North Dakota Workforce Safety & Insurance allows chiropractic care without prior authorization only during an initial window of 10 visits or 60 days, whichever comes first. To continue, the treating chiropractor submits this UR Chiropractic Review Request listing the ICD-10 code for each treated area, the manipulation code, modalities, visits requested and completed, and the worker's current work status.
The treating chiropractor completes Sections 1 to 4, including NPI, facility and the person to notify with the decision. The injured worker does not complete or sign any part.
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UR Chiropractic Review Request
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After the initial window of 10 visits or 60 days of care, whichever occurs first. The initial evaluation counts toward the window, and only one initial window is allowed per claim. Further visits need a UR Chiropractic Review Request on SFN 59693 or the same request in myWSI.
Section 3 offers CPT 98940, 98941, 98942 and 98943 for the manipulation requested, plus the number of modalities per visit (none, 1 or 2) and their CPT codes. It also asks for the ICD-10 code for each treated area and the start and end dates of upcoming treatment.
Whether all previously approved visits have been completed, the date of the most recent visit and number of visits completed, whether the patient is also receiving physical or occupational therapy, and whether the worker is on full duty, restricted duty or not working. Section 4 leaves room for additional information.