Fillable UR REVIEW REQUEST SECTION 1 Injured employee's information

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UR REVIEW REQUEST SECTION 1 Injured employee's information

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UR-C
UR REVIEW REQUEST
UTILIZATION REVIEW DIVISION
SFN 58385 (12/2021)
1600 E Century Ave, Ste 1
PO Box 5585
Bismarck ND 58506-5585
Telephone Number 701-328-5990
Toll Free Number 888-777-5871
Local Fax 701-328-3765
Toll Free Fax 866-356-6433
TTY Number (hearing impaired)
701-328-3786
www.workforcesafety.com
Fax recent medical notes with request to 866-356-6433. To prevent a delay of your review complete required sections 1-4.
Retrospective review requests – complete the Medical Bill Appeal (M6) form based on receipt of a denied bill.
SECTION 1 – Injured employee's information
Date
Claim number
Injured employee's (First name)
(Last name)
Date of injury
Date of birth
Social Security number*
Precertification Appeal
Scheduled date of procedure/admission
Person to notify with decision
Preferred method of notification of recommendation
Telephone call OR Fax
Telephone number
Fax number
Facility name
Facility mailing address
City
State
ZIP code
Facility telephone number
Facility fax number
Provider’s full name (MD, NP, PA)
Date of recent office visit
Clinic name
Clinic mailing address
City
State
ZIP code
Clinic Federal Tax ID
Clinic telephone number
Facility name
Facility address
City
State
ZIP code
Facility Federal Tax ID
Facility telephone number
**Complete only the section(s) for the service(s) being requested**
* In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory pursuant to N.D.C.C. § 65-05-02. The Social
Security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request.
Form continued on next page. Submit all pages to WSI.
Provider's NPI
UR REVIEW REQUEST (cont’d) PAGE 2 OF 2
Claim Number
Injured employee's (First name)
(Last name)
UR-C
SECTION 6 – Surgery request
Outpatient Inpatient
Non-implantable DME
(Refer to WSI DME Guide)
Type of surgery
Workforce Safety & Insurance (WSI) requires additional forms for certain surgeries. The forms are located under Medical Treatment
Guidelines section of our website, www.workforcesafety.com.
SECTION 7 – Injection request (**Levels are required where indicated)
Epidural steroid injection (ESI)
lumbar
right left bilateral
translaminar / intralaminar ESI cervical thoracic
transforaminal ESI or selective nerv
e root block: specific level(s) required**
Regional sympathetic block
upper extremity: stellate ganglion block right left number of injection(s)
lower extremity: lumbar sympathetic block right left number of injection(s)
Intra-articular sacroiliac (SI) joint injection (fluoroscopy or CT guidance) right left bilateral
Botox injection: area
Viscosupplementation (Hyaluronic acid) injection right left bilateral knee(s)
Series number of injection(s)
Synvisc® One injection
Facet joint intra-articular block** Level(s) right left bilateral
Facet medial branch block** Level(s) right left bilateral
Radiofrequency medial branch neurotomy (ablation)** Level(s) right left bilateral
Other (examples: peripheral nerve block(s) or plexus block(s))
SECTION 8 – Therapy request (Complete section per therapist treatment plan)
Occupational
Physical Speech
Area of body Chief complaint
Date of surgery (if applicable)
Specific treatment (i.e. exercise, modalities)
Start date of upcoming treatment End date of upcoming treatment
Total number of visits being requested
Have all prior approved visits been completed?
Yes No N/A
Date of last visit
Number of visits used
Therapist name
SECTION 9 – Other services requested (provide description)
caudal
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UR REVIEW REQUEST SECTION 1 Injured employee's information

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Completed 10 February 2022

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