides a comprehensive listing and description of the reason codes utilized by WSI.
A 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 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.