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5:04:31 PM CDT
Wednesday, April 23, 2014

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Utilization Review

Topics Forms & Publications Electro Medical Device Certification Request (M5)
General Information Utilization Review Guide Provider Request for Adjustment (M6)
Authorization Process Utilization Review Request (UR-C) Independent Exercise or Work Hardening/Conditioning Program Requests (C59a)
Physical and Occupational Therapy Treatment Window Utilization Review Request (UR-C) Guidelines Quick Tips for Physical & Occupational Therapists
Durable Medical Equipment (DME) Post Injection Pain Response Note  
Treatment Guidelines    

Authorization Process

Prior Authorization (Precertification) Process

Prior authorization is the process of reviewing information prior to procedures and services being performed.

  • Requests are reviewed on pending claims and on claims for which WSI has accepted liability. To verify the status of a claim, click here Claim Status.
  • To request a prior authorization, complete and submit the Utilization Review Request (UR-C) form including supporting medical documentation.
    • Fax request and medical documentation to 701.328.3765 or toll free 1.866.356.6433
  • Authorization must be obtained at least 24 hours or the next business day in advance of providing certain medical treatment, equipment, or supplies.
  • WSI has 3 business days to complete a review upon receiving the request and medical notes.
  • If not utilized within 3 months (6 months for elective fusions), the request must be re-submitted with updated medical information for additional review.
  • Some services require prior authorization from the claims adjuster. To contact the claims adjuster for prior authorization, call 701.328.3800 or toll free 1.800.777.5033. Please have the injured workers’ social security or claim number available.

Concurrent Review Process

Concurrent Review is the process of reviewing utilization management activities that take place during an inpatient level of care or an ongoing outpatient course of treatment.

  • Requests are reviewed on pending claims and on claims for which WSI has accepted liability. To verify the status of a claim, click here Claim Status.
  • To request a concurrent review, complete and submit the Utilization Review Request (UR-C) form including supporting medical documentation.
  • Emergency medical service means a serious, unexpected, and dangerous situation requiring immediate medical attention. Emergency medical services may be provided without prior authorization however, notification is required within 24 hours of, or by the end of the next business day following, initiation of emergency treatment.

Retrospective Review Process

Retrospective Review is the process of reviewing a service after the treatment occurred.

  • Retrospective reviews are considered only if:
    • Injured worker did not inform the provider, and the provider did not know that the condition was, or likely would be, covered by WSI.
    • Prior authorization of medical services was not requested by provider and injured worker's claim status at time of service was presumed closed or a claim was not filed.
  • To request a retrospective review, complete and submit the Provider Request for Adjustment (M6) form including supporting medical documentation.

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