North Dakota Workforce Safety & Insurance's utilization review department must preauthorize imaging, surgery, injections and many therapies, and the two-page UR-C is the paper request. It covers new requests and appeals, identifies the ordering provider and servicing facility by NPI and TIN, and has checklists for imaging studies, surgery, spinal and joint injections by level and side, and therapy visits.
The ordering provider (MD, NP or PA) or that office completes both pages, including the date of the most recent office visit and a contact person for the decision. The servicing facility's NPI and TIN go in Section 5.
Download the current version from the source each time; forms change without notice.
UR-C Prior Authorization Review Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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WSI's prior authorization guide lists non-emergent inpatient admissions and surgeries, imaging such as MRI and CT, injections, chronic pain programs, work hardening, speech and vision therapy, spinal cord stimulator trials and implants, bone growth stimulators and skin substitutes, plus therapy beyond the initial window.
Check Appeal in Section 2 of the UR-C, or appeal in myWSI, and include new, relevant medical information that disputes the rationale in the UR notification letter. If the disagreement continues after the appeal is complete, the provider can request binding dispute resolution on SFN 19605.
The form asks for the individual ordering provider's NPI plus the facility group or billing NPI and tax identification number, and the same for the servicing facility. WSI says it relies on this information to correspond with the individual provider and the facility about the request.