Fillable MEDICAL BILL APPEAL MEDICAL SERVICES DIVISION

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MEDICAL BILL APPEAL MEDICAL SERVICES DIVISION

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M6
MEDICAL BILL APPEAL
MEDICAL SERVICES DIVISION
SFN 58310 (10/2021)
1600 E Century Ave, Ste 1
PO Box 5585
Bismarck ND 58506-5585
Telephone 800-777-5033
Toll Free Fax 888-786-8695
TTY (hearing impaired) 800-366-6888
Fraud and Safety Hotline 800-243-3331
www.workforcesafety.com
SECTION 1 – Injured employee’s information
Claim number
Injured employee’s (First name)
(Last name)
SECTION 2 – Provider’s information
Provider/facility name
Contact name
Telephone number
Fax number
SECTION 3 – Appeal information
WSI bill number(s)
Reason for appeal (select all that apply)
Medical records not received (RC 212)
Attach medical records with this form
Service not pre-certified (RC 80) & (RC 91)
Provide description of appeal in Section 4
Reconsideration of payment
Provide description of appeal in Section 4
Dates of service
Place of
service
CPT/HCPCS/ADA/Rev code
Modifier
Tooth
number/
surface
Amount
billed
Amount
paid
From
To
SECTION 4 – Explanation of appeal
Please attach supporting documentation.
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MEDICAL BILL APPEAL MEDICAL SERVICES DIVISION

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Completed 22 June 2022

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