CurrentHawaii Medical Service Association (HMSA)Policy C14

Complementary Care Rider — coverage for acupuncture, chiropractic, massage, and related services

This rider describes covered complementary care services (acupuncture, chiropractic, massage therapy, supports/appliances, and related adjunctive modalities) for HMSA members and how benefits are administered by ASH Group; it applies to members whose medical plan includes this Rider and to Participating and Nonparticipating providers as specified.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyComplementary Care Rider — acupuncture, chiropractic, massage, and related services

Policy CodePolicy C14

Change TypeNo material changes

Effective DateJanuary 2025

Next Review DateN/A

Key ActionObtain ASH Group prior authorization for all chiropractic services other than the initial evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$15Copayment per visit (participating)

20Max visits/year (participating)

No coverageNonparticipating provider coverage

ASH GroupAdministrator

What the Rider Covers

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Chiropractic Covered Services

Covered when services meet the definitions and are provided by Participating Providers within benefit limits and utilization review requirements.

Chiropractic services (general): A New Patient exam or an Established Patient exam for the initial evaluation of a new condition or new episode to determine appropriateness; Established patient exams when used to determine the appropriateness of Chiropractic Services; follow-up office visits that include manipulation of the spine, joints, and/or musculoskeletal soft tissue, reevaluation, and/or other services; adjunctive modalities and procedures (e.g., rehabilitative exercise, traction, ultrasound, electrical muscle stimulation) only when provided during the same Course of Treatment and in support of chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissue.

All Chiropractic Services except for the initial evaluation must be approved by ASH Group as medically necessary; utilization review requirements are the responsibility of the Participating Provider and ASH Group will respond to completed forms per its process.

Acupuncture and Massage Covered Services

Covered when services meet the Rider definitions and are provided in accordance with professional standards.

Acupuncture and Massage: Acupuncture Services for treatment or diagnosis of Musculoskeletal and Related Disorders, Nausea, and Pain (stimulation by single-use needles and/or electroacupuncture; may include adjunctive physiotherapy modalities when provided during the same Course of Treatment). Massage Therapy Services for treatment of Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, and/or lymphedema via manual physical actions (compression, stroking, friction, vibration, joint movement, percussion).

Services must be provided in accordance with professionally recognized, evidence-based standards of practice; adjunctive modalities are covered only when provided during the same Course of Treatment in support of the primary service.

Cost Sharing and Visit Limits

Member payment and benefit maximum rules.

Cost sharing and limits: Participating provider copayment is $15 per visit; copayments do not apply for x-rays and radiological consultations; Participating Provider benefit maximum is no more than 20 visits per calendar year.20 visits/year

When authorized by ASH Group, adjunctive therapy is available at each office visit; adjunctive therapy provided without an adjustment counts as an office visit toward the Benefit Maximum. If an exam or re-exam is supplied without an adjustment, it will count as an office visit toward the Benefit Maximum.

The Rider specifies several general and chiropractic‑specific exclusions. Services or supplies provided by a nonparticipating provider are not covered; the member is liable for the entire charge. General exclusions also expressly exclude Acupuncture Services and Massage Therapy Services and Supplies, services in excess of any benefit maximum, services not permitted by state scope‑of‑practice rules, and a range of other items (e.g., hospitalization, surgery, anesthesia, thermography, magnets, ion cord devices, and certain injection therapies). (See list of General Exclusions.)

Chiropractic‑specific exclusions further limit coverage. The Rider excludes chiropractic supports and appliances, advanced diagnostic imaging such as MRI, CT, bone scans, and nuclear radiology (therapeutic and diagnostic radiology beyond plain films), and adjunctive physiotherapy modalities unless they are provided during the same Course of Treatment and in direct support of chiropractic manipulation of the spine, joints, or related soft tissue. These exclusions align coverage to services directly connected to an authorized chiropractic Course of Treatment.

The Rider excludes care that is elective or maintenance in nature. Specifically, services provided for elective or maintenance care are not covered when the member’s treatment records indicate that they have reached maximum therapeutic benefit. Providers should document clinical progress and objective findings demonstrating ongoing therapeutic gain; absence of such documentation may result in denial of coverage for continued visits deemed maintenance or elective.

What Providers and Members Must Do

Prior Authorization

Prior Authorization Required for Chiropractic Services

All chiropractic services (except the initial evaluation) require prior authorization and utilization review approval from ASH Group as medically necessary for treatment of Musculoskeletal and Related Disorders or Pain Syndromes. ASH Group will respond within one week of receipt of the completed utilization review form; notification of the clinical decision will be mailed or faxed directly to the provider and will include the name and phone contact information of the peer-clinician who rendered the decision. Services provided during the review period will be reimbursed if determined to be medically necessary and approved by ASH Group.

Prior authorization required for all Chiropractic Services except the initial evaluation.
ASH Group response target: within one week of completed form; decision sent to provider with peer-clinician contact.

Documentation Required

Adjunctive Therapy Coverage Rules

Adjunctive modalities and procedures (for example: rehabilitative exercise, traction, ultrasound, electrical muscle stimulation, and other therapies) 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. If adjunctive therapy is provided without an adjustment, the adjunctive therapy will count as an office visit toward the benefit maximum. Exams or re-exams provided without an adjustment similarly count as an office visit toward the benefit maximum.

Adjunctive therapies must be provided during the same Course of Treatment and support chiropractic manipulation.
Adjunctive therapy or exam/re-exam without an adjustment counts as an office visit toward the Benefit Maximum.

Denial Risk

Nonparticipating Provider Exclusion

Services provided by nonparticipating providers are not covered. Members are responsible for the entire charge when care is rendered by a nonparticipating provider.

Nonparticipating provider services are excluded from coverage; member liable for full charge.

Note

EOB Financial Responsibility

When ASH Group determines that a service is not covered or otherwise creates member financial responsibility, the member will be notified via the Explanation of Benefits (EOB). The EOB is not a bill; it communicates the total amount charged, the allowed amount, the amount covered by ASH Group, and the amount the member is responsible to pay.

EOB shows: total charged, allowed amount, amount covered, and member portion.
EOB notifies member of financial responsibility when services are not covered.

Billing Rule

Claim Submission Requirements for Non‑filing Providers

For services received from a provider who does not file claims on the member's behalf, members must submit a separate claim form for each provider and include required supporting information and the itemized bill. There is no submission timeframe for commercial nonparticipating providers; for Medicare nonparticipating providers, claims must be filed within 365 days from the date of service.

Complete a separate claim form per provider (claim form available on ASHLink.com under Resources).
Include: itemized date(s) of service; diagnosis code; procedure code; billed charge per service; provider name and credentials; provider full address; provider tax ID/EIN or SSN; provider NPI.
Attach the itemized bill and mail to: American Specialty Health Group, Inc., P.O. Box 509077, San Diego, CA 92150.
No submission timeframe for commercial nonparticipating providers; Medicare nonparticipating: file within 365 days.

Note

Prior Authorization and Step Therapy — Not Stated

The policy does not state any additional prior authorization rules beyond the chiropractic-specific requirement described above, and no step therapy requirements are specified for these services.

No other prior authorization pathways are described in this section.
No step therapy requirements are stated for chiropractic or adjunctive services.

Key Terms and Service Definitions

inv-17: Acupuncture Services — definition and scope to display as field/value

Definition'Acupuncture Services' — stimulation of specific points by insertion and removal of single-use, sterilized, disposable needles and/or electrical stimulation (electroAcupuncture) to normalize physiological functions and to prevent or modify perception of pain; used to treat Musculoskeletal and Related Disorders, Nausea, and Pain.

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

Clinical use casesIndicated for treatment or diagnosis of musculoskeletal and related disorders, nausea (including post‑operative, chemotherapy, and pregnancy‑related), and pain conditions.

inv-18: Chiropractic Services — definition emphasizing manipulation and scope

Definition'Chiropractic Services' — services provided 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 servicesIncludes differential diagnostic examinations, related diagnostic x‑rays and radiological consultations when used to determine appropriateness, follow‑up office visits that include chiropractic manipulation, reevaluation, and related services.

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

inv-19: Massage Therapy Services — definition of manual techniques and treatment goals

Definition'Massage Therapy Services' — manual physical actions, primarily by hand, to treat Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, and/or lymphedema.

Techniques includedMay include techniques such as compression, stroking, joint movement, friction, vibration, and percussion.

Treatment goalsAimed at addressing myofascial/musculoskeletal conditions, improving function, and relieving pain or lymphedema-related symptoms.

inv-20: Course of Treatment — definition describing sequence of visits tied to diagnosis and treatment

Definition'Course 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.

Relationship to servicesAdjunctive modalities (e.g., physiotherapy, acupuncture adjuncts, rehabilitative exercise) are covered only when provided during the same Course of Treatment and in support of the primary therapy (for chiropractic: in support of chiropractic manipulation).

Use for evaluation and follow‑upEstablished patient exams and follow‑up visits must occur within the Course of Treatment and are used to assess need to initiate, continue, extend, or change the Course of Treatment.

Diagnosis code	Required on member-submitted claim forms
Procedure code	Required on member-submitted claim forms
Provider NPI	Required on member-submitted claim forms

Itemized date(s) of service	Required on member-submitted claim forms
Billed charge per service	Required on member-submitted claim forms
Provider's name and credentials	Required on member-submitted claim forms
Provider's full address	Required on member-submitted claim forms
Provider's tax ID/EIN/SSN	Required on member-submitted claim forms

OpenPayer

Complementary Care Rider — coverage for acupuncture, chiropractic, massage, and related services

What the Rider Covers

Billing and Claim Codes

What Providers and Members Must Do

Key Terms and Service Definitions

Context and Rationale

Policy Changes and History