Remittance advice reason codes explain how WSI processed a claim or charge and why a payment, adjustment, or denial occurred. Use the table below to review each code and understand what action may be needed.
| Reason code | Complete description |
|---|---|
| 1 | WSI denied the entire claim for a compensable injury. WSI is not liable for payment of any charges relating to this injury. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 2 | WSI denied this charge because this service is unrelated to the patient’s work injury. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 3 | WSI previously determined there is no liability or the charge was not necessary to treat or diagnose the work injury. The charge is the patient’s responsibility. Contact the patient for payment or for other insurance information. |
| 4 | Suspended benefits exist as part of a third-party settlement. The balance of the allowed fee schedule is the patient’s responsibility. Contact the patient for payment of the approved amount or other insurance information. |
| 5 | WSI denied this charge because medical documentation indicates this service was prior to the date of the patient's injury. The charge is the patient's responsibility. Contact the patient for payment or other insurance information. |
| 6 | WSI denied this charge because this type of service or procedure is a non-reimbursable service. This charge is not billable to the patient or other insurance. |
| 7 | WSI reduced this charge because the funeral expenses exceeded the allowed amount. Contact the responsible party for the remaining balance due. |
| 9 | WSI denied this charge as a duplicate. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 10 | WSI accepted this claim on an aggravation basis and is responsible for payment on an aggravation percentage. The balance of the allowed fee schedule is the patient’s responsibility. Contact the patient for payment or for other insurance information. |
| 11 | WSI reduced this charge by 50 percent of the fee schedule amount. Medical documentation indicates services provided were partially unrelated to the work injury. The balance of the charge is the patient’s responsibility. Contact the patient for payment or for other insurance information. |
| 12 | WSI denied this charge because this service is unrelated to the patient’s work injury. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 14 | WSI denied this charge because the patient’s primary care provider did not order the services. There was no approval or a request for the patient to treat with a different provider. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 17 | WSI reduced this charge because the submitted amount exceeds the maximum payable amount. The charge is the injured employee’s responsibility. Contact the injured employee for payment information. |
| 18 | WSI denied this charge because the element of N.D.C.C. 65-02-35(3) have not been met. To request reconsideration, contact WSI's Legal Department in writing within 45 days from the date of the remittance advice. |
| 20 | WSI received the bill with a zero charge. Resubmit a corrected billing if billed with a zero amount in error. |
| Reason code | Complete description |
|---|---|
| 30 | Do Not Deduct Overpayment. |
| 31 | Adjustment to Previous Charge. |
| 32 | Do Not Deduct Overpayment and Do Not Apply Aggravation. |
| 37 | WSI denied this request because itemized receipts are required for personal reimbursement. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice and provide the original receipt (s). The C183 form is located on the website at www.workforcesafety.com. |
| 38 | WSI denied this personal reimbursement because receipts submitted are past the one-year timeframe. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 41 | WSI reduced or denied this charge because the school expenses for this school term exceeded the allowed amount. The charge is the student’s responsibility. Contact the student for payment. |
| 42 | WSI denied this charge because the services billed are prior to the date of entitled fees and costs. The charge is the injured employee’s responsibility. Contact the injured employee for payment information. |
| 43 | WSI processed this charge according to a settlement with the patient. The remaining balance is not billable to the patient or other insurance. |
| 44 | This charge has been processed according to a settlement with the patient. The balance of the charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 45 | WSI denied this mileage reimbursement because at least 200 miles of travel must occur during a calendar month. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 46 | WSI denied this charge because the service or procedure is non-reimbursable or WSI did not authorize the service or procedure. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 47 | WSI reduced or denied this charge for mileage because the charged amount exceeded the allowed amount or there is no allowance for mileage reimbursement related to this vocational service. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| Reason code | Complete description |
|---|---|
| 51 | WSI denied this charge because the service does not meet the practice or treatment guidelines. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 52 | WSI denied this charge because the medical documentation received does not support the billed service. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 53 | WSI denied this charge because chiropractic modalities are limited to two per visit. The charge is not billable to the patient or other insurance. |
| 54 | WSI paid this charge per WSI's Medical and Hospital Fee Schedules. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. The remaining balance is not billable to the patient or other insurance. |
| 55 | WSI paid this charge in full because it was requested or pre-approved by WSI |
| 56 | WSI denied this charge per the WSI Evaluation and Management Services policy. The submitted medical documentation does not support this level of E&M service. The policy states WSI will reimburse the appropriate level of service based on the risk and complexity of the service rendered as supported by the medical documentation. For reconsideration of reimbursement, either submit a corrected bill with the appropriate E&M code, or submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 57 | WSI denied this charge because the therapy modifier is missing. Documentation received indicates a PTA or OTA provided the service, which requires the charge be billed with the appropriate CO or CQ modifier. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 58 | WSI paid this charge per the usual, customary, or reasonable (UCR) or contracted reimbursement rate. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The remaining balance is not billable to the patient or other insurance. |
| 59 | WSI added modifier 51 and reduced this charge because medical documentation indicated multiple procedures were performed on the same day or at the same session. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 63 | WSI denied this charge because the utilization review determined the service does not meet WSI’s practice or treatment guidelines. The letter denying the service included information on the right to appeal within 30 days from the date of the letter. There was no appeal received. The charge is not billable to the patient or other insurance. |
| 69 | Pay in full and override aggravation. |
| 71 | WSI denied this charge because there is no allowance for reimbursement of office, clerical, or copy charges. To request reconsideration, submit an appeal in writing within 45 days from the date of the remittance advice. This charge is not billable to the injured employee or other insurance. |
| 72 | WSI reduced or denied this charge because the case management hours exceeded the allowable hours. There was no timely written request for additional hours received. To request reconsideration, submit an appeal in writing within 45 days from the date of the remittance advice. This charge is not billable to the injured employee or other insurance. |
| 75 | WSI reduced or denied this charge because the service performed exceeded the approved amount or was unnecessary for the management of the claim. To request reconsideration, submit an appeal in writing within 45 days from the date of the remittance advice. This charge is not billable to the injured employee or other insurance. |
| Reason Code | Complete DescRIPTION |
|---|---|
| 76 | WSI denied this charge because the documentation received does not support the charges billed. To request reconsideration, submit an appeal in writing within 45 days from the date of the remittance advice. This charge is not billable to the injured employee or other insurance. |
| 80 | WSI denied this charge because the Utilization Review department did not review this service for prior authorization. To request a retrospective review, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 81 | WSI denied this request because missing work for a medical appointment is not a covered wage loss allowance. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 82 | WSI reduced or denied this meal reimbursement because it exceeds the maximum allowed or is not reimbursable within state guidelines. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 83 | WSI denied this charge as billed in error at the request of the medical facility or injured employee. |
| 84 | WSI denied this charge because the patient has not submitted the requested information. WSI is unable to establish liability for the charges. The charge is the patient’s responsibility. Contact the patient for payment or other information. |
| 85 | WSI denied this charge because the appeal for utilization review upheld the decision determining the service does not meet WSI’s practice or treatment guidelines. The letter denying the service included information on the right to appeal within 30 days from the date of the letter. The charge is not billable to the patient or other insurance. |
| 88 | WSI denied this charge because a retrospective review determined the service or treatment does not meet WSI’s practice or treatment guidelines. The letter denying the service included information on the right to appeal within 30 days from the date of the letter. The charge is not billable to the patient or other insurance. |
| 90 | WSI reduced or denied this charge. If payment was made, it is per the WSI Fee Schedule. The medical documentation indicates treatment exceeding WSI’s practice or treatment guidelines. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI.The charge is not billable to the patient or other insurance. |
| 91 | WSI denied this charge because there was no prior authorization for the service, equipment, or treatment provided. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 93 | WSI reduced or denied this charge because it exceeds the rule of reimbursement for durable medical equipment. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 94 | WSI reduced this charge because it exceeds the rule of reimbursement for prior medical records. WSI allows twenty dollars for twenty five or fewer pages and seventy-five cents per page for each page after the twenty-fifth page. In an electronic, digital, or other computerized format, WSI allows thirty dollars for twenty five or fewer pages and twenty-five cents per page for each page after the twenty-fifth page. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 95 | WSI denied this charge because there is no reimbursement allowed for medical records of current treatment to the patient. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| Reason code | Complete description |
|---|---|
| 116 | WSI changed the date of service as verified with your facility indicating a different date of service than previously submitted. |
| 117 | WSI denied this charge because the state health care tax is a non-reimbursable service. This charge is not billable to the patient or other insurance. |
| 118 | WSI is a tax exempt agency for North Dakota state sales tax with certificate number E-2001. This charge is not billable to the patient or other insurance. |
| 122 | WSI denied this charge because the procedure code does not support an assistant surgeon. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| Reason code | complete descRIPTION |
|---|---|
| 127 | WSI reduced or denied this charge because the hourly rate submitted exceeds the maximum hourly rate allowed, is outside of the scope of the terms of the contract or is an otherwise unpayable charge. |
| 130 | WSI reduced this charge because the billable units exceed WSI and National Billing guidelines. Reimbursement was per the WSI Medical and Hospital Fee Schedules. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 132 | WSI applied the approved amount of this charge to recover an overpayment on your claim. |
| 133 | WSI applied the approved amount of this charge to recover an overpayment from your facility. |
| 134 | WSI paid 50% of the costs of the Third-Party action. To request reconsideration, contact WSI’s Legal Department in writing within 45 days from the date of the remittance advice. |
| 136 | WSI reduced this motel reimbursement because it exceeds the maximum allowable amount for the room rates. To request reconsideration, complete the Personal Reimbursement Appeal form (C183), and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 137 | WSI denied this reimbursement because the expenses incurred by a traveling companion are non-reimbursable. There are no physician’s orders on file indicating your medical condition prevents you from traveling alone. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 138 | WSI denied this reimbursement because the expenses incurred were for medical treatment outside of your local area. WSI has no documentation on file to indication it was necessary to treat outside of your local area. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 139 | WSI does not reimburse for intracity mileage. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 140 | WSI denied this request for reimbursement because there is no verification of an appointment on this date. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 141 | WSI denied this charge as a duplicate charge. To request reconsideration, contact WSI’s Legal Department in writing within 45 days from the date of the remittance advice. |
| 142 | WSI denied this charge because NDCC Section 65-02-08 does not allow for payment of attorney fees and costs. To request reconsideration, contact WSI’s Legal Department in writing within 45 days from the date of the remittance advice. |
| 147 | WSI reduced this mileage reimbursement because it exceeds the actual miles necessary for traveling to the medical appointment. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 148 | WSI reduced or denied this personal reimbursement because the expenses submitted exceed the allowed amount or are non-reimbursable charges. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 149 | WSI paid this charge to your facility in error which has created an outstanding overpayment. A letter previously sent to your facility outlined the options for recovery of this overpayment. This is informational only and the charge is not included in calculating the total remittance amount. |
| 150 | WSI paid this charge to your facility in error which has created an outstanding overpayment. A letter previously sent to your facility outlined the options for recovery of this overpayment. This is informational only and the charge is not included in calculating the total remittance amount. |
| reason code | complete description |
|---|---|
| 151 | WSI has received and voided the returned check from your facility per your request. This is informational only and the charge is not included in calculating the total remittance amount. |
| 152 | WSI has received and deposited the check from your facility towards the overpayment. This is informational only and the charge is not included in calculating the total remittance amount. |
| 155 | WSI denied this motel reimbursement because there was no authorization. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 160 | WSI denied this charge because the claim is presumed closed. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 161 | WSI made an advance payment to you for your travel. If your total travel expenses exceed the amount of the advance without exceeding the maximum allowed, WSI will provide additional reimbursement to you. Submit a request for reimbursement on the Request for Personal Reimbursement form (C40a), with the original receipts for the additional reimbursement. Failure to submit the C40a form will result in WSI setting up an overpayment recovery for the previously paid money. An overpayment may also occur if your actual expenses are less than the advance payment. WSI will notify you by letter of any amount you are required to reimbursement WSI, if an overpayment occurs. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 163 | WSI denied this reimbursement for medical services because all medical providers must submit the charges directly to WSI. Contact the medical provider with your employees’ compensation information and have them submit the charges directly. If determined to be for the compensable injury, you may seek reimbursement from the medical provider. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 165 | The original recommendation relating to this charge has been adjusted. |
| 166 | The original recommendation relating to this charge has been adjusted. |
| 167 | The original recommendation relating to this charge has been adjusted |
| 168 | The original recommendation relating to this charge has been adjusted. |
| Reason Code | Complete Description |
|---|---|
| 176 | WSI denied this charge because the services were not provided by the employer’s designated medical provider. The patient is responsible for these charges. Contact the patient for payment or other insurance information. |
| 178 | WSI denied this charge because the service is part of the global period of the procedure performed. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 181 | WSI denied this charge because the medical records received were illegible. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI, and include the medical notes in a typed format. This charge is not billable to the patient or other insurance. |
| 183 | WSI denied this charge because the time spent on the requested service was not documented. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 188 | WSI paid this charge per the DRG Inpatient Hospital Fee Schedule. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The remaining balance is not billable to the patient or other insurance. |
| 189 | WSI paid this charge per the DRG Inpatient Hospital Fee Schedule with an outlier threshold. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The remaining balance is not billable to the patient or other insurance. |
| 192 | WSI down-coded the procedure code and reduced this charge because medical documentation indicates services provided beyond the treatment for the compensable work injury. Payment was made per the WSI fee Schedule. The remaining balance is not billable to the patient or other insurance. |
| 193 | WSI reduced this charge because it does not meet the rule of reimbursement for SIU transcription. |
| 194 | WSI reduced or denied this charge because the submitted expense exceeds the authorized amount or is a non-reimbursable charge. |
| 195 | WSI reduced this charge because the time billed does not coincide with the time logged on the investigation report. |
| 196 | WSI reduced this charge because the SIU travel time was incorrectly calculated. |
| 197 | WSI reduced this charge because the sub-totals are miscalculated. |
| 198 | WSI reduced this charge because the SIU surveillance time was incorrectly calculated. |
| 199 | WSI reduced this charge because the SIU mileage was incorrectly calculated |
| 200 | WSI denied this charge because the entire claim for this injury was withdrawn. WSI is not liable for payment of any charges relating to this injury. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| Reason Code | Complete description |
|---|---|
| 201 | WSI denied this charge because the bill received was past one year of the date of service or one year from the date WSI accepted liability for the work injury. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 204 | WSI denied this charge as the bill type does not qualify as submitted. Submit a corrected bill type for services rendered, or to request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 205 | WSI denied this charge because this service is a bundled service, as outlined by WSI’s Medical and Hospital Fee Schedule. This charge is not billable to the patient or other insurance. |
| 206 | WSI reduced this charge because the vehicle or home modification exceeded the allowed amount. The remaining balance is the patient's responsibility. Contact the patient for payment. |
| 207 | WSI denied this charge because it is not allowable by Return-To Work Services and there was no request for authorization. |
| 209 | WSI denied this reimbursement of pharmacy services because WSI requires all pharmacies to submit charges directly to the pharmacy benefit management (PBM) company, LucyRx. Contact your pharmacy with your workers’ compensation information and have them submit these charges. If determined to be for the compensable injury, you may seek reimbursement from the pharmacy. |
| 212 | WSI has not received the required medical records, which is resulting in the denial of this charge. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI, and include the appropriate medical records.This charge is not billable to the patient or other insurance. |
| 213 | WSI denied this charge because the required Medical Provider Payee Registration form (MPPR) is not on file or was incomplete. Once an MPPR is approved, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 215 | WSI denied this charge because the anesthesia modifier is missing. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice. A registered user may complete the appeal online through myWSI. Non-registered users must complete and send in the Medical Bill Appeal form (M6). This charge is not billable to the patient or other insurance. |
| 216 | WSI reduced or denied this charge because the service is not allowed or was unnecessary. |
| 217 | WSI reduced or denied this charge because the charge exceeded the maximum allowed amount. |
| 218 | WSI denied this charge because electrodiagnostic studies may only be performed by electromyographers certified or eligible for certification by the American Board of Electrodiagnostic Medicine, American Board of Physical Medicine and Rehabilitation, American Board of Neurology or Psychiatry’s certification in the specialty of Clinical Neurophysiology. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 219 | WSI denied this charge because the provider did not complete the approved service within the authorization time frame. To request a retrospective review, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI.This charge is not billable to the patient or other insurance. |
| 220 | WSI reduced or denied this charge because the total units billed for the timed-based code(s) does not match the medical documentation. Any reimbursement allowed is per WSI’s fee schedule. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 221 | WSI denied this charge because providers must submit all pharmacy or medication charges directly to the pharmacy benefit management company, LucyRx (877-860-8846). This charge is not billable to the patient or other insurance. |
| 222 | WSI denied this charge because of incorrect medical coding. WSI uses the AMA, CPT and National Correct Coding Initiative edits and guidelines as part of the Medical and Hospital Fee Schedule. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 223 | WSI denied this charge because there is a contract with Paradigm Management Services to manage, coordinate, and reimburse for this catastrophic work injury. Contact Paradigm Management Services for reimbursement. Telephone 800.676.6777; Fax 925.676.2197. This charge is not billable to the patient or other insurance. |
| 224 | WSI denied this charge because the code submitted is invalid per WSI's Medical and Hospital Fee Schedule guidelines. Submit a bill with the corrected code to WSI. This charge is not billable to the patient or other insurance |
| 225 | WSI denied this charge because the patient filed a employee compensation claim in another state. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| Reason code | complete description |
|---|---|
| 226 | WSI denied this charge because the service is not necessary for treatment or diagnoses of the compensable work injury. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 228 | WSI paid this charge per the WSI’s Medical and Hospital Fee Schedule. Medicare/Medicaid initially paid the charges in error. WSI has not accepted any additional liability past the charges paid. This charge is not billable to the patient or other insurance. |
| 229 | WSI denied this charge because it was paid correctly by Medicare/Medicaid. |
| 230 | WSI denied this charge because the principal diagnosis code is missing. Submit a bill with the corrected information to WSI. This charge is not billable to the patient or other insurance. |
| 231 | WSI denied this charge because the modifier 50 was incorrect per WSI's Medical and Hospital Fee Schedule guidelines. Submit a bill with the corrected billing code(s) to WSI. This charge is not billable to the patient or other insurance. |
| 232 | WSI reduced this charge by 50 percent of the fee schedule amount. Medical documentation indicates, in addition to the services related to the work injury, there were services provided unrelated to the patient’s work injury. The balance of the charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 233 | WSI reduced or denied this reimbursement because WSI has not received the required information for home health care services. The letter denying the service included information on the right to appeal within 30 days from the date of the letter. The charge is not billable to the patient or other insurance. |
| 234 | WSI reduced or denied the request for home health care services because these services or expenses exceed the previously approved amount. WSI sent the Notice of Decision (NOD) outlining the authorized service. The NOD included information on the right to appeal within 30 days from the date of the letter. This charge is not billable to the patient or other insurance. |
| 235 | WSI paid this charge per the Outpatient Hospital Fee Schedule utilizing APC pricing. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 236 | WSI has not received all of the required medical records to process this APC payment, which is resulting in the denial of all charges. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI, and include the appropriate medical records. This charge is not billable to the patient or other insurance. |
| 237 | WSI processed this charge as it is part of the APC pricing payment per the Outpatient Hospital Fee Schedule for services reimbursed related to the work injury. The charge for this service, however, is not related or is not necessary for the treatment or diagnoses of the compensable work injury. The remaining balance is not billable to the patient or other insurance. |
| 238 | WSI reduced or denied this charge because the injured employee has another claim where WSI has addressed the condition for this treatment. Submit the charges for this treatment to WSI under the injured employee's other claim for payment consideration. The remaining balance is not billable to the patient or other insurance. |
| 239 | WSI denied this personal reimbursement request because the request was not signed by you. To request reconsideration, complete the Personal Reimbursement Appeal form (C183) and submit to WSI within 30 days from the date of the remittance advice. The C183 form is located on the website at www.workforcesafety.com. |
| 240 | WSI denied this charge per the Definitive Drug Testing policy, written based on North Dakota Administrative Code 92-01-02-31.5 (c). The Definitive Drug Testing policy requires definitive/quantitative drug testing to determine the level of substance when presumptive screening returns a positive result. Failure to comply with the policy requirements are resulting in non-payment for this medical service. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 241 | WSI has not received the required W9 (Federal Taxpayer Identification Form), which is resulting in the denial of this charge. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI, and include the W9. This charge is not billable to the patient or other insurance. |
| 242 | WSI does not process bills for an interim stay. When the patient is discharged, rebill all applicable services on a single bill. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| 243 | WSI denied this charge per the WSI Falsified Medical Records policy. The submitted medical documentation does not support this service due to cloning. The policy states each entry in the record must have identifiable and appropriate updates specific to the individual encounter. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 244 | WSI denied this charge because the rendering provider listed on the bill does not match the rendering provider on the corresponding medical documentation. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 245 | WSI denied this charge because the Tax Identification Number (TIN) and Billing/Group National Provider Identifier (NPI) do not match a previously submitted Medical Provider Payee Registration. Resubmit the bill with an updated TIN or Billing/Group NPI. The charge is not billable to the patient or other insurance. |
| 246 | WSI denied this charge because the billed service does not match the service authorized by the Utilization Review department. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 247 | WSI denied this charge because it exceeds the maximum allowable benefit for this service, as defined by North Dakota Administrative Rule 92-01-02- 29.1.3. The charge is the patient's responsibility. Contact the patient for payment or for other insurance information. |
| 248 | WSI denied this charge because there is a more specific procedure code that better describes the service/item provided. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 249 | WSI denied this charge because the qualifications to bill for a new patient charge were not met. Only one initial visit is billable per specialty per medical group. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. The charge is not billable to the patient or other insurance. |
| 250 | WSI denied this charge as it is in paper format. A practice who submits more than 50 bills per year to WSI must submit both medical bills and supporting documentation via electronic data interchange (EDI) through Carisk Clearinghouse. This requirement is in accordance with Administrative Code 92-01- 02.45.2. Contact Carisk by email at [email protected] or by phone at 888-238-4792. Once an EDI connection is successful, submit an appeal within 30 days from the date of the remittance advice by completing the medical Bill Appeal form (M6) or online in myWSI. This charge is not billable to the patient or other insurance. |
| Reason Code | Complete Description |
|---|---|
| 251 | WSI has denied coverage of chronic opioid therapy for this patient. N.D.C.C. §65-05-39. This medical service is part of the chronic opioid therapy. Failure to comply with the policy requirements are resulting in non-payment for this medical service provided. To request reconsideration, submit an appeal within 30 days from the date of the remittance advice by completing the Medical Bill Appeal form (M6) or online in myWSI. This charge may be billed to the patient or other insurance. |