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Good Afternoon
1:36:21 PM CDT
Sunday, April 20, 2014

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Chiropractic Services

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

General Information

WSI allows chiropractic treatment for the course of an injury. Employers have the option of selecting a chiropractor as a Designated Medical Provider (DMP) for their employees.

The Utilization Review (UR) Department is responsible for determining the medical necessity for services based upon an injured worker’s clinical condition. Our staff utilizes evidence-based clinical guidelines from national and state authorities to guide utilization management involving prior authorization, concurrent review and retrospective review. The Utilization Review Guide outlines treatment requiring approval and is updated semi-annually, with the information available on the website.

  • It is the responsibility of the medical provider who provides or prescribes medical treatment, equipment, or supplies to submit requests.
  • Final Liability and payment decisions are the responsibility of the claims adjuster managing the claim.
  • Services will be reimbursed per WSI fee schedule.
  • Physician referral does not waive the prior authorization requirements.
  • Hot & cold packs are not reimbursed separately, as they are considered a bundled charge
  • Massage/manual therapy is not reimbursable when performed with the manipulation on the same spinal region on the same visit. This includes Therapeutic Codes (97112, 97124 & 97140) when billed with Chiropractic Manipulative Treatment (CMT) codes (98940-98943).
    • If therapeutics services are performed in a different region than the CMT, modifier 59 may be appended to the therapeutic code(s).

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