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Good Afternoon
3:23:10 PM CDT
Friday, March 12, 2010

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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)  

Prior Authorization Requirements
WSI allows a “window period” for treatment of each new claim. If the patient has treated for an injury and changes chiropractors, they are not given a new window period.

  • The window period allows 12 visits or 90 days of care whichever comes first
  • Any care needing to be extended beyond this parameter requires prior authorization
    • Prior Authorization can be obtained by contacting Orthopedic Chiropractic Consultants at 1-877-211-1906.
    • More information is under the Orthopedic Chiropractic Consultants link
  • Physician referral does not waive the prior authorization requirements
  • Prior authorization is done by peer review
  • WSI limits modalities to two (2) per visit, however they must be requested if they are part of the treatment
  • Hot & cold packs are considered a bundled charge and are not separately reimbursed

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