CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Complementary and Alternative Medicine (CAM) services reimbursement

Governs reimbursement for select complementary and alternative medicine services (chiropractic and acupuncture) for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyComplementary and Alternative Medicine (CAM) services reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must verify eligibility, coverage and authorization criteria prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12chiropractic annual limit

12acupuncture annual limit

90claim timeframe (days)

97810-14,98940-42listed procedure codes

Coverage Criteria for CAM Services

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ALL of the following

Covered services
- Chiropractic services
- Acupuncture services
All services must be medically necessary to qualify for reimbursement; Neighborhood may use NCD, LCD, InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.
Providers must verify eligibility, coverage and authorization criteria prior to rendering services; refer to the specific Prior Authorization Reference page and Neighborhood Clinical Medical Policies for details.
Benefit limits: chiropractic services are limited to 12 visits per rolling year; acupuncture services are limited to 12 visits per rolling year.

Acupuncture coverage criteria

Covered for the diagnoses and within the visit limits below:

ALL of the following

Acupuncture services are covered only for the following diagnoses: chronic low back pain, fibromyalgia, and migraine.
Acupuncture services are limited to 12 visits per rolling year.
Massage services are excluded from coverage due to insufficient medical necessity criteria; massage is not an approved indication for acupuncture coverage.

Procedure Codes and Visit Limits

Acupuncture and Chiropractic CPT/HCPCS equivalent codesmixedCovered

97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation; each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary).
97813	Acupuncture, 1 Or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient; with re-insertion of needle(s) (List separately in addition to code for primary procedure).
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.

Chiropractic visit limit

Limit12 visits per rolling year

Applies toChiropractic services (all covered members)

Timeframe definitionRolling 12-month year (limits apply across any consecutive 12-month period)

Reference sectionBenefit Limitations and Exclusions

Acupuncture visit limit

Limit12 visits per rolling year

Applies toAcupuncture services (covered for specified diagnoses)

Covered diagnosesChronic low back pain; Fibromyalgia; Migraine

Reference sectionBenefit Limitations and Exclusions

Provider Verification and Authorization Requirements

Prior Authorization

Prior verification and authorization required

It is the provider’s responsibility to verify member eligibility, coverage and any authorization requirements before rendering services. Providers should consult the specific Prior Authorization reference page and Neighborhood’s Clinical Medical Policies, and may contact Provider Services at 1-800-963-1001 for additional details.

Verify member eligibility and coverage prior to providing services.
Confirm whether prior authorization is required via the Prior Authorization reference page.
Refer to Neighborhood’s Clinical Medical Policies for applicable coverage/authorization rules.
Contact Provider Services at 1-800-963-1001 for assistance.

Definitions Related to CAM

Complementary and Alternative Medicine (CAM) services

DefinitionCAM services are treatment from a chiropractor, acupuncturist, and/or massage therapist.

ScopeIncludes chiropractic and acupuncture services addressed in this policy, and massage therapy (see exclusion).

Policy statement sourcePolicy Statement — Complementary and Alternative Medicine (CAM) services.

Massage therapy

Coverage stanceExcluded from coverage due to insufficient medical necessity criteria

ServiceMassage therapy

Source notePolicy Statement and Benefit Limitations and Exclusions indicate massage services are excluded.