medical insurance questions

Most health insurance companies include some level of chiropractic coverage in their policies. However, the extent and details of coverage differ from policy to policy.  It is important to understand the limits of your chiropractic insurance coverage.  When benefits become exhausted our office will provide cost effective wellness or maintenance care for our patients who have reached their insurance plan’s coverage limits.

Below are important insurance facts to consider when seeking chiropractic care using your health insurance:

 What is Acute Care Coverage?

Most insurance companies provide a specific number of visits designed to cover patients for “acute care” of injuries causing limited mobility, pain or other effects of a mis-aligned spine.  Chiropractic adjustments for acute pain are designed to restore the patient to an improved state of physdical function and reduced pain.  Acute care visits typically last between three to twenty-four visits depending on the severity of the injury.

Is Pre-authorization Required?

Some insurance policies do require prior authorization for chiropractic visits or -re-authorization after a specific number of visits (usually 12) have been completed.  United Health Care, Blue Cross Blue Shield and Cigna polices often require pre-authorization or recertification.  Each policy is different so check your benefits or have your chiropractor’s staff check visit limitations for you.

What is Chiropractic Maintenance Care?

Some insurance policies will not allow for billing of what they consider maintenance or wellness adjustments designed to improve body functions and prevent injuries.  Other policies do allow for maintenance care up to the policies maximum number of allowed visits.  Many Health Savings Accounts do allow for continued wellness or maintenance chiropractic care.  It is best to call for coverage clarification regarding maintenance chiropractic coverage.

Are Children Covered by my insurance?

Typically, insurance policies do not cover infants or children unless there is a muscular skeletal complaint. Pre-authorization for pediatric chiropractic is often required.

 How Many Visits are Included in our policy?

The number of visits covered by insurance providers varies from policy to policy.  Typically, the minimum number of visits covered is twelve. with many policies covering more each year.  Some insurance policies such as Blue Cross Blue Shield, United Health Care, Aetna, and Cigna may cover up to 30 or more visits annually, however, they may require pre-certification or recertification after a specific number of visits.  Additional paperwork filled out by the patient and the provider will need to be submitted by the chiropractor justifying the need for additional treatments after the initial authorized visits.  This paperwork must be received and approved prior to the visit to be covered.

How do I know if my chosen chiropractor is in network with my policy?

Just call your insurance company’s customer service line and ask if the chiropractor is covered.

What is a deductible?

A deductible is the amount of money that the insurance company requires patients to pay out of pocket before their coverage takes effect.  Deductible amounts vary with each policy.

Once your deductible has been paid your benefits will begin.  Your plan may have a copay or coinsurance amount that you are responsible for paying after the deductible.

What is a co-pay or Co-insurance?

A Co-payments or co-insurance is the portion of the fee that the patient is responsible for paying for each visit.  It serves to share the financial burden and keep insurance rates lower.

     A copay is a specific dollar amount the patient must pay as part of the fees for each visit.  Co-payment amounts can vary from policy to policy.

     Co-insurance is based on a percentage of the contracted rate the patient is required to pay for each visit.  Co-insurance amounts vary with each policy and range from 5% to as high as 80%.  Coinsurance fees must be calculated       based on the contracted rate for the services rendered at the time of each visit.

Why is my insurance company not paying my claims?

Failure of an insurance company to pay for contracted services is likely the result of one or more qualifying contractual conditions not being met such as:

  • The deductible has not been met.
  • Pre-authorization is required from the insurance company and was not obtained.
  • The patient is responsible for services provided.
  • The number of authorized visits has been exhausted and re-certification is required.
  • The services performed are not part of the contracted coverage.
  • The provider is not in network with the insurance company.
  • Services exceeded a maximum daily rate.
  • The insurance company feels that a secondary insurer is responsible for payment. This happens often when a patient has had an a  automobile accident or workers compensation claim.
  • Additional information is required from the provider.
  • The insurer does not approve the specific treatment or CPT codes that were submitted for payment.