Change to the Process of Request for an Adjustment

January 2015

Effective March 1, 2015, WSI will only accept a request for adjustment (appeal) of a processed charge on the Provider Request for Adjustment (M6) form.

A provider will be required to submit any appeals on the revised M6 form. Any appeals not received on the form will reject and the provider will receive notification to resubmit on the proper form.

To determine if an M6 is required, the reason codes that allow for an appeal via an M6 will have the following language printed at the end of the remittance advice.

To request reconsideration, complete the provider request for an adjustment form (M6) and submit to WSI within 30 days from the date of the remittance advice and provide a statement of why the reduction or denial is disputed.

Instances where an M6 would not be required:

  • Additional or late charges
    • Submit charges on a new UB-04 or CMS 1500
  • Corrected CPT or HCPC Codes originally processed with no payment
    • Submit charges on a new UB-04 or CMS 1500
  • Bills returned to the provider due to WSI’s requirement of red and white
    • Submit charges on required red and white versions of UB-04 or CMS 1500

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