Chiropractic insurance billing in California.

Medicare’s chiropractic rules are federal — the same in every state. Medicare Part B covers ONLY manual manipulation of the spine to correct a subluxation (CPT 98940–98942), and ONLY when the care is active or corrective — which you signal with the AT modifier. Maintenance care, exams, X-rays, and any therapies performed by a chiropractor are not covered, so a properly executed ABN is essential before non-covered services. The full federal rules are in our chiropractic Medicare billing guide.

Part B claims in California are processed by Noridian Healthcare Solutions (JE) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your California claims are measured against.

A California chiropractic or multi-specialty practice spends most of its commercial billing day with: Kaiser Permanente; Blue Shield of California; Anthem Blue Cross; Health Net; UnitedHealthcare; L.A. Care Health Plan. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

California is one of the most heavily ‘carved-out’ chiropractic markets in the country — chiropractic and physical-medicine benefits are usually delegated to a specialty network manager, NOT handled by the health plan directly, which changes where enrollment, prior auth/treatment plans, and claims must go. Two managers dominate:

• American Specialty Health (ASH / ASH Plans of California, ashlink.com) administers chiropractic (and often acupuncture/massage/PT) for Blue Shield of California (ASH is Blue Shield’s contracted chiropractic & acupuncture administrator), Health Net, Cigna (Cigna/ASH coverage policies), Aetna, and Anthem Blue Cross lines. When a plan is carved out to ASH, network enrollment, treatment-plan/medical-necessity review, prior auth, and CLAIMS route to ASH — not the health plan.
• Optum / OptumHealth Physical Health of California (ACN Group of California, Inc., myoptumhealthphysicalhealthofca.com), a UnitedHealth Group company, manages the chiropractic/physical-health network for UnitedHealthcare in California and certain UHC-administered plans. Separately, effective Sept 1, 2024, UnitedHealthcare began requiring prior authorization (delegated to Optum, reviewed under CMS Ch. 15 / LCDs / InterQual) for chiropractic and outpatient therapy for Medicare Advantage members — initial evaluations are exempt, but the treatment plan/number of visits needs auth (generally triggered above ~6 visits or 8 weeks). ALWAYS verify on the member’s card/portal whether chiropractic is carved out to ASH or Optum (and to which ASH/Optum entity), because that determines where authorizations and claims go; misrouting to the health plan instead of the delegate is a leading California denial cause.

What actually trips up chiropractic billing in California:

• Carve-out routing — because Blue Shield, Health Net, Cigna, Aetna, and Anthem chiropractic typically run through ASH and UnitedHealthcare through Optum/OptumHealth Physical Health of California, sending the claim or auth to the health plan instead of the delegated administrator is the single most common denial. Confirm the delegate before submitting.
• Visit caps + treatment-plan/medical-necessity gating — ASH-administered commercial riders commonly cap chiropractic at a set number of visits per calendar year (e.g., Blue Shield riders often 20-30 visits/year, some up to 60), and ASH front-loads clinical documentation: an initial treatment plan, periodic re-evaluation, and clear distinction between active/corrective care and ‘maintenance’ care (maintenance is non-covered). Optum applies similar treatment-plan and InterQual-based medical-necessity review.
• Medi-Cal limits — Medi-Cal fee-for-service covers chiropractic narrowly: a maximum of 2 services per month (combined with audiology, acupuncture, occupational therapy, and speech therapy), with that cap NOT applying to members under 21 (EPSDT), pregnant members, or SNF/long-term-care residents; services beyond the cap need prior authorization (TAR), and maintenance care is excluded. Verify each Medi-Cal managed-care plan’s own chiropractic rules.
• Modifiers/pre-auth quirks — expect the AT (active treatment) modifier on Medicare/Medicare-Advantage spinal CMT (98940-98942), correct GA/GY/GZ and -59/-XU usage for distinct services, and remember UHC/Optum MA now requires prior auth for Medicare-covered manipulation (routine maintenance excluded, initial eval exempt).
• No broad commercial chiropractic mandate — California does not impose a sweeping statutory commercial chiropractic-benefit mandate; chiropractic is typically an optional/rider benefit, so coverage and caps are plan-by-plan. Not legal advice — verify benefits and current rules per payer.

Largely contract/payer-set, not fixed by a single California statute — but California uniquely sets a regulatory FLOOR on the submission window. Under the Knox-Keene claims-settlement regulation (28 CCR 1300.71, implementing Health & Safety Code 1371) a health plan (or its capitated/delegated provider) may NOT impose a claim-receipt deadline shorter than 90 days for contracted providers or 180 days for non-contracted providers after the date of service.

So the common initial-filing window for California commercial/HMO plans runs roughly 90-180 days (many PPO/indemnity contracts allow longer, e.g., up to 12 months) — confirm the exact number in your participating-provider agreement or the payer’s provider manual.

California prompt-pay context (how fast the PLAN must pay YOU, not your submission deadline): a complete/clean claim must be reimbursed within 30 working days (45 working days for HMOs/Knox-Keene plans) of receipt, with automatic interest at 15% per annum on late payment (28 CCR 1300.71;

H&S 1371; Insurance Code 10123.13 for CDI-regulated PPO/indemnity disability insurance). As of 2025-2026; verify per payer and contract.

Federal limit: generally 12 months (one calendar year) from the date of service to submit an initial Medicare fee-for-service claim. Set by the Social Security Act (1842(b)(3)) and CMS, not by California. Medicare Advantage plans set their own deadlines (often similar, up to ~12 months) — confirm per plan.

California Medicaid (Medi-Cal): the standard fee-for-service timely-filing limit is SIX MONTHS from the end of the month in which services were rendered (the ‘6-month billing limit’), per the Medi-Cal Provider Manual (CMS-1500 and UB-04 Submission and Timeliness Instructions) and Welfare & Institutions Code 14115 / 14104.3.

Example: for a date of service in January, the claim must be received by the fiscal intermediary by the end of July. Late claims may still be reimbursed (often at a reduced rate) only with a documented delay-reason code and generally must be submitted within one year of the date of service; claims over one year old face heightened scrutiny and stricter rules.

Medi-Cal MANAGED-CARE plans (most Medi-Cal members) set their own timely-filing windows — commonly 6 months to 1 year — so confirm with the specific Medi-Cal managed-care plan (e.g., Health Net, Anthem, Molina, the county-organized health systems).

California Workers’ Comp: for dates of service / inpatient discharges on or after January 1, 2017, a medical provider must submit its bill within 12 MONTHS of the date of service (or 12 months of the date of discharge), per Labor Code 4603.2(b)(1) and the DWC Medical Billing and Payment Guide adopted under Title 8, CCR 9792.5.0-9792.5.3.

Missing this window can legally bar payment. Distinct shorter clocks exist for certain post-service disputes/exemptions: the SECOND-REVIEW/appeal of an Explanation of Review must be requested within 90 days; some bills exempt from prospective utilization review have 30-day (most services) or 180-day (emergency hospital) timeframes under Labor Code 4610.

Submit promptly and confirm the carrier/TPA’s e-billing instructions.

California is an at-fault (tort) state with NO no-fault/PIP system — the optional first-party coverage is MedPay (Medical Payments), purely contractual. There is NO fixed statutory deadline to submit medical bills to an auto carrier; any bill-submission/notice timeframe is set by the individual auto policy (many MedPay policies expect bills for treatment incurred within ~1 year, and require reasonable/prompt notice) — submit promptly per policy terms.

Practical norms: bill MedPay and/or the patient’s health insurance promptly to preserve coverage; the underlying third-party (liability) personal-injury claim is bound by California’s 2-year statute of limitations (Code of Civil Procedure 335.1), and on a lien/third-party-liability basis bills are typically presented at settlement.

Confirm each MedPay policy’s notice/submission terms.