Chiropractic Resources

Chiropractic Reference Manual
This manual has information regarding medical necessity requirements, utilization management, billing, and documentation requirements.
Chiropractic: Treatment Request Form
This form should be used to request prior authorization for chiropractic services for members with contractual visit limitations.
ICSI: Clinical Practice Guidelines for Low Back Pain
The clinical practice guidelines focus is on the acute (pain for up to 7 weeks) and sub-acute (pain for between 7 and 12 weeks) phases of low back pain. It includes the ongoing management of low back pain, including indications for spine specialist referral within the first 12 weeks of onset.
Health Care Services Referral Form
Keele STarT Back Tool
The Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identifies modifiable risk factors (biomedical, psychological and social) for back pain disability. The resulting score stratifies patients into low, medium or high risk categories.
Neck Disability Questionnaire
The Neck Disability Index Questionnaire (NDI) is a 10-item questionnaire that measures a patient’s self-reported neck pain related disability.
Oswestry Low Back Questionnaire
The Roland-Morris Disability Questionnaire is a self-administered disability measure in which greater levels of disability are reflected by higher number of a 24-point scale.
Roland-Morris Disability Questionnaire
The Oswestry Disability Index is currently considered by many as the gold standard for measuring degree of disability and estimating quality of life in a person with low back pain.

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