Out of State Case Management

When the WSI nurse case manager determines out of state case management services are necessary. The WSI administrative assistant works with the organization’s current contractors to assign the referral in the designated area.

• WSI administrative assistant will send out medical records (last 3 months of pertinent medical information), job description, and First Report of Injury (FROI) with the completed R7 to the contractor’s referral source.
• The contracted case manager should contact the WSI nurse case manager and the injured employee telephonically within 2 working days of the referral being assigned.
• If the contracted case manager has not received a response by phone within 3 working days, a letter should be sent. If there is no response to the letter within 5-7 days, the contracted case manager is to notify to the WSI nurse case manager for further direction on the claim.
• Catastrophic claims may require immediate intervention.

If requested on the referral (R7), the Nurse Case Manager Initial Evaluation is completed within 30 days of assignment. The initial evaluation can be completed telephonically or in-person. The initial evaluation is to be completed in a typed format using the Nurse Case Manager Initial Evaluation. All sections, boxes, and blank spaces are to be completed. Any “yes” response requires further explanation.

The completed report should be faxed to WSI at 1-888-786-8695 or emailed to [email protected].

The WSI administrative assistant will send a copy of the completed initial evaluation to the injured employee.

Should the injured employee identify any necessary changes, they will contact the contracted case manager to make the necessary changes and resubmit the document to WSI.

• Primary communication will be with the WSI nurse case manager.
• All communication should be responded to within 24 hours.
• If the WSI nurse case manager is not available due to vacation or illness, for urgent issues call WSI Customer Service at 1-800-777-5033 and ask for the nurse case manager’s supervisor or claims adjuster.

Email

• Emails are permissible between the WSI nurse case manager and the contracted case manager.
• No forms or documents are to be attached to emails sent directly to the WSI nurse case manager.
• All forms and documents must be emailed to WSI at [email protected] or faxed to 1-888-786-8695 with the injured employee’s name and claim number clearly visible.
• All emails are part of the injured employee’s claim and they should not include personal communication.

Fax

• The WSI fax number for all communications is 1-888-786-8695.

Text Messaging

• Text messaging is not billable.
• Copies of any communication sent or received by text message must be faxed to 1-888-786-8695 or emailed to [email protected].

When a contracted case manager is assigned and unable to continue management of the claim, the WSI nurse case manager requires immediate notification by phone or email. Prior to a transfer occurring, the following information is required:

• Identify the last date the contracted case manager will provide services.
• Notify the injured employee of the change.
• Provide name of the new contracted case manager and their contact information to the WSI nurse case manager.
• Current contracted case manager is responsible for providing an update to the newly assigned contracted case manager.
• When a claim is transferred, the remaining approved service hours continue.
• All reporting timeframes remain unchanged.

The contracted case managers will complete a 30-day action plan on all assignments. The initial 30-day action plan is due within 30 days from the date of the Initial Evaluation report. In cases where the initial evaluation has been waived, the initial action plan will be due 30 days from the date of assignment.

Report will include the following information:

• Action Plan Period: The action plan period should not be altered based on early or late completion
• Status/ODG: Are there any concerns with the documented ICD code. Current surgical status, complicating factors, and co-morbidities.
• Current Treatment Recommendation and Status: The action plan should state the treatment plan from the last medical appointment and indicate date of next appointment. This should include the status of any physical/occupational therapy, independent exercise program, work conditioning, speech/cognitive therapy, diagnostic testing.
• Return-to-Work Status/Physical Capabilities: 
  • Current level of release as outlined by the treating health care provider.
  • Can employer provide transitional work? If yes, was the offer written (formal) or verbal (informal)? The contracted case manager should stress the importance of a written job offer.
  • If injured employee is working, state progression of capabilities and/or work hours. If indicated, address functional assessment prior to next appointment.
  • Return to work date
  • Education level (high school or equivalency certificate)
  • Job analysis, ergonomic assessment
  • PLAN/RECOMMENDATIONS: Contracted case manager will outline the planning, coordination and outcomes expected within the next 30 days. Concerns
    identified in the action plan should also be included.

Action plans should be SMART: 

• Specific 
• Measurable
• Attainable
• Realistic
• Timely

WSI nurse case manager will notify the contracted case manager by email to close and submit their report.

The contracted case manager is responsible to notify the injured employee and the employer they are closing and instruct them to contact the claims adjuster with any questions or concerns.

For full contracted case management services, the report is to be completed within 14 days of notice. Limited/task assignment reports are to be sent in immediately upon notice. Reports should be faxed to WSI at 1-888-786-8695 or emailed to [email protected].

• All contracted case managers are responsible for tracking/documenting their hours.
• The contracted case manager is given 90 hours. Case management services will not exceed 90 hours per case without prior approval. If additional hours are required to bring the case to resolution, the contracted case manager will submit an NCM Extension Request (SFN 60730) to WSI prior to completion of the 90 hours. The request cannot exceed 45 hours and will justify the services necessary
  (i.e.: estimated number of hours including appointment attendance, travel time, and the estimated timeframe the services will cover).
• The request will be faxed to WSI at 1-888-786-8695 or emailed to [email protected].
• WSI nurse case manager will review the request and email a response to the contracted case manager indicating approval or denial; along with reasoning if reduced or denied.
• Hours are not carried over between requests.
• The date request is received will clear any prior hours available.

Employer contacts must be made within 2 working days after medical appointments.
When there are changes in physical capabilities/work restrictions, the following communication with the employer will include:

• Is the worker working transitional duty? If no, is the reason medical or employer related?
• Is the worker working full-time or part-time?
• If the employer is not able to provide transitional work, what is necessary for the worker to return to employment?
• Was transitional work offered?
• If there are no job descriptions on file for the pre-injury and any transitional positions, have they been requested?

• A C3 form is the physical Capability Assessment form that outlines the treating provider’s physical capabilities to be followed until the next scheduled appointment occurs. This
  outlining of restrictions provides a detailed physical restriction limit to be followed at work and at home.
• The restrictions on the C3 should only be completed on the accepted body parts affected during the work related injury. Those left blank will be considered as unrestricted.
• The C3 should be completed by the physician or by the primary treating provider (MD, PA, and FNP) after the initial medical treatment and after all ongoing medical treatment.
• OOS CMs should have a clear understanding of the form, its’ use, and have a copy available for the provider when attending every medical appointment.
• The form is not considered a substitute for chart notes.
•  A copy of the C3 should be provided to the injured worker and employer. The original needs to be faxed immediately to WSI at 1-888-786-8695 or emailed to [email protected]
  following each medical appointment. Be sure to include the injured worker’s name and claim number on each form.
•  C3 forms can be printed from the website at www.workforcesafty.com under the medical providers section to be found in the forms/resources.

A functional capacity evaluation (FCE) may be scheduled to coordinate return to work or assist a vocational case manager in identifying job goals or retraining. Most often an FCE is scheduled once the injured employee’s medical condition has stabilized or to obtain a baseline.
Obtain an order for an FCE by having the treating physician respond to the following questions:

1. Would a work conditioning/hardening program be recommended for (injured employee name) prior to participation in a FCE?  Yes____ No ____
2. Are there any medical contraindications in performing this evaluation?  Yes____ No____ If yes, explain with objective medical findings.
3. Are you comfortable with the therapist to fully test (injured employee name) within safe parameters?  Yes ____ No____ If no, explain why, and outline the restrictions recommended be implemented during testing.

Work Conditioning/Work Hardening

• Requires an order from the treating provider.
• Schedule the initial evaluation with a provider that accepts the North Dakota fee schedule.
• Prior authorization may be required; discuss with WSI nurse case manager for direction.

FCE

• Requires an order from the treating provider.
• Only approved with a PT/OT certified to perform FCE’s.
• Schedule the FCE at least 2 weeks in advance so WSI can send a notice to attend.
• The WSI nurse case manager will need the following information:
  • Facility name, address, and phone number
  • OT/PT name and credentials
  • Date(s) and time(s) of FCE
• The FCE order, job description, and any testing limitations/restrictions need to be sent to the therapist performing the FCE.
• Obtain a valid copy of the signed FCE report and send to WSI as soon as received.
•  Upon direction from WSI nurse case manager, schedule a follow-up appointment to review the FCE and job goals with the treating provider.
• Either the WSI nurse case manager or vocational case manager will work with the contracted case manager on what information is needed at the follow-up appointment with the health care provider.

WSI has the authority to require an independent medical evaluation (IME) for the purposes of obtaining a neutral medical opinion.
Common reasons for requesting an IME may include:

• Diagnosis of the injury or condition
• Causation or relatedness of the injury or condition
• Impact of a pre-existing medical condition
• Whether maximum medical improvement has been reached or if further treatment is recommended.
• Whether there has been a significant change in the injury or the medical condition.

WSI will schedule the IME and send the injured employee a notice to attend notifying of date, time, and facility address. WSI will assist with travel arrangements, if necessary, and reimburse the injured employee for expenses when attending the IME based on North Dakota state rates.

The contracted case manager does not attend the IME appointment.

WSI will send the treating provider a copy of the IME report for a medical opinion. The injured employee is able to request a copy of the IME report from WSI.

WSI reviews for services requiring prior authorization on a claim.

Review the Utilization Review (UR) Guide to determine if a service requires authorization. If authorization from the claim adjuster or Utilization Review (UR) department is needed.

Forms must be completed by the treating provider requesting the medical service, procedure, equipment, or supplies.

The forms are not to be completed by the contracted case manager

For the UR-C form: Sections 1-4 must be filled out completely; sections 5-9 only complete the section pertaining to the type of service requested. The contracted case manager is advised to carry a blank UR-C form to all medical appointments to avoid a delay in requesting approval for medical services.

For physical or occupational therapy, please review the Quick Reference for Physical & Occupational Therapists.

WSI has 3 business days to complete the review and respond to the provider indicating approval or denial of the request.

Contact the WSI nurse case manager with questions.

North Dakota Workforce Safety & Insurance (WSI) covers the cost of medications/supplies used to treat a condition accepted on an injured employee’s claim. This coverage includes prescriptions, over-the-counter medications, durable medical equipment (DME) and medical supply items. WSI does not provide direct reimbursement for these charges, which must be submitted through the Pharmacy Benefit Manager. WSI has contracted with LucyRX to provide the pharmacy benefit program to an injured employee (IE).

LucyRX approves medications based on those listed in the WSI formulary that do not require prior authorization. 

A provider dispensing a medication from a clinic or a pharmacy must bill LucyRx electronically. Use the Pharmacy Locator to find a participating pharmacy. To contract with LucyRx, contact them by phone at (877) 846-3397 or by email at [email protected].

Injured employees are sent a pharmacy identification card upon receipt of an open and active claim through eligibility. This card must be presented in order for the IE to fill their prescriptions.

If the IE does not have their card, their social security number may be used in place of the claim ID number.

LucyRX
BIN Number: 014658
Rx Group Number: 8001
ID Number: SSN or WSI Claim Number
PCN: WSI 

To locate a pharmacy near the IE, visit the IPM pharmacy locator online: https://portal.lucyrx.com/locator

Medications above $2,500 are blocked automatically and require prior authorization by the Pharmacy Department. WSI will not allow the use of long acting opioid medications for the treatment of acute pain within 90 days of the work injury.

LucyRx: 877.846.3397
Email: [email protected]

WSI has a pharmacist and a pharmacy technician on staff. For additional medication pharmacy related questions contact our Customer Service Department at 800.777.5033 and ask to be connected with the pharmacist or pharmacy technician.

For additional information go to: www.workforcesafety.com/medical-providers/pharmacy-services.

Vocational Rehabilitation Program is part of the Return to Work Services at WSI. Vocational case managers have specialized education and training to assist our injured employees in returning to work or identifying return-to-work options. 

WSI vocational case managers are assigned to in-state and out of-state claims. Vocational rehabilitation services are assigned at the request of the claims adjuster.

There may be instances when the WSI nurse case manager will close on the claim and the contracted case manager will remain open. In these instances, the vocational case manager will communicate directly with the contracted case manager. 

For any additional vocational related questions, contact the assigned vocational case manager.

Once a vocational case manager is assigned and initial contacts have been made, the Initial Rehabilitation Consultation meeting is scheduled.

The vocational case manager will meet with the injured employee face-to-face or telephonically, depending on their location. 

They will obtain information regarding: 

• Current release
• Employment history (including licenses/certificates)
• Military experience
• Transferable skills
• Education
• Psychosocial factors
• Other income sources
• Criminal history
• Reliable transportation/valid driver’s license

Injured employees are asked to complete various assessments, such as the Computer Skills Assessment Checklist; Job Readiness Skills Questionnaire; Skills-Personal, Transferable, and Job Related worksheet; and the Career Assessment Inventory. The results of these assessments are used to determine an injured employee’s computer skills, job readiness preparation, transferable skills, and interests. Injured employees may be referred for vocational testing, which may include academic and computer proficiency testing.

Action plans are completed every 60 days.

Injured employees should have, at minimum, a sedentary release to participate in vocational planning.

Following completion of the Initial Consultation, the vocational case manager will determine need for academic skill upgrading, obtaining his/her General Education Diploma (GED), and whether or not computer skills upgrading might be useful.

To determine if academic skills upgrading is necessary, injured employees are referred for academic testing.

• Academic assessments, such as the Test of Adult Basic Education, are usually taken at an adult learning center or adult basic education program.
• Injured employees whose second language is English may be referred for Best Plus testing or Best Literacy testing.
• Based on these scores, injured employees may be referred for academic skill upgrading or English Language Learner classes.
• Injured employees will participate until post-testing indicates their academic goals have been reached.
• Injured employees who have their high school diploma are referred for academic testing, as they may become a retraining candidate as the vocational planning continues.
• Not all injured employees are referred for academic testing, as they may have a recent college degree and transcripts indicate academic skill upgrading is not necessary.

Injured employees who do not have their GED, or HiSet in some states, are referred for academic testing and for attendance in GED preparation classes.

Injured employees completing academic skill upgrading may be referred for college placement testing. This testing is usually scheduled at a local community college.

To determine if computer skills upgrading is necessary, injured employees may be referred for computer proficiency testing.

• Injured employees may participate in computer skills upgrading on-line or by attending classes in person.

Although most injured employees will participate in some type of skill upgrading, not all will become retraining candidates.

• An injured employee’s eligibility for retraining depends on what vocational option is determined appropriate based on North Dakota statute. Even if an injured employee’s treating provider recommends retraining, they may not qualify.
• Retraining refers to participation in an educational or technical program up to 104 weeks in length, as determined appropriate based on an injured employee’s work history, transferable skills, education, academic test scores, and physical  capabilities.

Other services may be provided to injured employees include:

• Resume review and preparation
• Job Seeking Skills Workshops
• Registration with their local employment agency

What is a Vocational Case Manager’s Report (VCR)?

The VCR outlines the means to case resolution. This report reflects the professional opinion of the vocational case manager regarding the injured employee’s employability. It takes into consideration the injured employee’s current functional capabilities, educational and employment history, income test, and transferable skills.

How is a VCR option determined?
Vocational case managers follow North Dakota statute with regard to return to work options. The first appropriate option among the following, calculated to return the injured employee to substantial gainful employment must be chosen for the injured employee:

a. Return to the same position.
b. Return to the same occupation, any employer.
c. Return to a modified position.
d. Return to a modified or alternative occupation, any employer.
e. Return to an occupation within the local job pool of the locale in which the injured employee was living at the date of injury or of the employee's current address which is suited to the employee's education, experience, and marketable skills.
f. Return to an occupation in the statewide job pool which is suited to the employee's education, experience, and marketable skills.
g. Retraining of one hundred four weeks or less.

If an injured employee has a question regarding their VCR or North Dakota statute, they should contact their vocational case manager. The injured employee should address benefit related questions with their claims adjuster.

What if an injured employee returns to work?
• If an injured employee returns to work, contact your vocational case manager immediately. You will receive further direction, as approval for the new position may be needed from the health care provider or a job description may be requested.