Billing guide · Step 03 of 04
Check chiropractic coverage before the visit.
Many front-end denials in a chiropractic office trace back to a question nobody asked at intake: is this plan active, does it cover chiropractic, how many visits are left, and who actually manages the benefit? An electronic eligibility check answers most of them in seconds.
What to check, every time
A chiropractic coverage check answers more questions than “is the card active?” Here is the list, and why each one matters:
| Check | Why it matters |
|---|---|
| Coverage active on the date of service | A plan that ended last month returns CO-27 on every visit since. |
| The member’s details, exactly | Subscriber ID, name and date of birth that do not match the payer’s file get the claim rejected before anyone looks at it. |
| A chiropractic benefit | Some plans exclude chiropractic altogether, or cover only some services. |
| Your network status for this plan | In network for one product is not always in network for all of them. |
| Visit limit and visits used | Visits past the limit come back as 119, the benefit maximum. |
| Deductible left, copay or coinsurance | You can tell the patient what they will owe before the visit, and collect the copay at check-in. |
| Authorization or a visit plan | Some plans require one before visits, or after a set number of them. Missing it returns CO-197. |
| Who manages the chiropractic benefit | If a separate company manages it, the claim may go there, not to the name on the card. |
| Other coverage | A second plan changes which payer is billed first. Getting the order wrong returns CO-22. |
The guide to chiropractic denial codes covers each of those codes when one slips through.
The electronic eligibility check
Your EHR or clearinghouse sends the payer an eligibility request, an X12 270, and gets back a 271 response, usually in seconds. For chiropractic, ask for service type code 33, Chiropractic. Under the CAQH CORE operating rules, health plans must return chiropractic benefits in the eligibility response, including the deductible, copay and coinsurance and the deductible remaining, with in-network and out-of-network amounts reported separately. Visit limits are not on that required list. Some payers include them; many do not.
Read the chiropractic section of the response, not only the plan’s general medical benefits. The deductible, copay and visit limit for chiropractic can differ from the plan’s office-visit numbers. When the response leaves out the visit limit or the visits used, check the payer’s portal or call, and write down who you spoke to and the reference number.
An eligibility response is not a promise of payment. CMS says so about its own eligibility service, and commercial payers say the same: benefits are decided when the claim arrives, under the plan’s terms on the date of service. Save what the response said and when you checked.
Visit limits
Many plans cap chiropractic visits per year. Visits at another chiropractic office usually count toward the same cap, and the payer may not have processed them yet when you check. Three habits keep visit limits from turning into denials:
- Ask every new patient whether they have seen another chiropractor this plan year.
- Keep your own count of visits per patient per plan year, and compare it with the payer’s.
- Tell the patient before the last covered visit, not after the first denied one, and agree in advance how further visits will be paid, within what your contract allows.
When another company manages the benefit
Some health plans hand their chiropractic benefit to a specialty company. American Specialty Health, for instance, provides musculoskeletal provider networks to health plans and employers, and Optum Physical Health contracts with chiropractors for the plans it serves. When a separate company manages the benefit, it often sets its own rules for authorizations or visit plans and may take the claims itself. Sending the claim to the name on the card instead can return CO-109: not covered by this payer, send it to the correct one. The eligibility response, the back of the card or the payer’s portal usually names the manager.
Blue plans from other states
A patient with a Blue plan from another state is usually still your local Blue plan’s claim. Under the BlueCard program, you file with your local plan, which routes the claim to the right plan using the three-character prefix on the member’s ID card. Ask your local plan how it handles eligibility for out-of-area members. Federal Employee Program and Medicare Advantage members are handled separately from BlueCard.
Medicare patients
For a Medicare patient, add one question at intake: is this visit active treatment, or maintenance? Medicare pays for chiropractic manipulation only as active, corrective treatment. When your provider expects a visit to be denied as maintenance, the patient signs an Advance Beneficiary Notice before the visit, not after. The guide to chiropractic denial codes covers the AT and GA modifiers.
When to check
- At scheduling for every new patient, so a coverage problem surfaces before they arrive.
- Before the first visit, with the card in hand.
- At the start of each month for patients in an active plan of care, and whenever a patient mentions a new job, a new card or a birthday that moves them off a parent’s plan.
- At the start of the plan year, when deductibles reset and visit counts start over.
Who owns a coverage problem
Your front desk does. A coverage check is part of intake, and only your office can ask the patient for a new card or explain a plan change. When Claims Native bills for your practice, we check the patient’s coverage before we file, so a coverage problem shows up before the claim goes out, not weeks later on a denial. Problems that start at intake, such as wrong insurance on file or no coverage on the date of service, we report to you, and your office owns the fix.
Sources
- X12, 270/271 eligibility example. Service type code 33, Chiropractic.
- CAQH CORE, Eligibility and benefits 270/271 data content rule.
- CMS, HETS 270/271 companion guide.
- Blue Cross and Blue Shield of Oklahoma, Eligibility and benefits.
- American Specialty Health, Specialty health services.
- Optum Physical Health, Provider credentialing request.
- Arkansas Blue Cross and Blue Shield, BlueCard program.
- Blue Cross and Blue Shield of Illinois, BlueCard program.