Utilization Review Guide
UR Department
Phone:
701-328-5990
888-777-5871
Fax:
701-328-3765
866-356-6433
Customer Service
(Claims & Billing)
Phone:
701-328-3800
800-777-5033
Fax:
701-328-3820
888-786-8695
Address
1600 E Century Ave Ste 1
Bismarck ND 58503
Mailing Address
PO Box 5585
Bismarck, ND 58506
Website
www.workforcesafety.com
General Information
The Utilization Review (UR) Department is responsible for determining the
medical necessity for services based upon an injured worker’s clinical condition.
Our staff utilizes evidence-based clinical guidelines from national and state
authorities to guide utilization management involving prior authorization,
concurrent review and retrospective review.
 The medical provider who provides or prescribes medical treatment,
equipment, or supplies must submit the request(s).
 Reimbursement is per WSI fee schedule.
 For information on billing, contact Customer Service at 800-777-5033.
 Final liability and payment decisions are the responsibility of the
claims adjuster managing the claim.
Submitting a Prior Authorization Request
 Verify the status of a claim; visit our website, www.workforcesafety.com,
under Medical Providers, Online Services
 Review this guide to determine if prior authorization is required
 Complete UR Review Request (UR-C) form
 Fax UR-C form and supporting documentation to: 701-328-3765 or
866-356-6433
 Upon receipt of the request and medical notes, WSI has three business
days to complete the review
 If not utilized within three months (six months for elective fusions), the
request must be re-submitted with updated medical information for
additional review
 A medical provider may perform necessary emergency services for a serious,
unexpected, or dangerous condition without prior authorization. However,
notification is required within 24 hours of, or by the end of the next business
day following, the initiation of emergency treatment.
Submitting a Retrospective Authorization Review Request
 Review the Utilization Review Guide to determine if prior authorization is
required
 Submit a bill for processing if prior authorization was deemed necessary
 Complete the Medical Bill Appeal (M6) form upon receipt of a denied
charge, which will initiate the retrospective authorization review process
 Fax M6 form and supporting documentation to: 701-328-3765 or 866356-6433
Criteria for a Retrospective Authorization Review
WSI will allow a retrospective authorization review if the provider can
demonstrate one of the following:
 Provider was not aware the condition was, or likely would be, covered by
WSI
 Injured worker's claim status on date of service included: denied, presumed
closed, or claim not filed
Page 1 of 5
July 1, 2016
Prior Authorization List
The following chart outlines services which require prior authorization by the respective department: UR or Claims Adjuster.
Service
Requirements
UR
Acupuncture
Admissions (Inpatient
Medical/Surgical Procedures)
 Acute Inpatient
 Inpatient Rehab
 Inpatient Surgeries
 Inpatient Psychiatric
 Long Term Acute Care
 Subacute
 Swing Bed
 TCU
Admissions (Nursing Home)
Ambulance (non-emergent
transport)
Behavioral Health/Chemical
Dependency
 Chemical Dependency
 Detoxification
 Psychiatric Evaluations
Chiropractic
 Chiropractic Acute/Subacute
Care
 Chiropractic Palliative Care
 Acupuncture by Chiropractor
All acupuncture treatment requires prior authorization
 Non-emergent admission requires at least 24 hours
notification prior to the proposed admission or
surgery
 No prior authorization is required for
urgent/emergent inpatient services
X
Chronic Pain Management




Dental Procedures
Durable Medical Equipment
(DME)
 Refer to DME Guide
 External bone growth
stimulator
Home Health Care
Home Health Care PT/OT
IV Therapy Outpatient
Massage Therapy
Outpatient Services
 Arthrogram
 Bone scan
 CAT/CT scan

X
X
X
X




Authorization is required for all treatment extending
beyond the initial office visit
Complete the UR-Chiro form
Requests for palliative care must include the
required palliative care questionnaires
All acupuncture treatment requires prior
authorization
Initial evaluation
Chronic pain program
Performed in outpatient setting
External bone growth stimulator requires prior
authorization. Complete UR-C form
X
X
X
X
X

X
See therapy section
X

Not covered as a passive modality completed by a
licensed massage therapist. Massage may be
requested as part of a chiropractic or therapy
treatment plan
X
X

Prior authorization not required if performed within
30 days from date of injury and directly related to
work injury
Cryoablation
Page 2 of 5
Claims
X
X
July 1, 2016
Prior Authorization List
The following chart outlines services which require prior authorization by the respective department: UR or Claims Adjuster.
Service
Outpatient Services (continued)
 Discogram
 Facet rhizotomy
 Implantation of stimulator &
pump
 MRI
 Myelogram
 PET Scan
 Thermography
 Radiofrequency ablation
Outpatient Surgery
Essentially all outpatient surgeries
require prior authorization.
Physical and Occupational
Therapy
Requirements
X
X
X
X
X
X













Biofeedback
Driving Assessment
Endurance Testing (Biodex,
Cybex, B200)
Ergonomic Assessment
Functional Capacity
Evaluation/Assessment
Independent Exercise Program
Job Site Analysis
Neuro biofeedback
Specialized Rehabilitation
Page 3 of 5
Claims
X
X




UR
See chart Prior Authorization NOT Required on
Page 5
Reviewable after window period of 10 visits or 60
days of care, whichever comes first
Window period expires 60 days from initial
evaluation
One initial window period per claim, not per body
part or diagnosis
Post-surgical (inpatient or outpatient) window is 10
visits or 60 days, whichever comes first
o Treatment must start within 90 days postoperative
Limited to 2 modalities per visit during any window
period
Initial evaluation or re-evaluation visit is included in
the initial window or post-surgical window periods
For extension of timeframe on prior approved
therapy sessions call the UR department before
approval expires
o Time extensions do not apply to initial
window period
X
X
X
X
X
X
Billed using WSI specific code W0540
X
 Memberships
 Aquatic
 Complete C59a form
 Billed using WSI specific code W0555
Billed using WSI specific code W0550
X
X
X
X
July 1, 2016
Service
Physical and Occupational
Therapy (continued)
 Workability Assessment
Requirements




Work Hardening/Conditioning
Physician Consult or Referral
Speech Therapy
Therapeutic Injections
 Botox injection
 Epidural steroid injection
 Facet joint injection
 Facet nerve block
 Hyaluronic acid injection
(viscosupplementation)
 Nerve injection
 Nerve root injection
 Peripheral nerve block
 Plasma rich injection
 SI joint injection
 Stellate ganglion block
 Sympathetic nerve block
 Trigger point injection
exceeding 3 visits in a 2-month
period
Wound VAC Dressing
Page 4 of 5




UR Claims
Allowed once every 2 weeks, without prior
authorization
Must be scheduled 2 days prior to a physician visit to
assist providers in determining capabilities
o Utilized to accurately determine capabilities of
the injured worker
o Warranted only if the injury results in job
restrictions
A separate report is required, identifiable as the
workability report, even if the assessment is
completed on the same day as other therapy
Billed using CPT® code 97750
Allowed maximum of 3 units (45 minutes)
Complete C59b form
Billed using CPT® code 97545 (for initial 2 hours);
CPT ® code 97546 (add-on code, for each additional
hour)
X
X
X
X
**Effective March 1, 2016 approval through UR
X
X
X
X
X
X
X
X
X
X
X
X

No more than 20 injections may be paid over the life
of a claim
X
X
July 1, 2016
Prior Authorization Not Required
Outpatient Services
Angiogram
Bronchoscopy
CT angiogram
Colonoscopy
Cystoscopy
Echocardiogram
Electrodiagnostic study
 Provider must be certified or eligible for
certification by ABEM, ABPMR, AMNP
EEG
EKG
Endoscopy
Esophageal swallow study
Hydrascan
Indium scan for pain pump
Indium scan for WBC check
MUGA scan
Sleep study
Stress test
Splint modification
Tomogram (unless ordered in conjunction with other
imaging)
UGI
Ultrasound
Ultrascan
Venogram
Venous Doppler
X-ray
Outpatient Surgeries:
Acute bone grafting with ORIF
Acute Repairs (includes 60 days from date of injury)
 Digital amputation
 Digital and hand laceration
 Digital and hand tendon
 Digital and hand nerve
 Digital and hand artery
 Open or closed reductions
Carpal tunnel release
Cataract surgery
Cyst removal
de Quervain's release (dorsal compartment release)
Detached retina repair
Foreign body removal
Hardware removal
Heart catheterization
Hernia repair
Neuroma excision
Scar revision
Skin graft
Trigger finger release
Vitrectomy repair
Wound I & D
Physical and Occupational Therapy:
Crutch instruction
Initial evaluation
Whirlpool burn debridement and dressing change
Services Not Covered
Acupressure
Athletic trainer services provided under
agreement/contract
Chemonucleolysis
Dry Needling
Continuous-flow cryotherapy unit
Injections:
 colchicine except to treat an attack of gout
precipitated by a compensable injury
 chymopapain
 fibrosing or sclerosing agents except where
varicose veins are secondary to a compensable
injury and injections of substances other than
cortisone, anesthetic, or contrast into the
subarachnoid space (intrathecal injections)
Page 5 of 5
Intradiscal electrothermal annuloplasty (IDET)
Med-X spine strengthening program
NC Stat, Neurometric & Surface EMG
Prolotherapy (sclerotherapy)
Reflexology
Rolfing
Surface EMG
Vertebral axial decompression therapy (Vax-D
treatment)
July 1, 2016