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WSI has updated the Medical Bill Appeal (M6) form. The changes aim to simplify completion of the form and offer guidance on what documentation a provider should submit for common reason codes. The below outlines the significant elements.

  • Service not pre-certified (Reason code 80)
    • Medical necessity does not waive a prior authorization requirement, if indicated in the Utilization Review Guide. For example, an MRI performed in the emergency room may be medically necessary but still requires prior authorization. If a provider has questions on whether prior authorization needs to be submitted, contact the Utilization Review department at (701) 328-5990 or (888) 777-5871.
    • To appeal, provide documentation indicating either:
      • The provider was unaware the condition was a work-related injury, e.g., Documentation indicating provider billed the patient or other insurance, or
      • The injured employee’s claim status at the time of service was denied, presumed closed, or not filed.
  • Medical records not received (Reason code 212)
    • To appeal, attach medical notes supporting the charge(s).

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