Chiropractic Services
Effective July 1, 2011 WSI implemented a new process for approval of chiropractic care beyond the initial window period.
All requests need to be submitted to WSI using the new UR Chiropractic Review Request Form
(UR-Chiro)
The UR-Chiro form should be completed in its entirety and faxed to WSI at 701-328-3765 or 866-356-6433 along with supporting medical documentation.
The documentation required for a review has not changed.
Window Period
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
General Information
- Physician referral does not waive the prior authorization requirements
- Modalities limited to two per visit, however they must be requested if they are part of the treatment
- Hot and cold packs are not reimbursed separately and are considered a bundled charge
- Massage/manual therapy is not reimbursable when performed with manipulation on the same spinal region on the same visit.
This includes Therapeutic Codes (97112, 97124 and 97140) when billed with Chiropractic Manipulative Treatment (CMT) codes (98940-98943).
- If the therapeutic services are performed in a different region than the CMT, modifier 59 may be appended to the therapeutic code(s).
Prior Authorization Process
WSI contracts with Orthopedic Chiropractic Consultants (OCC) to provide peer review for prior authorization.
Chiropractors providing treatment to injured workers beyond the window period need to complete the UR-Chiro form and submit it to WSI.
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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