Chiropractic insurance billing in Louisiana.

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 Louisiana are processed by Novitas Solutions (JH) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Louisiana claims are measured against.

A Louisiana chiropractic or multi-specialty practice spends most of its commercial billing day with: Blue Cross and Blue Shield of Louisiana (and HMO Louisiana); UnitedHealthcare; Humana; Ambetter / Louisiana Healthcare Connections (Centene);

AmeriHealth Caritas Louisiana; Aetna. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

Chiropractic and physical-medicine benefits in Louisiana are frequently administered through delegated musculoskeletal / physical-health network managers, which changes WHERE claims, authorizations and treatment plans go. The two dominant managers nationally – and present in Louisiana – are:

• American Specialty Health (ASH / ASHLink), which administers chiropractic, acupuncture and PT networks for several large national carriers (historically Aetna, Cigna and various Anthem/Blue plans for chiropractic/acupuncture utilization management, claims, credentialing and visit authorizations routed through ASHLink rather than the health plan directly); and
• Optum Health / Optum Physical Health (the former ACN Group / OptumHealth Physical Health), which administers UnitedHealthcare’s chiropractic and outpatient-therapy network. As of plan-year 2025 in Louisiana (advance-notification/PA effective dates of Jan. 1, 2025 and Jan. 1, 2026), UnitedHealthcare/Optum requires prior authorization through Optum (via the UHC Provider Portal) for the chiropractic/PT/OT TREATMENT PLAN (a defined number of visits) on Medicare Advantage and many commercial plans – NOT the initial evaluation – and as of early 2025 allows up to six follow-up visits after the initial eval before clinical review is required. Blue Cross and Blue Shield of Louisiana (the largest in-state commercial payer) generally administers its OWN chiropractic/physical-medicine benefit under its Professional Provider Office Manual (Section 5.8) and iLinkBlue rather than delegating chiropractic to ASH. For Louisiana Medicaid, fee-for-service chiropractic is administered by LDH/Gainwell (hardcopy, Medical Review), while the Medicaid MCOs each handle adult chiropractic as an optional ‘In Lieu Of Services’ benefit. ALWAYS verify on the member’s card / via eligibility whether chiropractic is delegated to ASH or Optum (or carved out to the health plan) BEFORE sending the claim or authorization – misrouting is a top denial cause. (Delegation arrangements change by plan and year; confirm per member.)

What trips up chiropractic billing in Louisiana:

• Visit caps and benefit limits live in the member contract, not a single published policy – Blue Cross and Blue Shield of Louisiana’s manual expressly states the Member Contract/Certificate ‘may limit the number of days, visits or dollar amounts,’ and many plans aggregate chiropractic with PT/OT into a combined annual limit, so verify benefits per member before treating.
• Medical necessity / treatment-plan documentation is heavily enforced: BCBSLA requires skilled, reasonable and necessary care with a documented plan of care (diagnosis, long-term functional goals, frequency and duration), legible flow sheets and daily notes, and will recoup on audit; care that plateaus at maintenance level (no functional improvement) is not covered.
• Re-evaluation timing: BCBSLA bundles re-evaluation codes to therapy and does NOT allow a re-eval until 3 months after the initial evaluation (sooner only with a significant diagnosis change or a surgical procedure, on appeal with records).
• Modality / billing quirks: BCBSLA limits supervised modalities (97010-97028) to once per day regardless of areas, constant-attendance modalities (97032-97036) once per day, no duplicate heating modalities for the same area same day, and applies a steep multiple-procedure reduction (100/90/90/90/50/25/5% per unit) across CMT and therapy codes billed the same day; it also does NOT follow CMS ‘incident-to’ rules (each eligible provider must bill under his/her own number, and PTA services bill under the supervising PT).
• Modifier discipline: Medicare and most commercial plans require the AT modifier on active/corrective spinal manipulation (98940-98942), and Medicare covers ONLY spinal CMT by a DC (exams, x-rays and therapies billed by a chiropractor are statutorily excluded and need GY/ABN handling); UHC/Optum now requires PA on the chiropractic treatment plan.
• Auth routing: when chiropractic is delegated to ASH or Optum, the treatment plan and visit authorizations must go to that vendor, not the health plan – a frequent ‘no authorization’ denial.
• Louisiana Medicaid is very restrictive for chiropractic: fee-for-service covers chiropractic manipulative treatment ONLY for beneficiaries under age 21 (via an EPSDT referral from the PCP), limited to manipulation of up to four spinal regions, billed HARDCOPY and pended to Medical Review with the signed referral and medical-necessity documentation; adults 21+ are not covered under fee-for-service and only obtain chiropractic where a Medicaid MCO elects to offer it as an ‘In Lieu Of Services’ benefit. (Plan-specific caps, criteria, delegation and Medicaid MCO benefits change yearly – verify per member/plan; this is general guidance, not legal advice.)

No statewide statute fixes the provider’s INITIAL-claim filing window for commercial/private plans; it is set by each payer’s provider contract. In Louisiana the common contractual initial-filing window runs roughly 90-180 days from the date of service (some plans allow up to 12 months) – confirm the exact limit in each payer’s agreement.

Separately, Louisiana’s prompt-pay / clean-claim law governs how fast the PAYER must adjudicate a CLEAN claim once received, not the provider’s filing deadline: under La. R.S. 22:1832 and LDI Regulation 74, a health insurance issuer must pay a contracted provider’s clean claim within 25 days if filed electronically and within 45 days if filed on paper (non-contracted clean claims generally within 30 days); claims not timely paid accrue a late-payment penalty.

These prompt-pay rules bind the insurer’s payment timing, not the provider’s filing window.

12 months (one calendar year) from the date of service. This is a federal limit under 42 CFR 424.44 / Section 1842(b)(3) of the Social Security Act and applies in Louisiana exactly as nationwide (Novitas Solutions is the Part B MAC for Louisiana, Jurisdiction H).

Claims filed after 12 months are denied (e.g., CO-29) absent a narrow CMS exception (administrative error, retroactive Medicare entitlement, Medicare Secondary Payer recoupment, or a declared disaster).

12 months (365 days) from the date of service for straight (fee-for-service) Louisiana Medicaid claims, per the Louisiana Medicaid ‘Timely Filing Guidelines.’ Key variations: KIDMED claims must be filed within 60 days of service; for Medicare/Medicaid dual-eligible (crossover) claims, file with Medicare within 12 months and, if the claim fails to cross over, submit hardcopy to Medicaid within 6 months of the Medicare EOMB date; claims with third-party (other insurance) payment must reach Medicaid within 12 months of service.

A 2-year override is available only in defined situations (retroactive Medicaid certification, a won Medicare/SSA appeal granting retroactive benefits, or state-caused repeated denials) with proof of timely filing and a cover letter.

Louisiana Medicaid managed-care plans (Healthy Blue, AmeriHealth Caritas LA, Aetna Better Health, Humana Healthy Horizons, Louisiana Healthcare Connections, UnitedHealthcare) set their own filing limits by contract (commonly 365 days; confirm per plan).

Louisiana Workers’ Compensation does NOT impose a fixed number of days for a provider to SUBMIT a medical bill to the carrier/employer – neither La. R.S. 23:1201 nor the OWC medical-billing rules (LAC Title 40, Part I) set a hard provider-side timely-filing cutoff.

Practically, bills should be submitted promptly on the proper form (CMS-1500 / UB-04) with required documentation. The rules instead bind the CARRIER: under La. R.S. 23:1201 the carrier/employer generally has 60 days from receipt of the bill to pay or formally dispute it (Form LWC-WC-1008), and for a complete ELECTRONIC medical bill submitted under the e-billing rules (R.S. 23:1203.2) payment is due within 30 days; late/unpaid medical benefits expose the payer to penalties (up to the greater of 12% of the unpaid amount or $50/day) plus possible attorney fees.

Note: the injured worker’s overall WC CLAIM (not the medical bill) is subject to its own prescriptive periods under R.S. 23:1209. Confirm bill-submission expectations with the specific carrier/TPA.

Louisiana has NO fixed statutory deadline by which a provider must submit auto medical-payments (MedPay) or PIP bills, and Louisiana is a TORT (at-fault) state – it is NOT a no-fault/PIP state, and MedPay/PIP coverage is optional (not mandatory).

When a MedPay/auto policy exists, La. R.S. 22:1892 (and R.S. 22:1973) set the PAYER’s clock, not a provider filing cutoff: the insurer must pay the amount due within 30 days after receipt of satisfactory proof of loss, and an arbitrary/capricious failure exposes it to penalties (50% of the amount due or $1,000, whichever is greater, plus possible bad-faith damages).

Practical norm: bill the MedPay carrier promptly with records and an itemized bill; once MedPay is exhausted, the provider typically bills the patient’s health insurance (subject to that payer’s timely-filing window) or asserts a claim/medical lien against any third-party/liability recovery, which is governed by Louisiana’s personal-injury prescriptive period (now 2 years for delictual actions arising on or after July 1, 2024, per La.

C.C. art. 3493.1; 1 year for accidents before that date). Note Louisiana’s amended ‘No Pay, No Play’ rule (effective Aug. 1, 2025) can bar an uninsured motorist from recovering the first $100,000 of bodily-injury and property damages.