Utilization Review
WSI has a program for Utilization Review (UR) and quality assurance.
Utilization review contains the following elements:
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Pre-service review is the evaluation (by WSI or a managed care vendor)
of a proposed medical service for medical necessity, appropriateness,
and efficiency prior to the service being performed.
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Concurrent review is the monitoring (by WSI or a managed care vendor)
of the injured worker’s condition, treatments or procedures for medical
necessity and appropriateness, throughout the period of time in which
medical services are being provided. For inpatient hospital stays,
concurrent review is required when the length of stay exceeds 14 days.
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Retrospective review is a review (by WSI or a managed care vendor)
of a medical service for medical necessity, appropriateness, and efficiency
after treatment has occurred. Retrospective review is limited to those
situations when the provider can show that the injured worker did not inform
the provider or the provider did not know the condition was covered by workers’ compensation.
The Utilization Review Guide outlines treatment
requiring approval and is updated semi-annually, with the information available on the website.
Prior authorization needs to be requested at least 24 hours or the next business day in advance
of providing the treatment or services. Authorization not utilized within 3 months (6 months for
elective fusions) must be re-submitted with updated medical information for additional review.
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If a request is made on a pending claim (there must be an assigned claim number),
the UR department will complete the review and notify the provider of the approval
or denial for the procedure.
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The UR department will not review services on denied claims, presumed closed claims, or on claims that have not been filed.
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The UR department reviews for medical necessity and not for compensability decisions.
Payment for services on pending claims will be based on the compensability determination by the claims adjuster.
Utilization reviewers compare proposed treatment to guidelines
and criteria based on scientific based evidence to make decisions on medical necessity.
Approval for meeting WSI treatment guidelines does not guarantee reimbursement for the service provided.
To contact the UR department for prior authorization:
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Fax request and medical notes to 701-328-3765 or toll free 1-866-356-6433
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Request must include:
Some services outline in the Utilization Review Guide required
prior approval from the WSI claims adjuster. To contact the claims adjuster for prior authorization:
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Contact WSI by calling 701-328-3800 or toll free 1-800-777-5033
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Must include the injured workers’ Social Security or Claim number
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