Friday, December 14, 2018 - 08:00am Categories:
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Medical Provider Utilization Review

WSI recently published an article about the Advanced Beneficiary Notice (ABN) process.  After receiving several follow-up questions from providers about the article, WSI is providing further clarification.

The intent of the initial article was to inform a provider of WSI's requirement that, if a provider chooses to use an ABN form, the form is to be completed for each individual date the service will be provided.  In the past, WSI accepted a single ABN for services provided for one or more dates of service.

A provider may choose to use the WSI ABN when recommending a service or medical device for a compensable injury but that WSI never covers, WSI may not cover, or WSI does not deem to be medically necessary.  The following are circumstances and examples for which a provider may choose to complete an ABN form:

  • Service is statutorily excluded from coverage, e.g. hot/cold packs, biofreeze, dry needling
  • Service is statutorily limited in quantity, e.g. trigger point injections (maximum of 20 injections per claim)
  • Service may not be covered by WSI, e.g. massage therapy performed by a massage therapist
  • Service is deemed by WSI's Utilization Review department as not medically necessary to treat the work injury

In contrast, the following are circumstances and examples for which a provider does not need to use the ABN form:

  • Routine service related to the treatment of a compensable work injury, e.g. office visit, therapy
  • Treatment of a condition for which WSI has not determined liability or has denied liability
  • Service generally considered unnecessary for the treatment of a compensable work injury, e.g. treatment for communicable diseases (common cold), seasonal disorders (allergies), pre-existing conditions (diabetes)

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