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5:19:17 AM CDT
Wednesday, April 16, 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)  

Authorization Process

Prior Authorization (Precertification) Process
Prior authorization is the process of reviewing information prior to procedures and services being performed. WSI contracts with Orthopedic Chiropractic Consultants (OCC) to provide peer review for prior authorization.

  • Requests are reviewed on pending claims and on claims for which WSI has accepted liability. To verify the status of a claim, click here Claim Status.
  • To request a prior authorization, complete and submit the UR-Chiropractic Review Request (UR-Chiro) form including supporting medical documentation.
  • Fax request and medical documentation to 701.328.3765 or toll free 1.866.356.6433
  • Authorization must be obtained at least 24 hours or the next business day in advance of providing certain medical treatment, equipment, or supplies.
  • WSI has 3 business days to complete a review upon receiving the request and medical notes.
  • If not utilized within 3 months, the request must be re-submitted with updated medical information for additional review.

Concurrent Review Process
Concurrent Review is the process of reviewing utilization management activities that take place during an inpatient level of care or an ongoing outpatient course of treatment.

  • Requests are reviewed on pending claims and on claims for which WSI has accepted liability. To verify the status of a claim, click here Claim Status.
  • To request a concurrent review, complete and submit the UR-Chiropractic Review Request (UR-Chiro) form including supporting medical documentation.

Retrospective Review Process
Retrospective Review is the process of reviewing a service after the treatment occurred.

  • Retrospective reviews are considered only if:
    • Injured worker did not inform the provider, and the provider did not know that the condition was, or likely would be, covered by WSI.
    • Prior authorization of medical services was not requested by provider and injured worker's claim status at time of service was presumed closed or a claim was not filed.
  • To request a retrospective review, complete and submit the Provider Request for Adjustment (M6) form including supporting medical documentation.

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