CNC/pAYOR Policies

The CNC policies were developed by our CQI Committee, in conjunction with our managed care partners, to assist you in meeting the high standards in documentation, coding and billing established for all healthcare professionals.  It is not our objective to establish numerous or unnecessary rules and policies for our network providers, rather, policies that should be consistently followed to help protect your practice and to help you maintain the high standards that must be met by all participating providers.

CNC strongly encourages network providers to purchase the ACA Chiropractic Coding Solutions Manual as well as the ACA Clinical Documentation Manual (2nd edition) as additional reference guides. These books can be purchased directly from the ACA via their web site: www.acatoday.org/store or by calling ACA's Sales Office at (800) 368-3083.

Please be sure to review all information provided by your state licensing board, including practice guides, information regarding standard of care and scope of practice as well as all other rules and regulations established by your state licensing board. 

CNC providers must comply with all the requirements and policies included in this section provided they do not conflict with any state or federal requirements or policies of CNC contracted payors. However, these policies should not be followed if doing so could adversely affect the delivery of patient care.

CNC policies and payor corporate medical policies are listed in the blue box on this page.  Please click on the appropriate heading to review the policy.  

ACUPUNCTURE POLICY

POLICY:

Only those providers who have met the appropriate state Board of Examiner’s continuing education requirements for acupuncture, and have submitted evidence of such continuing education to that Board, may provide acupuncture services to patients whose claims are filed through CNC. 

Acupuncture is not covered by many insurance companies and as such, coverage for these services must be verified prior to the services being performed. Please remember to verify if acupuncture is covered when rendered by a chiropractor.

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ADVERTISING POLICY

POLICY:

CNC providers cannot advertise for free or reduced services in any manner to any member of a CNC contracted payor plan, for any services for which you normally charge a fee.

(Reminder: it is illegal to advertise for free or reduced services to members of ANY federally funded plan, including beneficiaries of Medicare, Medicaid and/or Federal Employees Health Plan.)

NC GENERAL STATUTES CONCERNING CHIROPRACTIC ADVERTISING

The NC Board of Chiropractic Examiners is charged with assuring that all licentiates conform to NC statutes.    The “State Laws and Statutes” section of the NC Board of Chiropractic Examiners web site, (www.ncchiroboard.com) states the following: 

90-154. b. 13 Grounds for professional discipline

b. 1.  Advertising services in a false or misleading manner

b. 10. Offering to waive a patient's obligation to pay any deductible or co-payment required by the patient's insurer.

b. 13. advertising any free or reduced rate service without prominently stating in the advertisement the usual fee for that service

90-154.1 Collection of certain fees prohibited.

The “Rules and Regulations” section of the NC Board of Chiropractic Examiner's web site, (www.ncchiroboard.com) states the following: 

0302 ADVERTISING AND PUBLICITY

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BALANCE BILLING POLICY

POLICY

CNC participating providers are contractually required to collect ONLY the allowable amount, for each service provided, that is shown on the CNC fee schedule(s) as payment in full for that service. Under no circumstances can CNC Providers collect more than the allowable amount shown on the fee schedules for any covered service they provide.

Only the appropriate co-payment, co-insurance and/or deductible amount can be collected from the member. The provider cannot balance bill the patient if the insurance company does not pay for a particular covered service nor may the provider balance bill the member for the contractual adjustment.

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CLAIM FILING POLICY

POLICY

All claims for all COVERED services provided to a patient with insurance that processes through CNC should be medically necessary and consistent with the patient’s diagnosis and consistent with CNC policies and the policies of our managed care partners, as well as practice guides issued by appropriate state licensing board, and state or federal laws.

POLICY

Claims for ALL covered services, provided to any patient whose insurance is processed by CNC, must be submitted to CNC for processing. This includes claims for all services regardless of the amount of the co-payment/ deductible and/or co-insurance and regardless of the wishes of the member. CNC participating providers are contractually required to file claims for ALL covered services.  Obtaining a signed waiver from the member does not negate the contractual responsibility of the provider to file claims for all covered services provided.

             For example, if the total charge for services provided on a single

             visit is less than the co-payment amount, the participating provider must

             still submit the claim to CNC.

Please note that the above filing policy refers only to COVERED services and should not be misconstrued.  Network providers should never submit claims to our managed care partners for NON-COVERED services.

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CODING POLICIES

Please contact your CNC Provider Representative with

ANY questions about CPT or HCPCS codes!

ICD-9 Codes

POLICY

Providers must use valid ICD-9 codes for the dates of service reported on an insurance claim.

Only valid ICD-9 codes should be reported on insurance claims submitted through CNC.

CPT Codes

POLICY

Providers should assure that the CPT codes reported on the insurance claim accurately reflect the services provided and are valid CPT codes for the dates of service.

HCPCS Codes

POLICY

Providers should use appropriate HCPCS codes when reporting and billing equipment and supplies.

Many HCPCS codes are not covered by CNC contracted payors so please check the Corporate Medical Policy and/or contact your CNC Provider Rep to verify the appropriateness of the service and/or HCPCS code.

E/M Consultation Codes

POLICY

Consultation E/M codes should ONLY be billed when another physician, insurer, employer, or other appropriate source has requested your opinion or advice.

A consultation initiated by a patient and/or family member, and not requested by a physician or other appropriate source, should not be reported using an E/M consultation code.

Evidence of a request for a consultation by an appropriate source, as well as the provider’s written opinion/response back to the appropriate source, must be documented in the patient health record.

Modifiers

POLICY

Providers should use appropriate CPT modifiers when reporting and billing for chiropractic services. The most commonly used modifiers are listed below for your reference.

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CO-PAYMENT/CO-INSURANCE COLLECTION POLICY

FOR ALL CNC CONTRACTS –

POLICY:

CNC provider’s may not bill the member for the discounted amount on covered services for any CNC contract.

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DIAGNOSIS/DIAGNOSTIC IMPRESSION

POLICY

Only diagnoses related to neuromusculoskeletal conditions should be reported on the insurance claim form.

Example: Patient presents with headache, suspected cause: cervical segmental dysfunction. Cervical segmental dysfunction should be the primary diagnosis reported on the claim form. Headache should be listed as secondary diagnosis and both diagnoses should be included in the patient's health record.

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HEALTHCARE RECORD POLICIES

Requests for Patient Records

POLICY

Copies of medical and financial records for patients whose claims should be submitted to CNC may be requested by CNC at any time OR may be requested at any time from a CNC contracted payor. This is to ensure that our managed care partners are paying only for treatment that is appropriate and necessary, and to assure compliance with the policies of CNC, our contracted payors and state and federal regulations.

When records are requested, providers must promptly respond to such requests.  When supplying documentation, you must submit complete copies of the entire patient health record. 

Retention of Records

POLICY

The patient record must be maintained in a safe and secure location.

CNC providers must retain patient records (including EOB’s) for a minimum of 7 years from last date of service OR, if the patient is a minor, for 7 years after the minor patient reaches age 19.  Once the patient reaches 19 and is still under care, the provider should retain the patient record for 7 years from the last date of service.

Abbreviation Legend

POLICY

If abbreviations are used in the health record, clear abbreviation legends should be maintained in the provider’s office.

Any release of health records should include the office legend. 

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INFORMED CONSENT POLICY

POLICY

CNC requires that written informed consent must be obtained from the patient prior to treatment and evidence of informed consent must be included in the patient’s health record.

Written consent of a parent or legal guardian is required for minors or patients that are incapacitated.  

Please note when reviewing and/or obtaining the patient's informed consent, the patient must be afforded an opportunity to ask questions.

A signed, written informed consent form is required by CNC as evidence that informed consent was obtained prior to treatment and must be on file in each “CNC” patient record.

Please review the sample template “INFORMED CONSENT FOR CHIROPRACTIC TREATMENT.”

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INSURANCE ID CARD POLICY

POLICY

All providers must obtain a current copy of each patient’s subscriber ID card each year.

These copies must be kept on file in the patient’s health record.

At each visit, the provider should ask if there have been any changes to the patient insurance information.

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LOCUM TENENS BILLING POLICY

On occasion, a physician may arrange for a Locum Tenens (substitute) physician to see patients if he or she is out of the office and unavailable to provide chiropractic services.  If a Locum Tenens physician is used, the office may submit claims under the regular physician’s name for all covered services provided, if all of the following requirements are met. 

A physician may have reciprocal arrangements with more than one physician.

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MAINTENANCE CARE POLICY

Chiropractic maintenance care and supportive care are considered non-covered by many of the CNC payors and therefore should not be billed to an insurance plan that does not cover maintenance and supportive care. 

Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

The American Chiropractic Association published the following definitions: 

“Supportive Care:  Long-term treatment/care . . . for patients who have reached maximum therapeutic benefit, but who fail to sustain benefit and progressively deteriorate when there are periodic trials of treatment withdrawal. Supportive care follows appropriate application of active and passive care including rehabilitation and/or lifestyle modifications. Supportive care is appropriate when alternative care options, including home-based self-care or referral have been considered and/or attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when risk of supportive care outweighs its benefit, i.e. physician/treatment dependence, somatization, illness behavior or secondary gain.”

“Preventive/Maintenance Care:  Elective healthcare that is typically long-term, by definition not therapeutically necessary but is provided at preferably regular intervals to prevent disease, prolong life, promote health and enhance the quality of life. This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. This care may incorporate screening/evaluation procedures designed to identify developing risks or problems that may pertain to the patient's health status and give care/advice for these. Preventive/maintenance care is provided to optimize a patient's health.”

Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur.

We understand that this can cause confusion for patients who are aware that their insurance includes coverage for chiropractic care. In such situations, CNC providers should review the applicable corporate medical policy with the patient so that the patient will understand that their health plan specifically excludes maintenance and/or supportive care.

To assist you in continuing to provide important maintenance and supportive care to your patients, please click here for a sample template, “Patient Waiver for Maintenance/Supportive Care.”

Maintenance/Supportive Care Policies

CIGNA HealthCare Members - Maintenance and/or supportive care is non-covered.

BCBSNC Members who do NOT have maintenance care coverage include:

• BCBSNC members
• NC State Employee Plan members
• Federal Employee Plan members
• ASO (self funded) groups
• HSA/HRA members (high deductible plans)

BCBS OUT-OF-STATE Members - Benefits for BCBS out-of-state members are determined by the member's home plan. Please contact the home plan directly to determine if maintenance and/or supportive care is covered.  If you are told, when verifying benefits, that maintenance care is covered, then you may provide maintenance care for that member and the claim must be filed through CNC.

MedCost Members - Many MedCost payors cover maintenance and supportive care. Please contact each payor to determine if maintenance and/or supportive care is covered for each of your MedCost patients.  If you are told, when verifying benefits, that maintenance care is covered, then you may provide maintenance care for that member and the claim must be filed through CNC.

PPC Members - Many PPC payors do cover maintenance and supportive care. Please contact each payor to determine if maintenance and/or supportive care is covered.  If you are told, when verifying benefits, that maintenance care is covered, then you may provide maintenance care for that member and the claim must be filed through CNC.

Kanawha Members - Many Kanawha plans do cover maintenance and supportive care. Please contact Kanawha to determine if maintenance and/or supportive care is covered for the member.  If you are told, when verifying benefits, that maintenance care is covered, then you may provide maintenance care for that member and the claim must be filed through CNC.

Select Health of South Carolina (First Choice Kids) Members - Maintenance and/or supportive care is non-covered.

Inclusive Health Members - Maintenance and/or supportive care is non-covered.

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MEDICAL NECESSITY POLICY

IMPORTANT NOTE:

Please review the Corporate Medical Policy for Chiropractic from CIGNA HealthCare and BCBSNC which includes additional information about Medical Necessity.  It is imperative that you become familiar with these corporate medical policies before providing chiropractic care to these members to assure that you are complying with their corporate medical policies.

POLICY

All services provided to a patient should be medically necessary and consistent with the patient’s diagnosis and consistent with CNC policies and the policies of our managed care partners, as well as state or federal laws.

CNC’s managed care partners allow coverage for chiropractic services when they are determined to be medically necessary and providing the medical criteria and guidelines in the payor corporate medical policies are met, providing the patient is eligible for benefits at the time of service and there are no plan limitations to the contrary.  The fact that a doctor may prescribe, order, recommend, or approve a service, procedure or supply does not, in and of itself, make it a covered service or medically necessary, even though it is not specifically listed as an exclusion.

For medically necessary services, the payors may compare the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered.

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NON-COVERED SERVICES POLICY

POLICY

Non-covered services cannot be billed to a CNC contracted payor.

All services provided to a patient should be medically necessary and consistent with the patient’s diagnosis and consistent with CNC policies and the policies of our managed care partners, as well as state or federal laws

Patients can ONLY be billed for non-covered services if, prior to the rendering of the non-covered service, the provider obtains an executed, appropriate Waiver for Non-covered Services from the patient and this signed waiver is maintained in the patient’s medical record.

Important note:

This waiver cannot be a generic waiver but must be specific to the actual procedure or service to be rendered to each individual member.  This waiver must be maintained in the member’s medical record and be readily available for review upon request or audit.

Click here for a sample WAIVER TEMPLATE: “PATIENT WAIVER FOR NON-COVERED SERVICES.”

or you may create your own waiver but all such waivers must include:

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RENDERING PROVIDER POLICY

POLICY

All claims submitted to CNC must include the name of the provider that actually rendered the chiropractic services that are reported on the claim(s).

If you are in a group practice with more than one provider or share call coverage with other providers, it is imperative that you take special care to assure the accuracy of the rendering provider’s name for each claim submitted. 

If you discover that a claim (or claims) was submitted incorrectly with the wrong rendering provider’s name, please contact your CNC Provider Rep and she will assist you in correcting this.  Your prompt recognition of this error and your immediate correction of the error can reduce payor concerns of suspected fraud and abuse.

New Associate/Partner - Chiropractor

If you have hired a new associate and he/she is not yet credentialed with CNC, you cannot submit claims in your own name for services provided by this new physician.   If you have hired a new associate, please contact CNC immediately so that we can assist with credentialing this provider. Please note, until the provider is credentialed by CNC, he/she must not provide any services to a patient whose insurance processes through CNC.

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SECONDARY CLAIM POLICY

POLICY

All CNC providers are required to file all secondary claims through CNC if the secondary coverage is provided by a CNC contracted payor.   

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TIMELY FILING POLICY

POLICY

All primary claims must be filed within 10 days of the date services were provided.

CNC recommends that original claims be filed to CNC within 1-3 days from the date service was rendered but in no condition, later than 10 days from date of service.

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VERIFYING BENEFITS POLICY

POLICY

CNC providers must verify eligibility before services are rendered by contacting the members health care plan. When calling payors, it is important to clarify that you are verifying chiropractic benefits.  

All services that are routinely performed in your office should specifically be addressed when verifying benefits to determine if the services that you may provide are covered services under the member’s plan. 

Verification of benefits should also be done at the beginning of each member's plan year as well as any time the patient obtains new insurance coverage or anytime you want to provide a new and/or different service.

Providers should also verify the following:

PLEASE REMEMBER, representatives from CIGNA HealthCare and BCBSNC frequently do not have access to Corporate Medical Policies for chiropractic.   Regardless of what you may be told by payor representatives, the payor corporate medical policies supersede any information you may receive from a payor representative when verifying benefits.  The payor corporate medical policies are on this page and can also be found under each payor's Quick Reference Guide (under the All About Claims link in the top menu bar).

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WAIVING CO-PAYS, DEDUCTIBLES & CO-INSURANCE POLICY

POLICY

It is a violation of CNC and CNC payor policies to waive or reduce co-payments, deductibles, co-insurances, or other patient responsibility payments.  This includes offering to discount co-payments and includes services deemed TWIP (take what insurance pays). 

Absent true financial hardship (with complete, documented, supporting evidence of such hardship in the patient’s health record), ALL co-payments, deductibles and co-insurance due and owed should be collected by all network providers.

Waiving or reducing co-payments is considered fraudulent activity.  When waiving or reducing a co-pay, you are actually misstating your charge amount.  Also, waiving co-pays may induce patients to see you rather than other providers, and this becomes a violation of the anti-kickback regulations.

If a patient has a financial hardship, there are possible steps to take to assist them, other than waiving the co-pay. You might consider establishing monthly payment plans that the patient can afford.  Additionally, you might consider referring the patient to the local social security office for assistance which can help the patient with all medical expenses, not just chiropractic care.  Should the patient refuse options such as this, they may not qualify as a “financial hardship.”

If the provider wants to extend a professional courtesy to a friend, colleague or family member, such discounts must be included in their compliance plan and should NOT be the amount of the co-payment or deductible. 

A Financial Hardship Policy should include:

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