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	Orthopedic Chiropractic Consultants (OCC)	Capability Assessment form (C3)
Subsequent Treatment		Medical Services Dispute Resolution Request (M2)

Orthopedic Chiropractic Consultants (OCC)
WSI contracts with OCC to provide peer review for prior authorization. Chiropractors providing treatment to injured workers need to contact OCC when extending care past the allowed window period. Contact OCC for prior authorization:

1-877-211-1906 to request additional care
Information needed when requesting additional care:

For Palliative Care requests, the following information needs to be completed and sent to OCC:

All objective findings

ICD-9-CM diagnosis codes

A proposed treatment plan that includes treatment modalities, name of provider performing the treatment, frequency of care, and duration of care provided

A description of how the requested palliative care is related to the accepted compensable condition

Describe how the proposed treatment plan will enable the claimant to continue employment or to perform the activities of daily living

Describe what the adverse effect would be to the claimant if palliative care is not approved

Necessary outcome measurements like the:

Last 6 months of progress notes