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Washington Apple Health (Medicaid)ChiropracticServices BillingGuide(For Clients Age 20 and Younger)October 1, 2020
DisclaimerEvery effort has been made to ensure this guide’s accuracy. If an actual orapparent conflict between this document and a Health Care Authority rulearises, the rule applies.Billing guides are updated on a regular basis. Due to the nature ofcontent change on the internet, we do not fix broken links in past guides.If you find a broken link, please check the most recent version of theguide. If this is the most recent guide, please notify us [email protected] this guide *This publication takes effect October 1, 2020, and supersedes earlierbilling guides to this program. Unless otherwise specified, the program inthis guide is governed by the rules found in WAC 182-556-0200.The Health Care Authority (HCA) is committed to providing equal accessto our services. If you need an accommodation or require documents inanother format, please call 1-800-562-3022. People who have hearing orspeech disabilities, please call 711 for relay services.Washington Apple Health means the public healthinsurance programs for eligible Washington residents.Washington Apple Health is the name used in WashingtonState for Medicaid, the children’s health insurance program(CHIP), and state-only funded health care programs.Washington Apple Health is administered by theWashington State Health Care Authority.Refer also to HCA’s ProviderOne billing and resource guide for valuableinformation to help you conduct business with the Health Care Authority.*This publication is a billing instruction.CPT codes and descriptions only are copyright 2019 American Medical Association.2 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
How can I get HCA Apple Health provider documents?To access provider alerts, go to HCA’s provider alerts webpage.To access provider documents, go to HCA’s provider billing guides andfee schedules webpage.Where can I download HCA forms?To download an HCA form, see HCA’s Forms & Publications webpage.Type only the form number into the Search box (Example: 13-835).Copyright disclosureCurrent Procedural Terminology (CPT) copyright 2019 American MedicalAssociation (AMA). All rights reserved. CPT is a registered trademark ofthe AMA.Fee schedules, relative value units, conversion factors and/or relatedcomponents are not assigned by the AMA, are not part of CPT, and theAMA is not recommending their use. The AMA does not directly orindirectly practice medicine or dispense medical services. The AMAassumes no liability for data contained or not contained herein.What has changed?SubjectChangeReason for ChangeEntire GuideRevised format ofentire guide.To comply withaccessibility standards.Apple Health Changesfor January 1, 2020Removed AppleHealth Changessection.This section isunnecessary, as it isoutdated. All regionsare now fully integratedmanaged care.CPT codes and descriptions only are copyright 2019 American Medical Association.3 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
SubjectChangeReason for ChangeIntegrated managedcare regionsRemoved listing ofregions and theirintegration dates.This section isunnecessary, as it isoutdated. All regionsare now fully integratedmanaged care.CPT codes and descriptions only are copyright 2019 American Medical Association.4 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Table of ContentsImportant Contacts . 6About the Program . 7What is the purpose of the Chiropractic Services for ChildrenProgram? . 7Who is eligible to be reimbursed for chiropractic services? . 7Fee Schedule . 7Client Eligibility . 8Who is eligible for chiropractic services for children? . 8How do I verify a client’s eligibility? . 8Verifying eligibility is a two-step process: . 8Are children enrolled in an HCA-contracted managed careorganization (MCO) eligible for chiropractic services? . 10Managed care enrollment. 11Clients who are not enrolled in an HCA-contracted managed careplan for physical health services . 12Integrated managed care . 12Integrated Apple Health Foster Care (AHFC) . 13Fee-for-service Apple Health Foster Care . 14Coverage Table . 15Billing. 21What Are the General Billing Requirements? . 21How do I bill claims electronically? . 21CPT codes and descriptions only are copyright 2019 American Medical Association.5 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Important ContactsNote: This section contains important contact informationrelevant to chiropractic services for children.TopicContact InformationBecoming a provider orsubmitting a change of addressor ownershipSee HCA’s ProviderOne ResourceswebpageFinding out about payments,denials, claims processing, orHCA managed careorganizationsSee HCA’s ProviderOne ResourceswebpageElectronic billingSee HCA’s ProviderOne ResourceswebpageFinding HCA documents (e.g.,medicaid billing guides, #memos, provider notices, feeschedules)See HCA’s ProviderOne ResourceswebpagePrivate insurance or third-partyliability, other than HCAmanaged careSee HCA’s ProviderOne ResourceswebpageCPT codes and descriptions only are copyright 2019 American Medical Association.6 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
About the ProgramWhat is the purpose of the Chiropractic Services forChildren Program?The purpose of the Health Care Authority’s (HCA’s) Chiropractic Servicesfor Children Program is to provide medically necessary chiropracticservices to eligible clients 20 years of age and younger.Who is eligible to be reimbursed for chiropracticservices?HCA pays only for chiropractic services that are all of the following: Provided by a chiropractor licensed in the state where services areprovided and enrolled as an HCA provider. Within the scope of the chiropractor’s license. Listed in this document (see Coverage). Medically necessary.Fee ScheduleFor maximum allowable fees, view HCA’s current Chiropractic Services forChildren Fee Schedule.CPT codes and descriptions only are copyright 2019 American Medical Association.7 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Client EligibilityWho is eligible for chiropractic services for children?To be eligible, clients must be 20 years of age and younger and referred†by a screening provider under the Early and Periodic Screening, Diagnosis,and Treatment (EPSDT) program.How do I verify a client’s eligibility?Most Apple Health clients are enrolled in an HCA-contracted managedcare organization (MCO). This means that Apple Health pays a monthlypremium to an MCO for providing preventative, primary, specialty, andother health services to Apple Health clients. Clients in managed caremust see only providers who are in their MCO’s provider network, unlessprior authorized or to treat urgent or emergent care. See HCA’s AppleHealth managed care page for further details.It is important to always check a client’s eligibility priorto providing any services because it affects who willpay for the services.Check the client’s services card or follow the two-step process below toverify that a client has Apple Health coverage for the date of service andthat the client’s benefit package covers the applicable service. This helpsprevent delivering a service HCA will not pay for.Verifying eligibility is a two-step process:Step 1.Verify the patient’s eligibility for Apple Health. Fordetailed instructions on verifying a patient’s eligibility forApple Health, see the Client Eligibility, Benefit Packages,Include the referring provider’s National Provider Identifier (NPI) on theelectronic professional claim. Keep referral information in the client's file.†CPT codes and descriptions only are copyright 2019 American Medical Association.8 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
and Coverage Limits section in HCA’s ProviderOne Billingand Resource Guide.If the patient is eligible for Apple Health, proceed to Step2. If the patient is not eligible, see the note box below.Step 2.Verify service coverage under the Apple Health client’sbenefit package. To determine if the requested service is acovered benefit under the Apple Health client’s benefitpackage, see HCA’s Program Benefit Packages and Scopeof Services webpage.CPT codes and descriptions only are copyright 2019 American Medical Association.9 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Note: Patients who are not Apple Health clients may submit anapplication for health care coverage in one of the following ways:1. By visiting the Washington Healthplanfinder’s website.2. By calling the Customer Support Center toll-free at: 855WAFINDER(855-923-4633) or 855-627-9604 (TTY)3. By mailing the application to: Washington Healthplanfinder, POBox 946, Olympia, WA 98507In-person application assistance is also available. To get informationabout in-person application assistance available in their area, people mayvisit the Washington Healthplanfinder’s website or call the CustomerSupport Center.Are children enrolled in an HCA-contracted managedcare organization (MCO) eligible for chiropracticservices?Yes. Most Medicaid-eligible clients are enrolled in one of HCA’scontracted managed care organizations (MCOs). For these clients,managed care enrollment will be displayed on the client benefit inquiryscreen in ProviderOne.All medical services covered under an HCA-contracted MCO must beobtained by the client through designated facilities or providers. The MCOis responsible for: Payment of covered services Payment of services referred by a provider participating with the planto an outside providerNote: A client’s enrollment can change monthly. Providerswho are not contracted with the MCO must receiveapproval from both the MCO and the client’s primary careprovider (PCP) prior to serving a managed care client.CPT codes and descriptions only are copyright 2019 American Medical Association.10 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Send claims to the client’s MCO for payment. Call the client’s MCO todiscuss payment prior to providing the service. Providers may bill clientsonly in very limited situations as described in WAC 182-502-0160.Managed care enrollmentApple Health (Medicaid) places clients into an HCA-contracted MCO thesame month they are determined eligible for managed care as a new orrenewing client. This eliminates a person being placed temporarily in FFSwhile they are waiting to be enrolled in an MCO or reconnected with aprior MCO. This enrollment policy also applies to clients in FFS who have achange in the program they are eligible for. However, some clients maystill start their first month of eligibility in the FFS program because theirqualification for MC enrollment is not established until the monthfollowing their Medicaid eligibility determination.New clients are those initially applying for benefits or those with changesin their existing eligibility program that consequently make them eligiblefor Apple Health managed care.Checking eligibility Providers must check eligibility and know when a client is enrolled andwith which MCO. For help with enrolling, clients can refer to theWashington Healthplanfinder’s Get Help Enrolling page. MCOs have retroactive authorization and notification policies in place.The provider must know the MCO’s requirements and be compliantwith the MCO’s policies.Clients have a variety of options to change their plan: Available to clients with a Washington Healthplanfinder account:Go to Washington HealthPlanFinder website. Available to all Apple Health clients:oVisit the ProviderOne Client Portal website:oCall Apple Health Customer Service at 1-800-562-3022. Theautomated system is available 24/7.CPT codes and descriptions only are copyright 2019 American Medical Association.11 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
oRequest a change online at ProviderOne Contact Us (this willgenerate an email to Apple Health Customer Service). Select thetopic “Enroll/Change Health Plans.”For online information, direct clients to HCA’s Apple Health ManagedCare webpage.Clients who are not enrolled in an HCA-contractedmanaged care plan for physical health servicesSome Medicaid clients do not meet the qualifications for managed careenrollment. These clients are eligible for services under the FFS Medicaidprogram. In this situation, each Integrated Managed Care (IMC) plan willhave Behavioral Health Services Only (BHSO) plans available for AppleHealth clients who are not in managed care. The BHSO covers onlybehavioral health treatment for those clients. Clients who are not enrolledin an HCA-contracted managed care plan are automatically enrolled in aBHSO with the exception of American Indian/Alaska Native clients. Someexamples of populations that may be exempt from enrolling into amanaged care plan are Medicare dual-eligible, American Indian/AlaskaNative, Adoption support and Foster Care alumni.Integrated managed careClients qualified for managed care enrollment and living in integratedmanaged care (IMC) regions will receive all physical health services,mental health services, and substance use disorder treatment throughtheir HCA-contracted managed care organization (MCO).American Indian/Alaska Native (AI/AN) clients have twooptions for Apple Health coverage:-Apple Health Managed Care; or-Apple Health coverage without a managed care plan(also referred to as fee-for-service [FFS])CPT codes and descriptions only are copyright 2019 American Medical Association.12 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
If a client does not choose an MCO, they will beautomatically enrolled into Apple Health FFS for all theirhealth care services, including comprehensive behavioralhealth services. See the Health Care Authority’s (HCA)American Indian/Alaska Native webpage.For more information about the services available underthe FFS program, see HCA’s Mental Health Services BillingGuide and the Substance Use Disorder Billing Guide.For full details on integrated managed care, see HCA’s Apple Healthmanaged care webpage and scroll down to “Changes to Apple Healthmanaged care.”Integrated Apple Health Foster Care (AHFC)Children and young adults in the Foster Care, Adoption Support andAlumni programs who are enrolled in Coordinated Care of Washington’s(CCW) Apple Health Foster Care program receive both medical andbehavioral health services from CCW.Clients under this program are: Under the age of 21 who are in foster care (out of home placement) Under the age of 21 who are receiving adoption support Age 18-21 years old in extended foster care Age 18 to 26 years old who aged out of foster care on or after their18th birthday (alumni)These clients are identified in ProviderOne as“Coordinated Care Healthy Options Foster Care.”The Apple Health Customer Services staff can answer general questionsabout this program. For specific questions about Adoption Support,Foster Care or Alumni clients, contact HCA’s Foster Care Medical Team at1-800-562-3022, Ext. 15480.CPT codes and descriptions only are copyright 2019 American Medical Association.13 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Fee-for-service Apple Health Foster CareChildren and young adults in the fee-for-service Apple Health Foster Care,Adoption Support and Alumni programs receive behavioral healthservices through the regional Behavioral Health Services Organization(BHSO). For details, see HCA’s Mental Health Services Billing Guide,under How do providers identify the correct payer?CPT codes and descriptions only are copyright 2019 American Medical Association.14 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Coverage TableChiropractic services consist of the manipulation of the spine to facilitatethe recuperative powers of the body and the relationship between themusculoskeletal structures and functions of the body to restore health.The Health Care Authority covers only the following chiropractic servicesfor children:Note: Due to its licensing agreement with the AmericanMedical Association (AMA), the Health Care Authoritypublishes only the official, brief CPT procedure codedescriptions. To view the entire descriptions, please referto your current CPT book.ProcedureCodeModifier Brief Description7202026EPA/PA Policy/CommentsX-ray exam ofspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.CPT codes and descriptions only are copyright 2019 American Medical Association.15 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
ProcedureCodeModifier Brief Description72020TCEPA/PA Policy/CommentsX-ray exam ofspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.72020X-ray exam ofspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.7204026X-ray exam of neckspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.CPT codes and descriptions only are copyright 2019 American Medical Association.16 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
ProcedureCodeModifier Brief Description72040TCEPA/PA Policy/CommentsX-ray exam of neckspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.72040X-ray exam of neckspineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.7207026X-ray exam ofthoracic spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.CPT codes and descriptions only are copyright 2019 American Medical Association.17 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
ProcedureCodeModifier Brief Description72070TCEPA/PA Policy/CommentsX-ray exam ofthoracic spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.72070X-ray exam ofthoracic spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.7210026X-ray exam oflower spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.CPT codes and descriptions only are copyright 2019 American Medical Association.18 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
ProcedureCodeModifier Brief Description72100TCEPA/PA Policy/CommentsX-ray exam oflower spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.72100X-ray exam oflower spineX-rays of the spine limited to: A single view when thetreatment area can beisolated. The cervical, thoracic, andlumbo-sacral (anteriorposterior and lateral) areas ofthe spine when treatmentcannot be isolated.98940ChiropracticmanipulationUnlimited chiropracticmanipulative treatments of thespine98941ChiropracticmanipulationUnlimited chiropracticmanipulative treatments of thespine98942ChiropracticmanipulationUnlimited chiropracticmanipulative treatments of thespineCPT codes and descriptions only are copyright 2019 American Medical Association.19 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Note: The Health Care Authority does not pay for any ofthe following items under the Chiropractic Services forChildren program:-Therapy modalities such as light, heat, hydro, andphysical.-Any food supplements, medications, or drugs.-Any braces, cervical collars, or supplies.CPT codes and descriptions only are copyright 2019 American Medical Association.20 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
BillingAll claims must be submitted electronically to the HealthCare Authority, except under limited circumstances.For more information about this policy change, seePaperless Billing at HCA.For providers approved to bill paper claims, see the HealthCare Authority’s Paper Claim Billing Resource.What Are the General Billing Requirements?Providers must follow the general billing requirements found in theHealth Care Authority’s current ProviderOne Billing and Resource Guide.These billing requirements include, but are not limited to, all of thefollowing: What time limits exist for submitting and resubmitting claims andadjustments. When providers may bill a client. How to bill for services provided to primary care case management(PCCM) clients. How to bill for clients eligible for both Medicare and Medicaid. How to bill for clients with third-party liability. What standards to use for recordkeeping.How do I bill claims electronically?Instructions on how to bill Direct Data Entry (DDE) claims can be found onthe Health Care Authority’s Billers and Providers webpage, underWebinars.For information about billing Health Insurance Portability andAccountability Act (HIPAA) Electronic Data Interchange (EDI) claims, seeCPT codes and descriptions only are copyright 2019 American Medical Association.21 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
the ProviderOne 5010 companion guides on the HIPAA Electronic DataInterchange (EDI) webpage.The following claim instructions relate to the Chiropractic Services forChildren program:NameEntryReferring Provider InformationEnter NPI of the EPSDT providerwho referred the servicePlace of ServiceEnter 11CPT codes and descriptions only are copyright 2019 American Medical Association.22 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE
Oct 01, 2020 · 2 CHIROPRACTIC SERVICES FOR CHILDREN BILLING GUIDE Disclaimer Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this document and a Health Care Authority rule arises, the rule applies.
