Chiropractic Services — Reimbursement Policy
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Defines reimbursement rules and prior authorization requirements for chiropractic manipulative treatment and related services billed to AmeriHealth Caritas Delaware; applies to providers submitting CMS-1500 or UB-04 claims for covered members.
No material clinical or coverage changes in this revision.
Chiropractic Coverage Criteria
Chiropractic coverage criteria
Reimbursement and utilization rules for chiropractic services.
ALL of the following
ALL of the following
- Patients under age 18 require prior authorization before any chiropractic treatment is provided.
- For patients 18 years and older, prior authorization is required after 24 visits of chiropractic manipulative treatment (CPT 98940-98942).
Threshold: 24 visits
ALL of the following
- Diagnostic X-rays to determine the existence of a vertebral subluxation are eligible for reimbursement.
- AmeriHealth Caritas Delaware allows one spinal X-ray per year (within 12 months prior to treatment or within 3 months following treatment).
One X-ray per 12-month period or within 3 months post-treatment; X-rays for new injury or re-exacerbation may be covered.
ALL of the following
- Chiropractic manipulative treatment codes (CPT 98940-98942) will be denied if billed more than one time per service date.
Codes, Visits, and Imaging Rules
| No codes listed |
Prior Authorization and Provider Requirements
Prior Authorization Requirements for CMT
Prior authorization is required for chiropractic manipulative treatment (CPT 98940-98942) as follows: patients under age 18 must obtain prior authorization before any chiropractic treatment is provided; patients 18 and older require prior authorization only after 24 visits of CMT.
Key Definitions
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