CurrentHawaii Medical Service Association (HMSA)Policy C15

Complementary Care Rider — Acupuncture, Chiropractic, Massage

Defines benefits, eligibility, covered services, exclusions, utilization review, and claims filing for complementary care administered by ASH Group for HMSA members under this Rider.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyComplementary Care Rider — Acupuncture, Chiropractic, Massage

Policy CodePolicy C15

Change TypeNo material changes

Effective DateJanuary 2025

Next Review DateN/A

Key ActionObtain ASH Group authorization for all chiropractic services except the initial evaluation; ASH Group responds within one week of a completed form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$15Participating provider copayment per visit

20Max visits per year (participating)

1 wkASH Group response time

365Claim filing limit (non‑participating Medicare)

5HMSA in-person centers listed

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Chiropractic — covered when all listed service conditions are met

Covered Chiropractic Services (when criteria met and approved by ASH Group):

Chiropractic covered services: A New Patient exam or an Established Patient exam for the initial evaluation of a patient with a new condition or new episode to determine the appropriateness of Chiropractic Services.

All Chiropractic Services except for the initial evaluation must be approved by ASH Group as medically necessary for treatment of Musculoskeletal and Related Disorders or Pain Syndromes.

Established patient exams as needed to assess the need to initiate, continue, extend, or change a Course of Treatment. The Established patient exam is only covered when used to determine the appropriateness of Chiropractic Services.

Exam or re‑exam provided without an adjustment will count as an office visit toward the Benefit Maximum.

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Adjunctive modalities and procedures (for example: rehabilitative exercise, traction, ultrasound, electrical muscle stimulation) are covered only when provided during the same Course of Treatment and in support of chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissue.

When authorized by ASH Group, benefits are available for adjunctive therapy at each office visit. If adjunctive therapy is provided without an adjustment, the adjunctive therapy will count as an office visit toward the Benefit Maximum (no more than 20 visits per calendar year for participating providers).

General exclusions apply to services and supplies that are not covered under this Rider. Notable exclusions include services or supplies provided by a nonparticipating provider, Acupuncture Services, and Massage Therapy Services and Supplies. Other exclusions include services provided in excess of any Benefit Maximum, services outside the practitioner's scope of practice, hospitalization/surgery/anesthesia-related services, and a range of specified therapies and devices (for example, hypnotherapy, thermography, magnets, ion cord devices, laser biostimulation, and certain injection therapies).

Chiropractic-specific exclusions list items that are not covered even when chiropractic care is otherwise eligible: chiropractic supports and appliances, advanced diagnostic imaging such as MRI, CAT/CT scans, bone scans, and nuclear radiology, and adjunctive physiotherapy modalities and procedures unless they are provided during the same Course of Treatment and in direct support of chiropractic manipulation.

Services provided for elective or maintenance care are excluded when treatment records indicate the member has reached maximum therapeutic benefit. Such care is considered not medically necessary and is therefore not covered under this Rider.

Provider Actions, Authorization, and Billing

Prior Authorization

Chiropractic services prior authorization

All Chiropractic Services except the initial evaluation require prior authorization and medical necessity review by ASH Group. ASH Group will respond within one week of receipt of the completed form; the clinical decision notice will be mailed or faxed to the provider and include the peer-clinician contact.

All Chiropractic Services except initial evaluation require ASH Group approval as medically necessary
ASH Group response time: within one week of completed form
Notification includes peer-clinician name and phone

Note

Adjunctive therapy conditions

Adjunctive therapies (rehabilitative exercise, traction, ultrasound, electrical muscle stimulation, etc.) are covered only when provided during the same Course of Treatment and in support of chiropractic manipulation. If adjunctive therapy or an exam/re-exam is provided without an adjustment, it will count as an office visit toward the Benefit Maximum (no more than 20 visits per calendar year for participating providers).

Adjunctive therapy covered only when provided during same Course of Treatment and supportive of manipulation
Adjunctive therapy or exam/re-exam without an adjustment counts as an office visit toward the 20-visit annual Benefit Maximum (participating providers)

Documentation Required

Claims documentation requirements

Claims documentation and submission requirements for services from providers who do not file claims for you: complete a separate claim form per provider and attach the itemized bill. Include itemized dates of service, diagnosis code, procedure code, billed charge per service, provider name and credentials, provider full address, provider tax ID/EIN/SSN, and NPI. For commercial non-participating providers there is no submission timeframe; for Medicare non-participating providers claims must be filed within 365 days of the date of service. Send claims to the ASH Group P.O. Box listed on the claim form.

Complete a separate claim form for each non-filing provider
Required claim elements: itemized dates of service; diagnosis code; procedure code; billed charge per service; provider name and credentials; provider full address; provider tax ID/EIN/SSN; NPI
Attach the provider's itemized bill
Commercial non-participating providers: no submission timeframe
Medicare non-participating providers: file within 365 days of date of service
Mailing address: American Specialty Health Group, Inc., P.O. Box 509077 San Diego, CA 92150

Denial Risk

Coverage denial triggers

Services provided by nonparticipating providers are not covered; the member is responsible for the entire charge. Coverage denials for nonparticipating providers are listed as exclusions. The EOB will notify members of any financial responsibility (other than copayments) but is not a bill.

Services from nonparticipating providers: not covered — member owes entire charge
Nonparticipating provider services explicitly listed under general exclusions
EOB communicates financial responsibility (total charged, allowed amount, amount covered, amount you pay) and is not a bill

Note

No other denial triggers specified / EOB content

No additional denial triggers are specified in these sections beyond the stated exclusions and nonparticipating provider rule. The EOB will communicate any financial responsibility but is not a bill.

No other denial triggers specified in these sections
EOB content: total amount charged, allowed amount, amount covered by ASH Group, amount member pays; EOB is informational, not a bill

Definitions and Key Terms

inv-13: Acupuncture Services — definition and permitted techniques/devices

DefinitionAcupuncture Services: stimulation by insertion/removal of single-use sterile disposable needles and/or electrical stimulation (electroAcupuncture) to normalize physiological functions, prevent or modify perception of pain, or to treat Musculoskeletal and Related Disorders, Nausea, or conditions with pain as a primary symptom.

Adjunctive modalitiesMay include adjunctive physiotherapy modalities and procedures provided during the same Course of Treatment and in support of Acupuncture Services.

IndicationsProvided for treatment or diagnosis of Musculoskeletal and Related Disorders, Nausea, and Pain Syndromes (including adult post-operative, chemotherapy, and pregnancy-related nausea when appropriate).

Technique specificsUse of single-use, sterilized, disposable needles; electrical stimulation (electroAcupuncture) is an optional component.

inv-14: Chiropractic Services — definition and scope (manipulation, adjunctive therapies)

DefinitionChiropractic Services: services by a Chiropractor for treatment or diagnosis of Musculoskeletal and Related Disorders and Pain Syndromes primarily through chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissue.

Included componentsIncludes differential diagnostic examinations, related diagnostic x-rays and radiological consultations when used to determine appropriateness, and follow-up office visits that include chiropractic manipulation during the Course of Treatment.

Adjunctive therapiesMay include adjunctive physiotherapy modalities and procedures provided during the Course of Treatment and in support of chiropractic manipulation (e.g., rehabilitative exercise, traction, ultrasound, electrical muscle stimulation as described elsewhere).

Provider credentialProvided or made available to a Member by a Chiropractor duly licensed to practice in the state or jurisdiction where services are rendered.

inv-15: Course of Treatment — definition of sequence/series of visits

DefinitionCourse of Treatment: a sequence or series of office visits directly related to a diagnosed disease state, illness, or injury and provided in conjunction with a defined clinical outcome.

Relation to servicesAdjunctive physiotherapy modalities and procedures are covered only when provided during the same Course of Treatment and in support of the primary modality (e.g., acupuncture or chiropractic manipulation).

Visit content requirementFor Chiropractic Services, follow-up office visits within the Course of Treatment must include provision of chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissue.

OpenPayer

Complementary Care Rider — Acupuncture, Chiropractic, Massage

Coverage Criteria — Complementary Care Rider

Provider Actions, Authorization, and Billing

Definitions and Key Terms

Background and Scope