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Good Morning
12:51:41 AM CDT
Friday, April 18, 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

Palliative Care Requirements

For palliative care requests, the following information needs to be completed:

  • Completed UR-Chiro form
  • 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 the following:
    • How the requested palliative care is related to the accepted compensable condition
    • How the proposed treatment plan will enable the claimant to continue employment or to perform the activities of daily living
    • What the adverse effect would be to the claimant if palliative care is not approved
  • Necessary outcome measurements applicable to the treatment, such as:
  • Last 6 months of progress notes

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