CurrentmhnPolicy N/A

Acupuncture and Chiropractic Services — Coverage Criteria

Defines coverage, limits, exclusions, and administrative details for acupuncture and chiropractic care provided through ASH Plans in partnership with Health Net, affecting members enrolled in the plan.

Policy Summary

Payermhn

PolicyAcupuncture and Chiropractic Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and visit limits with ASH Plans and the member's Evidence of Coverage before scheduling; up to 20 visits per calendar year allowed per therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20maximum visits per calendar year (each therapy)

$20acupuncture office visit copayment

$5chiropractic office visit copayment

TTY 711customer service accessibility

Coverage Criteria for Acupuncture and Chiropractic

Acupuncture Coverage: Service is provided by a participating ASH Plans acupuncturist; service is for a covered condition (e.g., headache; back or neck pain; shoulder, hip, and knee joint pain; osteoarthritis and other arthritic pain; pain involving other joints and associated soft tissues; postoperative nausea and vomiting (PONV), nausea associated with pregnancy, or nausea associated with chemotherapy); care is within the plan limit of up to 20 visits per calendar year; applicable office visit copayment is paid.up to 20 visits/year

No PCP referral required; verify member's Evidence of Coverage for plan-specific copayments and visit variations

inv-02: Chiropractic — Covered with criteria

Chiropractic care is covered when services are for neuromusculoskeletal disorders and within visit limits

Chiropractic Coverage: Service is provided by a participating ASH Plans chiropractor; service is for a covered neuromusculoskeletal condition (e.g., degenerative joint diseases/arthropathies; neurological conditions; inflammatory disorders; sprain/strain injuries to the spine and extremities; intervertebral disc injuries/disorders; headaches; muscular spasms and myalgias); care is within the plan limit of up to 20 visits per calendar year; applicable office visit copayment is paid.up to 20 visits/year

No PCP referral required; verify member's Evidence of Coverage for plan-specific copayments and visit variations

Excluded items include devices and personal/comfort items (for example, air conditioners, air purifiers, therapeutic mattresses, appliances, and other comfort items), vitamins, minerals, and nutritional supplements, and durable medical equipment.

Diagnostic imaging and similar studies are excluded: diagnostic scanning, MRI, CT scans, and thermography are not covered under these benefit sections.

Also excluded are exams and treatments that are unrelated to musculoskeletal, neuromusculoskeletal, pain, nausea, or other covered conditions described for acupuncture and chiropractic services.

Services or supplies excluded under the acupuncture or chiropractic care programs are not covered under these benefit sections and may only be covered under the medical benefits portion of the member's plan when applicable; providers and members should consult the member's Evidence of Coverage (EOC) for plan-specific rules and coverage pathways.

When an item or service falls within the listed limitations and exclusions (for example, diagnostic imaging or comfort items), coverage decisions may be handled through the plan's medical benefits processes rather than through the acupuncture or chiropractic benefit.

For questions about coverage exceptions or to determine whether an excluded service could be payable under another portion of the member's benefits, contact the plan or refer the member to their EOC; customer service information (including TTY 711) is available in plan materials.

Provider Responsibilities and Billing Rules

Note

Referral Requirement

No PCP referral is required to see a participating ASH Plans chiropractor or acupuncturist. Members may consult their PCP if they wish, but a referral is not required for participating providers.

Note

Member / EOC Consultation

Advise members to consult their Evidence of Coverage (EOC) for full benefit details and any plan-specific variations. Services or supplies excluded under the chiropractic or acupuncture program may be covered under the medical benefits portion of the member's plan; members should contact customer service for clarification. For assistance call Health Net at 1-800-275-4737 (TTY: 711). Office hours Oct 1–Mar 31: daily 8 a.m.–8 p.m.; Apr 1–Sep 30: Mon–Fri 8 a.m.–8 p.m. A messaging system is used after hours, weekends, and federal holidays.

Denial Risk

Exclusions That May Trigger Denial

The following exclusions and inconsistencies may trigger claim denial under the chiropractic and acupuncture programs. Confirm coverage under the member's EOC or medical benefits before billing:

Devices, personal and comfort items (e.g., therapeutic mattresses, air purifiers, air conditioners).
Vitamins, minerals, nutritional supplements.
Durable medical equipment, appliances, and other non-covered supplies.
Diagnostic scanning, MRI, CT scans, and thermography.
Exams and treatments not directed to musculoskeletal, neuromusculoskeletal, pain, nausea, or other covered conditions as defined for acupuncture/chiropractic services.
Services or supplies inconsistent with the program's limitations and exclusions (see member EOC).

Clinical Indications and Definitions

Covered clinical indications

HeadacheCovered as a qualifying indication for acupuncture and chiropractic services

Back or neck painCovered for treatment under both acupuncture and chiropractic programs

Joint pain (shoulder, hip, knee) and osteoarthritis (OA)Included among covered conditions for musculoskeletal care

Postoperative nausea and vomiting (PONV), pregnancy- or chemotherapy-associated nauseaCovered indication for acupuncture care; may require co-management with the member's provider

Degenerative joint disease, neurological conditions, and inflammatory disordersCovered indications for chiropractic services addressing neuromusculoskeletal disorders

Sprain/strain and intervertebral disc injuries; muscular spasms/myalgiasCovered for evaluation and treatment within plan visit limits

Background

This policy defines coverage for acupuncture and chiropractic services provided through ASH Plans in partnership with Health Net for enrolled members. It covers care for musculoskeletal, neuromusculoskeletal, and related pain conditions—such as headaches, back or neck pain, joint pain, osteoarthritis, sprain/strain injuries, intervertebral disc disorders, and muscular spasms—as well as certain causes of nausea (for example, postoperative or chemotherapy-associated nausea) when those indications are listed in the covered conditions.

Coverage is limited to services delivered by participating ASH Plans providers and is subject to administrative limits: up to 20 visits per calendar year for each therapy (acupuncture and chiropractic) and the applicable office visit copayment per visit. Providers should verify member eligibility, visit limits, and any plan-specific variations by consulting the member's Evidence of Coverage (EOC) before scheduling services.

This policy does not cover treatments unrelated to the listed indications; exclusions include items such as diagnostic imaging, durable medical equipment, and comfort items. No PCP referral is required for members to receive care from a participating acupuncturist or chiropractor, but standard plan rules and member cost-sharing (copayments) apply.