CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chiropractic care payment and coverage policy

Defines coverage, coding, documentation, and billing rules for chiropractic services provided to Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChiropractic care payment and coverage policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and prior authorization requirements before providing chiropractic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12commercial plan annual chiropractic visit limit

1/daylimit of one chiropractic treatment code unit per day

No annual limitIntegrity plan visit limit

AuditableClaims subject to audit

LCD/NCD/InterQualSources used to determine medical necessity

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Plan-specific Coverage Rules

Plan-specific coverage rules

Coverage, limits, and exclusions differ by plan (Medicaid/Integrity/Commercial):

ANY of the following

Commercial
- Covered services: Chiropractic treatment services and chiropractic evaluation & management services; initial evaluation to beginning chiropractic treatment is covered when billed with the appropriate E&M code.
- Visit limit: The chiropractic medicine benefit is limited to twelve (12) visits per plan year.
- Daily limit: Not more than one treatment per day (one unit of chiropractic manipulative treatment codes).
- Excluded services: Maintenance therapy (see definition); treatment for non-neuromusculoskeletal conditions; asymptomatic persons or persons without an identifiable clinical condition; additional treatment after 30 days of modified treatment without improvement; additional treatment with no documented improvement after the initial two weeks; room/ward fees for intensive care; diagnostic/therapeutic services (including X-rays) ordered or furnished by the chiropractor are not covered for payment though X-rays may be used for documentation.
Integrity
- Covered services: Chiropractic treatment services, chiropractic evaluation & management services, and initial evaluation when billed with appropriate E&M code.
- Visit limit: No annual limit (no annual limit placed on visits).
- Daily limit: Not more than one treatment per day.
- Excluded services: Maintenance therapy; room/ward fees for intensive care; treatment for non‑musculoskeletal conditions; diagnostic/therapeutic services (including X-rays) ordered or furnished by the chiropractor are not covered for payment though X-rays may be used for documentation.
Medicaid
- Scope: Policy applies to Medicaid members excluding Extended Family Planning (EFP); medical necessity criteria apply per referenced sources (LCD/NCD/InterQual/EOHHS/CMP).

Note: Maintenance Therapy is defined as services that seek to prevent disease, promote health, prolong or enhance quality of life, or maintain/prevent deterioration of a chronic condition; when further clinical improvement cannot reasonably be expected and care is supportive rather than corrective, treatment is considered maintenance therapy and is excluded (per plan rules).

Approved Chiropractic Codes and Billing Limits

Approved chiropractic and adjunct therapy codesCPTCovered

98940	Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941	Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942	Chiropractic manipulative treatment (CMT); spinal, 5 regions
97010	Application of a modality to 1 or more areas; hot or cold packs
97012	Application of a modality to 1 or more areas; traction, mechanical
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97140	Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
G0283	Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a plan of care therapy

Units per day — Chiropractic CMT codes

Units per dayOne unit of listed chiropractic CMT codes (e.g., 98940, 98941, 98942) allowed per day

Applicable codes (examples)98940, 98941, 98942 are CMT codes referenced for the one-unit-per-day limit

Additional modality codesAdjunct modality codes (e.g., 97010, 97012, 97014/ G0283) are listed separately and subject to policy coding rules

Prior Authorization, Eligibility, and Documentation

Prior Authorization

Prior authorization and eligibility verification

Providers must verify member eligibility, benefits, and any required prior authorizations before delivering services. Prior authorization is required when specified by Neighborhood Health Plan of Rhode Island clinical policies or the Prior Authorization Reference page. Verify authorization requirements and obtain approvals in advance to avoid claim denials or delayed payment.

Contact Provider Services at 1-800-963-1001 for questions about prior authorization or coverage.
Check Neighborhood's Prior Authorization Reference page and applicable Clinical Medical Policies for procedure- and service-specific requirements.

Documentation Required

Documentation requests and audits

Neighborhood reserves the right to request medical records and supporting documentation for any billed service and to perform audits to validate billed services and medical necessity. Medical record documentation must support the services billed and meet CMS documentation standards. Failure to provide requested records may result in claim adjustment, denial, or recovery.

Retain complete clinical records that justify the diagnosis, treatment, and services billed.
Provide records within the timeframe requested during an audit or documentation review to avoid administrative actions.
All services billed are subject to audit and reimbursement is contingent on member eligibility, benefit coverage, and documentation supporting medical necessity.

Terms and Definitions

Maintenance Therapy — definition and note

DefinitionMaintenance Therapy: services that seek to prevent disease, promote health, prolong/enhance quality of life, or maintain/prevent deterioration of a chronic condition; considered maintenance when further clinical improvement cannot reasonably be expected and care is supportive rather than corrective.

Coverage implicationMaintenance therapy is excluded from coverage for Commercial plans (identified as an excluded service).

Clinical thresholdClassified as maintenance when ongoing care yields supportive rather than corrective benefit and no further clinical improvement is reasonably expected.

Related exclusionsMaintenance therapy exclusion is listed alongside other commercial exclusions such as treatment for non-neuromusculoskeletal conditions and asymptomatic persons.