Chiropractic insurance billing in Maine.

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 Maine are processed by National Government Services (JK) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Maine claims are measured against.

A Maine chiropractic or multi-specialty practice spends most of its commercial billing day with: Anthem Blue Cross Blue Shield of Maine; Harvard Pilgrim Health Care; Maine Community Health Options; Aetna; Cigna; UnitedHealthcare. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

American Specialty Health (ASH) is the dominant delegated chiropractic/physical-medicine network manager operating in Maine; ASH lists Maine as an active state and partners nationally with Anthem Blue Cross Blue Shield, Aetna, and Cigna for chiropractic, acupuncture and related physical-medicine benefits.

Where benefits are delegated to ASH, providers credential through ASH (ASHLink), submit medical-necessity review forms to ASH, and route claims/authorizations to ASH rather than the health plan directly – even though the member’s coverage is branded under the insurer.

For UnitedHealthcare, chiropractic and outpatient therapy utilization management is delegated to Optum (Optum Physical Health / myoptumhealthphysicalhealth.com); since 9/1/2024 UHC/Optum requires prior authorization for the treatment plan (number of visits) on therapy and Medicare-covered chiropractic services, while the initial evaluation and routine/maintenance care follow separate rules.

ALWAYS verify the specific Maine plan/product on the member’s card, because delegation varies by plan, employer group, and line of business (commercial vs. Medicare Advantage), and arrangements change – confirm whether claims/auths go to ASH, Optum, or the plan directly before billing.

Maine mandates chiropractic coverage: 24-A M.R.S. Sec. 2748 (individual) and Sec. 2840-A (group) require that when a health contract covers physician/doctor services, therapeutic, adjustive and manipulative services be covered whether performed by an allopathic, osteopathic or chiropractic doctor, and bar an insurer from refusing to reimburse an in-network chiropractor for a covered service or discriminating based on the chiropractic license – subject to reasonable medical-management, visit caps, coinsurance, deductibles and exclusions. In practice, what trips up Maine chiropractic billing:

• Delegation – on Anthem/Aetna/Cigna plans that delegate to ASH, claims/auths sent to the wrong entity deny; ASH typically allows the first few visits then requires a Medical Necessity Review Form before continued care, so missing the ASH review is a common denial driver.
• UHC/Optum prior authorization – since 9/1/2024 the treatment plan (visit count) needs Optum PA for therapy and Medicare-covered chiropractic; the initial eval does not, and maintenance care is non-covered/handled separately.
• Visit caps and medical necessity – most Maine commercial plans cap covered chiropractic visits per year and require an active, documented treatment plan with measurable functional improvement; visits beyond the cap or ‘maintenance’ care without documented necessity are denied.
• Medicare – only manual manipulation of the spine to correct a subluxation (98940-98942) is covered, requires the AT modifier for active/corrective treatment, and exams/therapies/X-rays billed by the chiropractor are statutorily non-covered (use GA/GY/GZ appropriately).
• Re-evaluation/documentation – payers and ASH require periodic re-eval to justify continued care; stale or missing treatment plans are a frequent denial reason. Verify visit limits, modifier and PA rules per the member’s specific plan before each course of care.

Largely contract/payer-set, not fixed by Maine statute. Commercial/private payers in Maine commonly require initial clean claims within 90 to 180 days of the date of service (e.g., Anthem and many plans use 90 days for participating providers; some plans allow up to 365 days) – always confirm the specific payer/plan contract.

Maine’s prompt-pay law (24-A M.R.S. Sec. 2436) governs the OTHER direction: once a carrier receives an undisputed/clean claim, it must pay or deny within 30 days or the claim is overdue and accrues interest. Note: Maine prompt-pay sets the insurer’s payment clock, not the provider’s filing window.

12 months (one calendar year) from the date of service. This is a federal limit applicable in every state, set by Sections 1814(a)(1), 1835(a)(1) and 1842(b)(3)(B) of the Social Security Act and 42 CFR 424.44, as reduced by the Affordable Care Act for services on or after 1/1/2010.

Limited exceptions exist (administrative error, retroactive entitlement, retroactive Medicaid). Applies to Medicare FFS (Parts A/B); Medicare Advantage plans may set their own, usually similar, limits per contract.

MaineCare (Maine Medicaid) requires claims to be filed correctly within one

• year (365 days) from the date services are provided. Where there is other insurance or Workers’ Compensation, the claim must be filed correctly within one
• year from the date on the other carrier’s explanation of benefits (EOB). If MaineCare eligibility is determined retroactively after service, providers generally have one year from the date eligibility was granted to bill. Basis: MaineCare Benefits Manual, Chapter I, Section 1.10 (Submission of Claims), 10-144 C.M.R. ch. 101. Confirm current language, as the manual is amended periodically.

Maine WC does NOT set a single fixed statutory provider bill-submission deadline the way it sets a payment deadline. Under the Maine WC Board Medical Fees rule (90-351 C.M.R. ch. 5), the insurer/employer must pay a compliant bill within 30 days of receipt unless it is controverted or denied, and providers must furnish required medical reports on the Board’s timelines (e.g., initial report generally within 5 business days of the exam, and updated reports roughly every 30 days during ongoing treatment).

Practically, submit bills promptly after service; the underlying claim itself is subject to broader filing periods under Title 39-A. Confirm the carrier’s own bill-submission window and the current Chapter 5 rule.

Maine has no fixed statutory deadline for a provider/insured to SUBMIT auto medical bills. Maine is an at-fault (tort) state and does not mandate no-fault PIP; auto MedPay is the relevant first-party coverage. Maine law (29-A M.R.S. Sec. 1605-A) requires a minimum of $2,000 per person in medical payments coverage, and that coverage applies only to medical costs incurred within one

• year following the date of injury – so bills must arise from treatment within that 12-month window, and higher policy limits/terms are contractual. Once proof of loss is received, the insurer generally must pay within 30 days (24-A M.R.S. Sec. 2436 / Sec. 2436-A unfair claims practices). Practical norm: submit bills as promptly as the policy requires and confirm each carrier’s proof-of-loss/notice terms.