Chiropractic insurance billing in Kentucky.

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 Kentucky are processed by CGS Administrators (J15) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Kentucky claims are measured against.

A Kentucky chiropractic or multi-specialty practice spends most of its commercial billing day with: Anthem Blue Cross Blue Shield (Elevance Health); Humana; UnitedHealthcare; Aetna (CVS Health); WellCare; CareSource. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

The dominant DELEGATED chiropractic/musculoskeletal network and utilization managers operating in Kentucky are American Specialty Health (ASH) and Optum (UnitedHealth Group).

• AMERICAN SPECIALTY HEALTH (ASH) — ASH is the chiropractic network/UM administrator for CIGNA nationally (all 50 states, including Kentucky): when a Cigna plan delegates to ASH, network contracting, credentialing, utilization/medical-necessity review (treatment-plan approval), AND claims processing route to ASH (ashlink.com), NOT to Cigna directly. A Cigna chiropractic claim or auth sent to Cigna instead of ASH is a common denial cause — check the member card. (Separately, in Sept/Nov 2023 Cigna expanded ASH to also manage outpatient PHYSICAL/OCCUPATIONAL THERAPY in additional markets including certain Kentucky counties — a distinct program from the long-standing chiropractic delegation.) ASH also administers chiropractic/clinical review for ANTHEM and Aetna plans in many markets — Anthem (Kentucky’s dominant commercial payer) materials describe chiropractic services being determined medically/clinically necessary by ‘ASH PLANS’ under a submitted treatment plan, so for many Anthem KY chiropractic benefits the treatment-plan review (and often claims) run through ASH.
• OPTUM / Optum Physical Health (UnitedHealth Group) — manages chiropractic and outpatient therapy for UnitedHealthcare; effective 9/1/2024 UHC requires prior authorization (delegated to Optum Physical Health, via the Optum/UHC Provider Portal) for Medicare-covered chiropractic for UnitedHealthcare and AARP Medicare Advantage members in Kentucky — the request auto-qualifies for up to 6 visits over 8 weeks, with clinical review only beyond that; routine/maintenance manipulation is non-covered and not auth-eligible. Always verify on the member’s card/portal whether chiropractic is carved out to ASH (Cigna, and many Anthem/Aetna plans) or whether auth runs through Optum (UHC), because that determines where authorizations and claims go; delegation arrangements change by plan/product/year, so re-confirm.

What trips up chiropractic billing in Kentucky:

• KENTUCKY CHIROPRACTIC INSURANCE MANDATE — KRS 304.17A-171 requires health benefit plans that INCLUDE chiropractic benefits to meet defined access/coverage requirements for chiropractic care, and KRS 304.17A-175 LIMITS the copayment or coinsurance a plan may charge for chiropractor services (a cost-share protection meant to keep chiropractic cost-sharing in line with comparable physician services). These do not force a plan to cover a service it otherwise excludes, set provider rates, or override Medicare/Medicaid program rules — but they shape how covered chiropractic benefits and cost-shares must be administered in Kentucky.
• ANTHEM IS THE DOMINANT KY COMMERCIAL PAYER — Anthem Blue Cross and Blue Shield (Elevance) holds the largest commercial market share in Kentucky (one of only a few states where Anthem leads), followed by UnitedHealthcare, Humana (Louisville-based, very strong in Medicare Advantage statewide), Aetna, and Cigna. Anthem and Cigna chiropractic benefits are commonly administered through ASH PLANS, which require a submitted, approved TREATMENT PLAN and ongoing medical-necessity review; Anthem HMO chiropractic benefits are often capped (e.g., ~30 chiropractic/acupuncture visits per calendar year, plan-dependent) and ‘maintenance’/supportive care is generally not reimbursable.
• COMMERCIAL VISIT CAPS / MEDICAL-NECESSITY / MODIFIERS — plans generally cover spinal manipulation (98940-98942) only when medically necessary for an active neuromusculoskeletal condition under a documented treatment plan with periodic re-evaluation; many impose annual visit caps and per-date unit/code caps. Extra-spinal manipulation (98943) and therapy/exercise modalities (97xxx) often need correct modifiers (e.g., -59/-XS for distinct services, GP under a PT plan of care) and may be denied as bundled/not separately payable.
• PRIOR-AUTH / DELEGATION QUIRKS — Cigna chiropractic is delegated to ASH (send auth/claims/treatment plan to ASH, not Cigna); many Anthem (and Aetna) chiropractic benefits route clinical review through ASH PLANS; UHC Medicare Advantage and AARP MA now require Optum prior auth for Medicare-covered chiropractic (effective 9/1/2024) after which up to 6 visits/8 weeks auto-qualify — sending these to the wrong entity is a leading denial cause.
• KENTUCKY MEDICAID CHIROPRACTIC — covered under 907 KAR 3:125 but tightly limited to TWENTY-SIX (26) visits per recipient per 12-month period; covered services are evaluation/management, chiropractic manipulative treatment, diagnostic X-rays, and certain physical modalities (heat/cold, traction, electrical stimulation, ultrasound), reimbursed at the lesser of billed charge or the Medicaid physician fee schedule; the chiropractor must hold an active Medicare provider number, and coverage is medical-necessity-driven (907 KAR 3:130). Medicaid MCOs may apply their own auth rules.
• MEDICARE — spinal CMT (98940-98942) must carry the AT modifier for active/corrective treatment; routine ‘maintenance’ manipulation is non-covered (bill GA/GZ as appropriate with an ABN); CMT is the ONLY chiropractor service Medicare pays (exams, X-rays, and therapy ordered/performed by a chiropractor are statutorily non-covered for Medicare).
• WORKERS’ COMP — bills must be submitted within 45 days (KRS 342.020 / 803 KAR 25:096), reimbursement follows the Kentucky WC fee schedule, and the provider cannot balance-bill the injured worker for care denied solely for the 45-day lateness.
• AUTO/PIP — Kentucky no-fault PIP ($10,000 BRB) pays chiropractic MVA care with a strong statutory presumption of reasonableness/necessity and a 30-day-after-proof-of-loss payment rule; once PIP is exhausted, care shifts to health insurance or a lien/letter-of-protection on the third-party claim (2-year SOL). Not legal advice — verify benefits and current rules per payer.

Largely contract/payer-set, NOT fixed by a Kentucky statute. The common initial-claim filing window for commercial/private payers in Kentucky runs roughly 90-180 days from the date of service (e.g., Humana — headquartered in Louisville — commonly uses ~90 days for participating providers; many Anthem Blue Cross and Blue Shield of Kentucky / Elevance, UnitedHealthcare, Aetna, and Cigna commercial plans use ~90, 120, or 180 days; some allow up to 365 days).

Confirm the exact number in your participating-provider agreement or the payer’s provider manual, since it varies by plan and product. Kentucky context: the state’s PROMPT-PAY / clean-claim law — KRS 304.17A-700 to 304.17A-730 (and 806 KAR 17:360) — governs how fast the INSURER must adjudicate a CLEAN claim, generally requiring payment within thirty (30) days of receipt with interest accruing thereafter; it does NOT set the provider’s SUBMISSION deadline, which remains contractual.

Note: a fully-insured commercial plan governed by Kentucky law differs from a self-funded ERISA plan (where the federal plan document controls) — verify which applies. As of 2025-2026; confirm per payer.

Federal limit: generally 12 months (one calendar year) from the date of service to submit an initial Medicare fee-for-service (Part B) claim. This is set by the Social Security Act (Sec. 1842(b)(3)(B)) and CMS in the Medicare Claims Processing Manual (Ch. 1), not by Kentucky.

Kentucky’s Part A/B MAC is CGS Administrators (Jurisdiction 15). Medicare Advantage plans set their own contractual filing deadlines (often up to ~12 months, sometimes shorter) — confirm per plan. (For chiropractic specifically, Medicare covers only manual manipulation of the spine to correct a subluxation, 98940-98942, and requires the AT modifier for active/corrective treatment — see payerNuance.)

Kentucky Medicaid (administered by the Dept. for Medicaid Services / DMS within the Cabinet for Health and Family Services, fiscal agent Gainwell Technologies) is a 12-MONTH state: initial fee-for-service claims must generally be received within twelve

• months from the date of service; OR twelve
• months from the date retroactive eligibility was established; OR within six
• months of the Medicare adjudication/pay date for Medicare-crossover claims (whichever is later for crossovers); claims may also be filed within 12 months of the last Kentucky Medicaid denial. REJECTED/CORRECTED claims (invalid or missing data elements) must be re-submitted within 180 calendar days. Claims older than 12 months require documentation proving timely original receipt by DMS/Gainwell. The Medicaid MCOs/managed-care plans (Aetna Better Health of Kentucky, Anthem, Humana Healthy Horizons, Passport by Molina, UnitedHealthcare Community Plan, WellCare) generally set their own timely-filing windows (often shorter — many use 180 days or 365 days) — confirm each MCO’s provider manual. Medicaid is the payer of last resort.

Kentucky Workers’ Comp: a medical provider must submit a COMPLETE statement for services (the bill with supporting medical records) to the employer/payment obligor within FORTY-FIVE (45) DAYS of the date treatment is initiated and at least every 45 days thereafter while treatment continues, per KRS 342.020(4) and 803 KAR 25:096 (Medical bill audits and reimbursement), administered by the Kentucky Dept. of Workers’ Claims.

CRITICAL protection: a provider who fails to submit within 45 days may be barred from collecting for those services AND shall NOT bill the patient/employee for services denied solely for late (45-day) submission. The payer must then pay, deny, or contest a complete bill within thirty (30) days of receipt (803 KAR 25:096).

Reimbursement follows the Kentucky WC medical fee schedules (e.g., 803 KAR 25:089 for physicians). The 45-day clock is the easiest timely-filing deadline to miss in Kentucky — submit promptly and re-bill every 45 days.

Kentucky is a NO-FAULT (PIP) state under the Motor Vehicle Reparations Act (MVRA, KRS 304.39): every Kentucky auto policy includes Basic Reparation Benefits (BRB/PIP) of $10,000 per person unless formally rejected, paying medical expense, lost wages, and replacement services regardless of fault. There is NO short ‘days-from-service’ BILL-submission deadline like some PIP states have — instead, the reparation obligor must pay PIP benefits within thirty (30) days after receiving reasonable proof of the fact and amount of loss (overdue payments bear 12%/18% interest), and PIP medical bills carry a statutory presumption of reasonableness/necessity (KRS 304.39-020, -210, -220). The outer LIMITATION is KRS 304.39-230: a PIP claim/action must generally be brought within two

• years after the accident OR within two years after the last PIP payment, whichever is later, and benefits are payable only for loss incurred within that window. PRACTICAL norm: bill PIP/BRB (and any added/optional PIP or MedPay) promptly with proof of loss; once PIP is exhausted, care commonly shifts to health insurance or to a lien/letter-of-protection against the third-party bodily-injury claim, which runs on its own two-year personal-injury statute of limitations. Confirm each policy’s proof-of-loss terms.