Chiropractic Services

Topics	Documentation Requirements	Forms & Publications	Provider Request for Adjustment (M6) form
Chiropractic Services	Prior Authorization Requirements	First Report of Injury (FROI) Form	Chiropractic Progress/Final Report (C25)
Claim Information		Capability Assessment form (C3)	Utilization Review Chiropractic Request (UR-Chiro)
Subsequent Treatment		Medical Services Dispute Resolution Request (M2)

Chiropractic Services
WSI allows chiropractic treatment for the course of an injury. Employers have the option of selecting a chiropractor as a Designated Medical Provider for their employees. When WSI accepts a work related injury, there will be an acceptance for a specific ICD-9 diagnosis. If treatment is for other diagnosis’s or body parts, there is a potential for the charges to be denied. There are specific prior authorization guidelines chiropractors need to follow when providing treatment to an injured worker. Prior Authorization guidelines can be found in the Utilization Review section or under the prior authorization section on this page.