Chiropractic insurance billing in Florida.

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 Florida are processed by First Coast Service Options (JN) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Florida claims are measured against.

A Florida chiropractic or multi-specialty practice spends most of its commercial billing day with: Florida Blue (GuideWell / BCBS of Florida); UnitedHealthcare; Aetna (CVS Health); Cigna Healthcare; Humana; AvMed. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

Florida chiropractic and physical-medicine benefits are frequently ‘carved out’ to a delegated specialty network manager rather than handled by the health plan directly, which changes where credentialing, prior auth/treatment plans, and CLAIMS must go.

• American Specialty Health (ASH / ashlink.com, ashcompanies.com) is the dominant chiropractic/physical-medicine administrator operating in Florida and manages chiropractic (and often acupuncture/PT) for Florida Blue (Blue Cross and Blue Shield of Florida) and for Aetna and Cigna lines in Florida. When a member’s chiropractic is carved out to ASH, network enrollment, the treatment-plan/Medical Necessity Review (MNR), prior authorization, and claims route to ASH — not to Florida Blue/Aetna/Cigna. Misrouting to the health plan is a leading Florida chiropractic denial cause; always verify on the member card/portal whether chiropractic runs through ASH.
• Optum / Optum Physical Health (a UnitedHealth Group company) manages the chiropractic/physical-health network for UnitedHealthcare. Effective Sept. 1, 2024, UnitedHealthcare Medicare Advantage (excluding Dual Complete/SNP) requires prior authorization — delegated to Optum Physical Health, reviewed under CMS Ch. 15, applicable LCDs and InterQual — for Medicare-covered spinal manipulation billed with the AT modifier; the initial evaluation is exempt, and (per the Jan. 13, 2025 update) the first 6 visits within 8 weeks of the first DOS are covered without clinical review, with only plans exceeding 6 visits / 8 weeks going to medical-necessity review. Routine (non-covered/maintenance) chiropractic does not require this PA. ALWAYS confirm on the member’s card/portal whether chiropractic is delegated to ASH or Optum (and to which entity), because that determines where authorizations and claims go.

What actually trips up chiropractic billing in Florida:

• Carve-out routing — because Florida Blue, Aetna, and Cigna chiropractic typically run through ASH and UnitedHealthcare through Optum Physical Health, 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.
• ASH Medical Necessity Review (MNR) + ‘paper cap vs. real cap’ — a Florida Blue plan may show a generous annual chiropractic visit allowance (e.g., 20-35 visits), but ASH’s MNR routinely authorizes far fewer visits than the contractual maximum, reduces the number of therapy units/modalities per visit (e.g., from 4 to 2, and a daily cap can push it to 1), requires an initial treatment plan and periodic re-evaluation, and does NOT pay for maintenance/wellness care or care outside an acute episode. Document acute medical necessity, functional goals, and measurable progress to get visits approved.
• UHC/Optum Medicare Advantage PA — Medicare-covered manipulation (98940-98942 with the AT modifier) needs prior auth through Optum for the treatment plan/visit count (initial eval exempt; first 6 visits/8 weeks auto-approved as of 1/13/2025; maintenance excluded).
• Modifiers and coverage rules — expect the AT (active/corrective treatment) modifier on Medicare/MA spinal CMT, correct GA/GY/GZ and -59/-XU usage for distinct services, and note Medicare/MA cover only manual spinal manipulation to correct subluxation (exams, x-rays, and therapies are statutorily excluded under traditional Medicare chiropractic).
• PIP-specific quirks — under s. 627.736, PIP generally reimburses at 80% of 200% of the Medicare Part B fee schedule (or the applicable schedule), enforces the 35/75-day billing look-back, the 14-day-initial-care rule, and the $2,500-vs-$10,000 EMC cap, and lets PIP insurers require an independent medical exam / records and demand a written report from the provider — all common chiropractic PIP friction points.
• No broad commercial chiropractic mandate — Florida does not impose a sweeping statutory commercial chiropractic-benefit mandate (chiropractic is generally an optional/rider or plan-defined benefit), so caps and rules are plan-by-plan; verify benefits and current rules per payer. Not legal advice.

Largely contract/payer-set — the exact initial-filing window is in your participating-provider agreement and the payer’s provider manual, and the common commercial/PPO range runs roughly 90 to 180 days from the date of service (many plans allow up to a year; tightly-managed networks can be shorter).

Florida, however, embeds a meaningful statutory baseline in its prompt-pay laws: for insurer/PPO claims under s. 627.6131 and for HMO claims under s. 641.3155, Florida Statutes, a provider’s claim is treated as timely if submitted within 6 MONTHS after the date of service (outpatient) or discharge (inpatient), or within 6 months after the provider is furnished correct insurer information;

SECONDARY/COB claims must be submitted within 90 days after the primary payer’s final determination. Note that this 6-month statutory figure governs the prompt-pay framework and does not override a contract that grants a LONGER filing window — so use the longer of (contract window, statutory baseline) and confirm per payer.

Florida prompt-pay context (how fast the PLAN must pay YOU, not your submission deadline): on a clean/complete claim the insurer or HMO must pay or deny/contest within 20 days of receipt for ELECTRONIC claims (40 days for paper/non-electronic); failure to pay or deny within 120 days (electronic) / 140 days (paper) creates an ‘uncontestable obligation to pay,’ with statutory interest on overdue clean claims (ss. 627.6131, 641.3155).

As of 2025-2026; verify the exact number 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 Florida (Florida’s Part A/B MAC is First Coast Service Options).

Medicare Advantage plans set their own contractual deadlines (often similar, up to ~12 months) — confirm per plan.

Florida Medicaid (fee-for-service): the timely-filing limit is 12 MONTHS (365 days) from the date of service, per the AHCA Florida Medicaid Provider Reimbursement Handbooks (CMS-1500 and UB-04) and the Provider General Handbook (Rule 59G-5.020, F.A.C.).

For claims where another payer is primary (third-party liability/COB) or for Medicare crossover claims, the limit generally runs 12 months from the date the provider receives the primary payer’s Explanation of Payment / Medicare Remittance Advice.

Limited timely-filing exceptions are claimed via AHCA Form 2040 (Timely Filing Certification Statement). IMPORTANT: most Florida Medicaid recipients are in Statewide Medicaid Managed Care (SMMC) plans, which set their own, SHORTER windows — commonly 180 DAYS from the date of service for contracted providers (e.g., Sunshine Health, Aetna Better Health of Florida), with COB typically 180 days from DOS or 90 days from the primary payer’s determination, whichever is later.

Always bill the member’s specific SMMC plan to its own deadline, not the 12-month FFS limit.

Florida Workers’ Comp: there is no single ‘X days to bill’ provider-submission statute like some states; the governing rules are in s. 440.13 and s. 440.20, Florida Statutes, and the DFS Division of Workers’ Compensation Health Care Provider Reimbursement Manual (Rule 69L-7.020, F.A.C.) and provider billing/reporting rule (Rule 69L-7.730, F.A.C.). Submit medical bills promptly on the proper standardized form (e.g., CMS-1500/DWC-9 equivalent); the practical hard stops are:

• the authorized treating physician must furnish a preliminary notice of injury/treatment by the close of the third business day after the first treatment and a complete report within 15 days thereafter (s. 440.13(4)(a));
• the carrier must pay, disallow, or deny a properly submitted bill within 45 days of receipt (s. 440.20), and
• if the carrier disallows/adjusts payment, the provider must file a Petition for Resolution of Reimbursement Dispute with the DFS Medical Services Section within 45 days of receiving the Explanation of Bill Review (EOBR) (s. 440.13(7); Rule 69L-7). Bills for unauthorized care, or care not properly reported, can be barred — bill promptly and follow the carrier/TPA e-billing instructions. Confirm current rule incorporations on the myfloridacfo.com DWC provider pages.

Florida is a no-fault / PIP state. Under the PIP statute (s. 627.736, Florida Statutes) there is a strict bill-submission timing rule, NOT a long deadline: a provider’s statement of charges to the PIP insurer may NOT include charges for treatment/services rendered more than 35 DAYS before the postmark date of the statement.

That window EXTENDS to 75 days if the provider sends the insurer a ‘notice of initiation of treatment’ within 21 days after first examining/treating the patient. If the insured gave the provider the wrong PIP-insurer name/address, the provider gets 35 days from obtaining the correct information.

Charges submitted late are unpaid AND the provider may NOT bill the injured patient for them (any such agreement is unenforceable) — so the 35/75-day clock is high-stakes and rolling. Note separately: PIP also has a 14-day rule (the patient must receive initial care within 14 days of the accident for PIP to apply) and a $10,000 PIP cap ($2,500 without an emergency medical condition determination).

For non-PIP first-party MedPay or third-party/liability claims, submission timing is policy- or settlement-driven; the underlying auto bodily-injury tort claim is governed by Florida’s negligence statute of limitations (2 years for causes accruing on/after March 24, 2023 per s. 95.11, as amended; previously 4 years).

Confirm per policy and the current statute.