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).
If you have questions about this article, please send an email to firstname.lastname@example.org. Click here to sign-up to receive email notifications of the latest Medical Provider News. Make sure to follow us on Facebook and Twitter.