Treating an Injured Worker
A medical provider, is a vital member of the Claims Management Team.
When the Claims Management Team works together, everyone benefits. A
productive work force contributes to the economic health of a company,
shortens the injured workers’ recovery period, and establishes common
goals to strengthen ties between the employer, injured worker, medical
provider, and WSI. When stay-at-work and return-to-work options are
utilized, the injured worker is more likely to be happier and healthier
by staying an active worker and employee.
During treatment of the injured worker, if any concerns arise (such
as the injured worker not attending physical therapy, symptoms not
consistent with the injury, cancellation of medical appointments, or
noncompliance with treatment plan), please contact us promptly at (701)
328-3800 or 1-800-777-5033. This information is critical in the
management of a claim.
It is required a claim be filed by one of the three methods:
WSI will inform the injured worker of their claim number in writing upon
registering the claim. If the claim is filed online, a claim number will
immediately be assigned. The assigned claim number is only a confirmation
of the claim being registered. All pertinent information relating to the
injury will need to be received and applied to North Dakota statutes for a
decision of either acceptance or denial.
A claims adjuster is assigned to the claim and starts to review the
information within 24 hours of receiving a completed claim form. There
are two types of claims:
- Medical only claim – If the injured worker is off work for fewer
than five calendar days in a row; or if there is no loss of earning, the claim is a medical only claim.
- Time-loss claim – If the injured worker is off work five or more
consecutive calendar days and there is a loss of earnings, the claim is a time-loss claim.
Treatment with more than one doctor is not allowed except in emergency
situations or when the services require a consulting doctor, surgeon, or
anesthetist. In this case, one doctor must be designated as the primary
treating doctor. The primary treating doctor establishes the work
restrictions. Note: “Doctor” means a licensed medical doctor, surgeon,
chiropractor, osteopath, podiatrist, psychologist, dentist or optometrist.
If the doctor refers patients to another doctor, authorization from
WSI is not needed; however, if the patient is choosing to seek treatment
from a different doctor or wishes to change their primary treating doctor
without obtaining a referral, they must complete and submit a Change of
Doctor form to WSI for prior approval.
For subsequent medical treatment the
Capability Assessment form (C3)
form must be completed. This information will assist employers in
determining appropriate accommodations. Keeping a worker on the job
in transitional duty reduces the worker’s likelihood of long-term disability.
Please return the original form to WSI, provide a copy for the injured
worker to give to their employer, and retain a copy for your records.
Completion of the C3 is not a substitute for chart notes. Notes (e.g., SOAP format)
are needed for continued management of the claim as well as for payment of services.
All medical documentation, including the C3 forms, should continue to be faxed to
1-888-786-8695 or 1-701-328-3820. Providers may call WSI Customer Service at
1-800-777-5033 to obtain a supply of the C3 forms. The C3 form cannot be used to
file a claim.
For WSI to process claims in a timely manner the ICD-9 diagnosis code(s)
must be submitted on the First Report of Injury (FROI) or C3 forms.
WSI sends the injured worker, employer and primary treating doctor a
letter notifying them of claim acceptance which includes the specific ICD-9
code(s) and body part(s).
WSI use reference materials to review for “best practices”. Reference material utilized includes:
- Official Disability Guidelines (ODG)
- American College of Occupational and Environmental Medicine’s Practice Guidelines
- Guide to Physical Therapy Practice
- Medical Disability Advisor
- Diagnosis and Treatment of Physicians and Therapist Upper Extremity Rehabilitation
- Treatment Guidelines of the American Society of Hand Therapists
WSI has an online feature which allows providers to look up claim numbers.
This feature can be accessed by following these steps:
- Visit the website at www.WorkforceSafety.com
- Click on the “Medical Provider” section on the left side of home page
- Click on the “Claim Lookup” link
- Type in the Social Security number (no dashes)
- Type in the date of injury (DOI) using the following format: mm/dd/yyyy
- Click on “lookup”
There are several different appeal processes available to medical providers
in the event medical charges or services have been denied by WSI.
For services denied by the Utilization Review Department (UR):
- Submit the appeal in writing, along with additional information to support the necessity to overturn the decision
- Submit within 30 days of the denial
- Submitted by the injured worker or the medical provider
Should the denial be upheld during the appeal, providers can submit a
Medical Services Dispute Resolution Request (M2)
form for Binding Dispute Resolution.
This form must be submitted within 30 days of receiving notification of the appeal outcome.
For bills denied or paid incorrectly: