130 CMR 441.00 — Chiropractor Services

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

4. Program Regulations

130 CMR 441.00 Chiropractor Services

441.401 Introduction ............................................................................................................. 4-1

441.401: Introduction ............................................................................................................. 4-1

441.402 Definitions ................................................................................................................. 4-1

441.402: Definitions ................................................................................................................. 4-1

441.403 Eligible Members ..................................................................................................... 4-1

441.403: Eligible Members ..................................................................................................... 4-1

441.404 Provider Eligibility ................................................................................................... 4-2

441.404: Provider Eligibility ................................................................................................... 4-2

441.405 Out-of-state Chiropractor Services ........................................................................... 4-2

441.405: Out-of-state Chiropractor Services ........................................................................... 4-2

441.406 Payable Services ...................................................................................................... 4-2

441.406: Payable Services ...................................................................................................... 4-2

441.407 Service Limitations ................................................................................................. 4-3

441.407: Service Limitations ................................................................................................. 4-3

441.408 Reporting Requirements .......................................................................................... 4-3

441.408: Reporting Requirements .......................................................................................... 4-3

441.409 Radiology Services ................................................................................................... 4-3

441.409: Radiology Services ................................................................................................... 4-3

441.410 Nonpayable Services ............................................................................................... 4-4

441.410: Nonpayable Services ............................................................................................... 4-4

441.411 Prior Authorization .................................................................................................. 4-4

441.411: Prior Authorization .................................................................................................. 4-4

441.412 Record-keeping Requirements ................................................................................ 4-5

441.412: Record-keeping Requirements ................................................................................ 4-5

441.413 Rates of Payment ..................................................................................................... 4-5

441.413: Rates of Payment ..................................................................................................... 4-5 (130 CMR 441.414 through 441.419 Reserved)

441.420 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ........... 4-6

441.420: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ........... 4-6

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-1 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.401 Introduction

441.401: Introduction

130 CMR 441.000 establishes the requirements for the provision and payment of chiropractor services under MassHealth. All chiropractors participating in MassHealth must comply with MassHealth regulations including, but not limited to, 130 CMR 441.000 and 130 CMR 450.000: Administrative and Billing Regulations.

441.402 Definitions

441.402: Definitions

The following terms used in 130 CMR 441.000 have the meanings given in 130 CMR 441.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 441.402 is not determined by these definitions, but by application of 130 CMR 441.000 and 130 CMR 450.000: Administrative and Billing Regulations.

Chiropractic Manipulative Treatment – the correction of misalignments, subluxations, or segmental joint dysfunction of the bony articulations of the vertebral column, the pelvis, and adjacent areas.

Chiropractor – one who is licensed to practice chiropractic manipulation to correct interference with spinal nerves by adjusting the spinal column.

Community Health Center (CHC) – a participating community health center enrolled as a MassHealth CHC provider under 130 CMR 405.000: Community Health Center Manual.

Office Visit – a visit by a MassHealth member to a chiropractor's office for evaluation and management services performed by a MassHealth-enrolled chiropractor, or to a community health center (CHC) for evaluation and management services performed by a qualified chiropractor employed by, or under contract with, a MassHealth-enrolled CHC. These services do not include chiropractic manipulative treatment.

Subluxation – a segmental joint dysfunction, misalignment, fixation, or abnormal spacing of the vertebrae.

441.403 Eligible Members

441.403: Eligible Members

(A) (1) MassHealth Members. The MassHealth agency pays for chiropractor services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105: Coverage Types specifically states, for each coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program.

(B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107: Eligible Members and the MassHealth Card.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-2 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.404 Provider Eligibility

441.404: Provider Eligibility

The MassHealth agency pays only chiropractors who are participating in MassHealth on the date of service. Chiropractors must meet the following eligibility requirements.

(A) In-state Providers. To be eligible to participate in MassHealth, an in-state chiropractor must (1) be licensed by the Massachusetts Board of Registration of Chiropractors; (2) be an active MassHealth provider; and (3) participate in the Medicare program as a chiropractor.

(B) Out-of-state-Providers. To be eligible to participate in MassHealth, an out-of-state chiropractor must (1) obtain a MassHealth provider number and maintain active provider status; (2) participate in his or her own state's Medicaid program; (3) be currently licensed as a chiropractor in his or her own state, or in a state that does not license chiropractors, be legally authorized to perform the services of a chiropractor in that state; and (4) participate in the Medicare program as a chiropractor.

441.405 Out-of-state Chiropractor Services

441.405: Out-of-state Chiropractor Services

(A) The MassHealth agency pays out-of-state chiropractors for covered services provided to an eligible MassHealth member when the chiropractor practices in a community of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont that is within 50 miles of the Massachusetts border and he or she provides covered services to a member who resides in a Massachusetts community near the border of the chiropractor's state. The out-of-state chiropractor's office must be more accessible to the member than the office of an in-state chiropractor who participates in MassHealth.

(B) Prior authorization is required from the MassHealth agency before a chiropractor whose office is located in a community more than 50 miles from the Massachusetts border may provide covered chiropractor services to a member. Prior authorization will not be granted if the MassHealth agency determines that the chiropractor's office is less accessible to the member than the office of any other chiropractor participating in MassHealth. All requests for prior authorization must be submitted in accordance with the instructions found in Subchapter 5 of the Chiropractor Manual. The MassHealth agency does not pay for covered services provided at a site more than 50 miles from the Massachusetts border unless the chiropractor obtains prior authorization from the MassHealth agency before the delivery of service. The MassHealth agency does not grant retroactive requests for prior authorization.

441.406 Payable Services

441.406: Payable Services

The MassHealth agency pays chiropractors (or the CHC in the case of chiropractor services provided on site at the CHC by a CHC-employed or contracted chiropractor) only for the following services as specified in Subchapter 6 of the Chiropractor Manual, subject to the restrictions and limitations specified in 130 CMR 441.000 for chiropractic manipulative treatment, office visits, and radiology services.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-3 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.407 Service Limitations

441.407: Service Limitations

(A) The MassHealth agency pays for medically necessary chiropractic treatment related to a neuromusculoskeletal condition only. Services must have a direct therapeutic relation to the patient’s condition and must be provided by the chiropractor in the chiropractor's office, or in the case of a MassHealth-enrolled CHC billing for chiropractor services provided on site by a CHC- employed or contracted chiropractor, at the CHC. Conditions that may be considered to provide therapeutic grounds for chiropractic treatment include functional disabilities of the spine, nerve pains, and documented incidents that produce sprains and strains of the spinal axis.

(B) The MassHealth agency does not pay for both an office visit and chiropractic manipulative treatment provided to a MassHealth member on the same day. This limitation does not apply to a significant, separately identifiable office visit provided by the same chiropractor on the same day of the procedure or other service.

(C) The MassHealth agency limits payment for chiropractor services to a total of 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments, up to a total of 20, per member per calendar year, without prior authorization. Office visits and chiropractic manipulative treatments above these limits require prior authorization in accordance with 130 CMR 441.411. (See 130 CMR 441.409 for limits on radiology services.)

441.408 Reporting Requirements

441.408: Reporting Requirements

Chiropractors who furnish services to MassHealth members must report the results of these services to the member’s primary-care provider or PCC in writing. The chiropractor may report the results of treatment initially by telephone, but he or she must then submit a written report.

441.409 Radiology Services

441.409: Radiology Services

(A) The MassHealth agency pays for radiology services when the services are needed to confirm the existence of a neuromusculoskeletal condition requiring treatment.

(B) Payment for radiology services is not included in the fees for office visits or chiropractic manipulative treatment and must be claimed separately.

(C) All equipment used in providing radiology services must be inspected and approved by the Massachusetts Department of Public Health.

(D) The MassHealth agency pays chiropractors for only those radiology services provided in the chiropractor's office and only when the films are developed and read in the chiropractor's office; provided, however, that in the case of a MassHealth CHC provider that bills for chiropractor services provided on site by a CHC-employed or contracted chiropractor, the radiology services must be provided in, and the films must be developed and read in, the CHC.

(E) All X-rays must be labeled with the member's name, date of the exam, and the nature of the exam and must be maintained in the member’s medical record in accordance with 130 CMR 441.412.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-4 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.410 Nonpayable Services

441.410: Nonpayable Services

Nonpayable services include, but are not limited to, the following:

(A) the chiropractic treatment of diseases and pathological disorders other than those related to a neuromusculoskeletal condition (including, but not limited to, rheumatoid arthritis, muscular dystrophy, multiple sclerosis, pneumonia, and emphysema);

(B) chiropractic manipulative treatment, office visits, and radiology services not personally provided by the chiropractor, in accordance with 130 CMR 450.301: Claims;

(C) chiropractor services provided in settings other than the chiropractor's office, or in the case of a MassHealth CHC provider billing for chiropractor services provided on site by a CHC-employed or contracted chiropractor, at a CHC. Nonpayable settings include, but are not limited to, inpatient or outpatient hospitals, nursing facilities, rest homes, and the member's home;

(D) laboratory services;

(E) orthotic devices, corrective devices, and orthopedic appliances;

(F) research, or experimental, unproven, or medically unnecessary procedures or treatment;

(G) maintenance therapy, that is, chiropractic manipulative treatment to maintain health or prevent regression when the member is no longer suffering or presenting symptoms;

(H) supportive services such as, but not limited to, nutritional counseling, educational services, and printed materials;

(I) physiotherapy, physical therapy, muscular stimulation, heat packs, or massage; and

(J) vitamins, minerals, food supplements, or other such supplies.

441.411 Prior Authorization

441.411: Prior Authorization

(A) Services that Require Prior Authorization. The MassHealth agency requires that the chiropractor obtain prior authorization as a prerequisite to payment for more than 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments, above a total of 20, per member per calendar year.

(B) Submission Requirement. The chiropractor must submit all prior-authorization requests in accordance with the billing instructions in Subchapter 5 of the Chiropractor Manual. Prior authorization determines only the medical necessity of the authorized service, and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. See 130 CMR 450.303: Prior Authorization for additional information about prior authorization.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-5 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.412 Record-keeping Requirements

441.412: Record-keeping Requirements

(A) Federal and state regulations require that all MassHealth providers maintain complete written medical records of all patients who are MassHealth members. Medical records must comply with the provisions of 233 CMR 4.04: Insurance Requirements for Limited Liability Companies and Limited Liability Partnerships. All records must be kept for a minimum of six years after the date of service. Payment for maintaining the member's medical record is included in the fee for chiropractic services. Each medical record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery in accordance with 130 CMR 450.000: Administrative and Billing Regulations.

(B) The medical records must contain the following: (1) MassHealth member identification, including name, address, telephone number, date of birth, and the MassHealth member’s identification number; (2) a complete medical history; (3) examination results, including a description of the chief complaint and diagnosis; (4) a written referral from the member's primary-care provider or PCC; (5) copies of X-rays, with interpretations; (6) copies of all prior-authorization requests for out-of-state services; (7) the date and nature of each visit, including a complete description of services furnished, written and signed by the chiropractor; (8) when more than one visit is indicated, a treatment plan for future visits written and signed by the chiropractor, which is updated on an ongoing basis to reflect changes in the member’s presenting symptoms; (9) upon completion of treatment, a summary of the treatment and the member's current condition; (10) recommendations for additional treatment, signed and dated by the chiropractor; and (11) if the medical record or any component included therein is released for use by another party, the medical record must also contain a release form signed by the member. Release of the medical record to MassHealth for authorized use does not require the member's consent.

441.413 Rates of Payment

441.413: Rates of Payment

(A) The Executive Office of Health and Human Services (EOHHS) determines the payment rates for chiropractor services. Payment is subject to the conditions, exclusions, and limitations set forth in 130 CMR 441.000. Payment for a service will be in accordance with 101 CMR 317.00: Medicine or 101 CMR 318.00: Radiology.

(B) The payment rates established for chiropractor services include payment for all aspects of service delivery including administrative costs. Providers may not bill separately for services such as, but not limited to the following: (1) telephone contacts; (2) information and referral services; and (3) recordkeeping.

(130 CMR 441.414 through 441.419 Reserved)

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-6 Chiropractor Manual Transmittal Letter CRP-24 Date 03/22/19

441.420 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

441.420: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

The MassHealth agency pays for all medically necessary chiropractor services for EPSDT- eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 441.000, and with prior authorization.

REGULATORY AUTHORITY

130 CMR 441.000: M.G.L. c 118E, §§ 7 and 12.