Prior Authorization

WSI reviews for services requiring prior authorization on a claim with a pending or accepted status. WSI does not review for services on a claim with a denied status, or for a claim not filed. To obtain a claim number and/or status, access the Claim Lookup application.

Prior to submitting a request for authorization, a medical provider is responsible for reviewing the Utilization Review (UR) Guide to determine whether a service requires authorization. For a service identified as requiring authorization from the injured worker's claim adjuster or the UR department, review the applicable information below.

REQUEST PRIOR AUTHORIZATION FROM CLAIMS ADJUSTER

For most services requiring prior authorization from an injured worker's claim adjuster, a provider must contact WSI at 701-328-3800 or 800-777-5033. The exceptions to this are listed below.

     American Dental Association (ADA) Dental Claim Form for dental services

     Electro Medical Device Certification Request (M5) form for electro medical devices

A provider should fax these forms with supporting documentation to 701-328-3820 or 866-786-8695.

REQUEST PRIOR AUTHORIZATION FROM UR

Complete the appropriate prior authorization request form, listed below, and submit with supporting documentation. WSI will complete a review within 3 business days of receiving the required information. The UR department provides notification of the UR recommendation to the requesting provider, using the preferred method of communication identified on the form.

     Independent Exercise (C59a) form for independent exercise

     Work Hardening or Conditioning Program Request (C59b) form for work hardening/conditioning

     Non-Emergent Air Ambulance Facility-to-Facility Request (M13) form for all non-emergent air ambulance facility-to-facility services

     UR Chiropractic Review Request (UR-Chiro) form for chiropractic services

     UR Review Request (UR-C) form for all other services

APPEAL A UR DECISION

Review the UR notification letter for information on WSI's rationale for denial of authorization. Complete the applicable form (UR-C/UR-Chiro) and mark the "Appeal" box in section 2. Submit the applicable form with additional documentation which disputes the rationale provided in the UR notification letter.

REQUEST RETROSPECTIVE AUTHORIZATION

Complete the Medical Bill Appeal (M6) form to request a retrospective authorization review only after a provider has received a denied charge for no prior authorization. Submit the M6 form with supporting documentation and provide an explanation to demonstrate one of the following:

  • The medical provider was not aware the condition was a work-related injury
  • The injured worker's claim status at time of service included: denied, presumed closed, or a claim not filed

Below are additional aspects of prior authorization pertaining to certain types of services. A medical provider should use this information in conjunction with the standard prior authorization processes.

AMBULANCE/TRANSPORTATION

WSI may require prior authorization for ambulance or transportation services, e.g. stretcher van, taxi, depending on the circumstances as outlined below:

Emergent Ground/Air Ambulance Service

WSI does not require prior authorization for an emergent ground or air ambulance service.

 

Non-Emergent Ground Ambulance Service

WSI requires a provider obtain prior authorization from an injured worker's claim adjuster for a non-emergent ground ambulance service. To request authorization from an injured worker's claim adjuster, contact WSI at 701-328-3800 or 800-777-5033.

 

Non-Emergent Air Ambulance Service

WSI requires a provider obtain prior authorization from the UR department for a non-emergent air ambulance service. It is WSI's expectation a provider use one of the following air transportation companies, when possible: Bismarck Air Medical, Sanford Health (Sanford Air Med), TravelAire, and Trinity Health System (NorthStar Criticair). WSI has established Memorandums of Understanding (MOUs) with these companies to facilitate safe and cost-effective air transportation.

To request authorization, complete the Non-Emergent Air Ambulance Facility-to-Facility Request (M13) form and submit with supporting documentation. WSI will complete a review within 24-hours, or by the end of the next business day, of receiving the required information. The UR department provides notification of the UR recommendation to the requesting provider, using the preferred method of communication identified on the M13 form. WSI also sends a follow-up UR notification letter.

 

Transportation Service

WSI requires a provider obtain prior authorization from an injured worker's claim adjuster for a transportation service. To request authorization from an injured worker's claim adjuster, contact WSI at 701-328-3800 or 800-777-5033.

CHIROPRACTIC

A chiropractor may provide chiropractic care to treat a work injury without prior authorization during the initial window period, which includes:

  • 10 visits or 60 days of care, whichever comes first, including the initial evaluation
  • Treatment of all body parts accepted on a claim
  • Up to 2 modalities per visit

A change in treating chiropractor during an established course of treatment does not initiate a new window period.

Acute/Subacute Chiropractic Care

WSI requires a chiropractor obtain prior authorization from the UR department for all treatment extending beyond the initial window period, which may be requested using the UR Chiropractic Request (UR-Chiro) form. A referral for chiropractic care from the primary treating provider does not waive the prior authorization requirements.

 

Palliative Care

Palliative care may be medically appropriate for an injured worker who has reached maximum medical improvement (MMI). WSI requires a chiropractor obtain authorization from the UR department for palliative care. To request authorization, submit the UR-Chiro form with supporting documentation and the applicable form(s) listed below.

DENTAL

WSI requires a dental provider obtain prior authorization from the injured worker's claim adjuster for the dental services listed below, which may be requested by submitting the American Dental Association (ADA) Dental Claim Form.

  • Restorative fillings, crowns, bridges, and veneers
  • Dentures and implants including; partial or impartial and fixed or removable
  • All dental surgical procedures, whether performed in the office or outpatient setting, including; endodontics, periodontics, oral, and maxillofacial surgery
DURABLE MEDICAL EQUIPMENT (DME)

A provider should refer to the Durable Medical Equipment Guide, which outlines WSI's authorization requirements for DME items. To request authorization for an electro medical device, submit the Electro Medical Device Certification Request (M5) form. For all other DME requiring prior authorization, contact the injured worker's claim adjuster.

INJECTIONS

WSI requires a provider obtain prior authorization from the UR department for most injections, as outlined in the UR Guide, which may be requested by submitting the UR Review Request (UR-C) form.

A provider should review the Documentation Requirements for Prior Authorization of Therapeutic Injections medical policy, which outlines minimum elements of documentation required by the UR department. A provider may utilize the Post Injection Pain Response Note form to assist in meeting the documentation requirements when requesting authorization for subsequent injections. The use of this form is not mandatory, and it does not replace the UR-C form.

PHYSICAL/OCCUPATIONAL THERAPY

A therapist may provide therapy treatment without prior authorization during the initial window period and/or post-op window period, which include:

  • 10 visits or 60 days of care, whichever comes first
  • Treatment of all body parts accepted on a claim
  • Up to 2 modalities per visit
  • Up to 4 units per visit, including timed and/or non-timed codes

Treatment must begin within 90 days of the surgery or manipulation to qualify for a post-op window period. WSI allows separate window periods for physical and occupational therapy. A change in treating therapist during an established course of treatment does not initiate a new window period.

WSI requires a therapist obtain prior authorization from the UR department for all treatment occurring outside of an initial or post-op window period, which may be requested by submitting the UR Review Request (UR-C) form.

Work Hardening/Work Conditioning

WSI requires the treating therapy facility obtain prior authorization from the UR department for all work hardening (WH)/work conditioning (WC) services, which may be request by submitting the Work Hardening or Conditioning Program Request (C59b) form. WSI does not differentiate between WH/WC services; a therapist should be aware that an approval for WH/WC does not include the following:

  • Evaluation and Management (E/M) services
  • Psychological evaluation or treatment
  • Functional Capacity Assessment/Evaluation (FCA/FCE)

 

Independent Exercise Program

WSI may authorize up to 3 months of an independent exercise program as an extension of a formal therapy program. To initiate an independent exercise program, the primary treating provider or therapist must obtain authorization from the UR department, which may be requested by submitting the Independent Exercise Request (C59a) form. Subsequent requests for an independent exercise program may be submitted by the primary treating provider, therapist, or fitness facility.