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Good Evening
10:58:21 PM CDT
Wednesday, April 23, 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

Chiropractic Treatment Window

WSI allows a window period for chiropractic treatment of each new claim. A new window period is not allowed if the patient changes chiropractors during treatment.

  • The window period is 12 visits or 90 days of care, whichever comes first
  • Modalities are limited to two per visit
  • One window period per claim, not per body part or diagnosis
  • Any care needing to be extended beyond these parameters requires prior authorization

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