CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chiropractic care payment and coverage policy

Policy governing reimbursement and coverage rules for chiropractic services provided to Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), Integrity, and Commercial lines of business.

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 rendering chiropractic services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12maximum commercial visits per plan year

no annual limitIntegrity line visits

1max treatments per day reimbursed

98940-98942primary CMT codes listed

97010-97755additional modality codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and exclusions

Coverage varies by line of business (Medicaid/Integrity/Commercial) and requires medical necessity per listed sources.

All services must be medically necessary; Neighborhood may reference LCDs, NCDs, InterQual, RI EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

Line-specific coverage rules

Integrity/Medicaid: No annual visit limit for Integrity; treatment is based on medical review; reimbursement limited to not more than one treatment per day; if a chiropractor orders/takes/interprets X‑rays or other diagnostic procedures to demonstrate subluxation, the X‑ray may be used for documentation but those services are not covered or payable when furnished by the chiropractor.
Commercial: Chiropractic benefit limited to 12 visits per plan year; if a chiropractor orders/takes/interprets X‑rays or other diagnostic procedures to demonstrate subluxation the images may be used for documentation but those services are not covered or payable when furnished by the chiropractor; maintenance therapy, treatment for non‑neuromusculoskeletal conditions, care of asymptomatic persons, additional treatment after 30 days of modified treatment, and continued treatment with no documented improvement after an initial two weeks are excluded.

Treatment frequency limits: Not more than one treatment per day will be reimbursed (applies to Medicare/Integrity as noted); Integrity has no annual visit limit; Commercial is limited to 12 visits per plan year.

Maintenance and intensive care exclusions: Maintenance therapy is excluded when ongoing care is supportive rather than corrective (defined as services intended to prevent disease, promote health, prolong quality of life, or maintain/prevent deterioration when further clinical improvement is not reasonably expected). Intensive Care concepts that include multiple daily visits and room/ward fees are excluded; room/ward fees are not covered and reimbursement is limited to not more than one treatment per day.

Documentation and claims: Neighborhood may request medical records to support billed services and medical necessity and follows CMS documentation standards; claims are subject to contractual timely‑filing rules and standard coding requirements (CPT, ICD‑10‑CM, HCPCS); inclusion of a code does not guarantee payment.

Billed codes, limits, and coding guidance

Chiropractic manipulative treatment (CMT) 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

Modalities and therapeutic procedure codes (for chiropractors with physiotherapy license where applicable)mixedCovered

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
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended)
97016	Application of a modality to 1 or more areas; vasopneumatic devices
97018	Application of a modality to 1 or more areas; paraffin bath
97022	Application of a modality to 1 or more areas; whirlpool

Modalities and therapeutic procedure codes (for chiropractors with physiotherapy license where applicable)mixedCovered

97024	Application of a modality to 1 or more areas; diathermy (eg, microwave)
97026	Application of a modality to 1 or more areas; infrared
97028	Application of a modality to 1 or more areas; ultraviolet
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033	Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97034	Application of a modality to 1 or more areas; contrast baths, each 15 minutes
97036	Application of a modality to 1 or more areas; Hubbard tank; each 15 minutes
97039	Unlisted modality (specify type and time if constant attendance)
97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement; balance, coordination, kinesthetic sense, posture, and/or proprioception

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treatments_per_day_limit

Daily treatment reimbursement limitNot more than one treatment per day reimbursed.

ApplicabilityStated under Integrity line and aligns with Medicare reimbursement limits.

Effect on intensive care billingRoom/ward fees for intensive care are not covered; reimbursement limited to one treatment per day.

commercial_visit_limit

Commercial visit limitThe chiropractic medicine benefit is limited to twelve (12) visits per plan year.

X-rays/diagnostics when ordered by chiropractorX-rays or other diagnostic procedures ordered, taken, or interpreted by a chiropractor may be used for documentation but are not covered or payable when furnished by the chiropractor.

Exclusions related to maintenance therapyMaintenance therapy is excluded under the Commercial line (see Maintenance Therapy definition).

Provider responsibilities and billing requirements

Prior Authorization

Prior authorization and verification — action required

Providers must verify member eligibility, coverage and any authorization requirements prior to rendering services. Prior authorization may be required for certain services — see Neighborhood's Prior Authorization Reference page and applicable Clinical Medical Policies for details. Confirm any plan-specific prerequisites and obtain authorization where required to avoid claim denials or delays.

Verify eligibility and benefits before scheduling or providing services
Obtain prior authorization when required by the plan or Clinical Medical Policy
Contact Provider Services at 1-800-963-1001 with authorization questions

Documentation Required

Documentation requests — keep and produce records

Neighborhood reserves the right to request medical records and supporting documentation for any billed service. Medical records must substantiate the services billed and demonstrate medical necessity. Documentation must meet CMS standards for proper medical record keeping; maintain legible, dated, and signed records including history, exam, findings, treatment plan, and rationale for services provided.

Retain complete medical records at the time of service
Provide records promptly upon Neighborhood's request to support claims and medical necessity
Include clinical notes, test results, imaging, orders, and authorizations as applicable

Billing Rule

Claim submission and coding standards — billing rules

Submit complete, accurate claims in accordance with contractual timely filing rules. Use current coding standards: CPT (AMA), ICD-10-CM, and HCPCS Level II. Ensure codes, modifiers, dates of service, member identifiers, and place of service are correct to prevent denials or payment delays.

Follow AMA CPT, ICD-10-CM, and HCPCS coding guidelines
Apply appropriate modifiers and place of service codes
Adhere to payer contractual timely filing requirements

Key definitions

Maintenance Therapy

DefinitionMaintenance Therapy: services that seek to prevent disease, promote health, prolong and enhance quality of life, or maintain or prevent deterioration of a chronic condition when further clinical improvement cannot reasonably be expected.

Clinical intentApplied when ongoing care becomes supportive rather than corrective in nature.

Coverage implicationMaintenance therapy is listed as an exclusion under both Integrity and Commercial lines where noted.

Intensive Care (chiropractic)

DefinitionIntensive Care (chiropractic context): an approach involving multiple daily visits (as many as four or five in a single day), often with patients confined and subject to room/ward fees.

Room/ward feesRoom or ward fees charged in this context are not covered.

Reimbursement limitationReimbursement under Medicare/Integrity will be limited to not more than one treatment per day despite multiple visits.

OpenPayer

Chiropractic care payment and coverage policy

Coverage rules and exclusions

Billed codes, limits, and coding guidance

Provider responsibilities and billing requirements

Key definitions