When a North Dakota Workforce Safety & Insurance decision on proposed or already provided treatment is still disputed after utilization review, a provider can ask for binding dispute resolution on SFN 19605. The form names the treatment in dispute as specifically as possible, such as a lumbar fusion at L5-S1 or a right shoulder MRI, and confirms that any UR appeal has been completed.
The provider usually completes it, with facility details and the treating provider's name if the requester is someone else; Section 4 is answered by the requesting party. The signature section shows it may instead be completed by the injured employee, the employee's attorney or the employer.
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Binding Dispute Resolution Request
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After the utilization review appeal is done. Section 4 asks whether the disputed treatment results from a UR decision and, if so, whether the UR appeal has been completed. If it has not, the provider must first appeal using the UR Review Request (UR-C) form before using SFN 19605.
When the UR appeal is complete, attach a statement summarizing the attempts made to resolve the dispute and any relevant, pertinent medical information about the dispute that has not already been provided to WSI. The request goes to WSI's Medical Services Division rather than the Utilization Review Division that handled the appeal.
Yes. Section 3 asks whether the requester is the treating provider and, if not, for the treating provider's name, telephone and address. Section 5 lets the signer indicate the form was completed by the provider, the injured employee, the employee's attorney or the employer.