M6 MEDICAL BILL APPEAL MEDICAL SERVICES DIVISION SFN 58310 (0 5 /201 6 ) 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 worker information Claim number (First name) (Last name) SECTION 2 Provider information Provider/facility n ame Contact name Telephone number Fax number SECTION 3 Appeal information WSI b ill number(s) CMS 1500 UB - 04 Reason for appeal (select all that apply) M edical 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 p ayment Provide description of appeal in Section 4 Dates of s ervice U nit ( s ) Place of s ervice CPT/HCPCS/ADA/Rev code M odifier Tooth number/ surface Amount b illed Amount p aid From To SECTION 4 Explanation of appeal Please attach supporting documentation. American LegalNet, Inc. www.FormsWorkFlow.com