Prior Authorization

Medium

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 employee's claim adjuster or the UR department, review the applicable information below.

Medium
REQUEST PRIOR AUTHORIZATION FROM CLAIMS ADJUSTER

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

    For dental services, complete the American Dental Association (ADA) Dental Claim Form.

    For electro medical devices, complete the Electro Medical Device Certification Request (M5) form.

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 from the list below, and submit it with supporting documentation. WSI will complete a review within 3 business days of receiving the required information. The UR department will provide notification of the UR recommendation via fax.

     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 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 receiving 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 employee's claim status at the time of service included: denied, presumed closed, or a claim not filed.
Medium

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.

Medium
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 employee's claims adjuster for a non-emergent ground ambulance service. To request authorization from the claims 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 uses one of the following air transportation companies when possible: Bismarck Air Medical, Sanford Health (Sanford Air Med), TravelAire, or 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 it 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 will provide notification of the UR recommendation to the requesting provider via fax. WSI also sends a follow-up UR notification letter.

Transportation Service

WSI requires a provider obtain prior authorization from an injured employee's claims adjuster for a transportation service. To request authorization from the claims 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 (including the initial evaluation) or 60 days of care, whichever comes first
  • Treatment of all body parts accepted on a claim
  • Up to 2 modalities per visit

Each claim has one window period, which encompasses all body parts accepted on a claim. A change in treating chiropractor during an established course of treatment does not initiate a new window period.

WSI does not reimburse for massage or manual therapy performed with a manipulation to the same spinal region on the same visit during the 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 includes:

  • Manipulations
  • Therapeutic Procedures
  • Modalities

To request authorization, submit 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 employee 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 employee's claims adjuster for the dental services listed below 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 employee's claims adjuster.

INJECTIONS

WSI requires a provider obtain prior authorization from the UR department for most injections as outlined in the UR Guide. To request authorization, submit the UR Review Request (UR-C) form.

A provider should review the Documentation Requirements for Prior Authorization of Therapeutic Injections policy, which outlines the 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 and/or post-op window periods, which include:

  • An initial evaluation or re-evaluation visit
  • 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. To request authorization, submit the UR Review Request (UR-C) form.

When a provider receives approval from the UR department for exercise, it includes:

  • Therapeutic Exercise - CPT® 97110
  • Neuromuscular Reeducation - CPT® 97112 
  • Gait Training - CPT® 97116
  • Manual Therapy - CPT® 97140
  • Therapeutic Activities - CPT® 97530
  • Self-Care / Home Management - CPT® 97535

Work Hardening/Work Conditioning

WSI does not differentiate between Work Hardening (WH) and Work Conditioning (WC) services. The treating therapy facility must obtain prior authorization from the UR department for all WH/WC services by submitting the Work Hardening or Conditioning Program Request (C59b) form. 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)

If WSI authorizes these services, a provider should bill CPT® 97545 for the initial 2 hours and CPT® 97546 for each additional hour.

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 by submitting the Independent Exercise Request (C59a) form. The primary treating provider, therapist, or fitness facility may submit subsequent requests for an independent exercise program.

If WSI authorizes this service, a provider should bill using WSI Specific Code W0555.

Functional Capacity Evaluation (FCE) / Functional Capabilities Assessment (FCA)

Only a therapist with FCE/FCA certification may perform the evaluation. An FCE/FCA requires prior authorization from an injured employee's claims adjuster. To request authorization from the claims adjuster, contact WSI at 701-328-3800 or 800-777-5033.

If WSI authorizes this service, a provider should bill using WSI Specific Code W0540.