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Good Afternoon
2:34:04 PM CDT
Saturday, April 19, 2014

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Treating an Injured Worker

Topics ICD-9 Forms & Publications Medical Provider's Guide
Treating An Injured Worker Treatment Guidelines First Report of Injury (FROI) Form  
Claim Information Claim Number Lookup Capability Assessment form (C3)  
Medical Treatment Medical Provider Appeal Process Medical Services Dispute Resolution Request (M2)  
Subsequent Treatment   Provider Request for Adjustment (M6) form  

Medical Provider Appeal Process
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:

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