Chiropractic insurance billing in Maryland.

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

A Maryland chiropractic or multi-specialty practice spends most of its commercial billing day with: CareFirst BlueCross BlueShield; UnitedHealthcare; Kaiser Permanente; Aetna; Cigna; Wellpoint (formerly Amerigroup). Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

Two delegated musculoskeletal/chiropractic network managers operate in Maryland, and which one applies determines where enrollment, treatment-plan/prior-auth review, and CLAIMS go.

• American Specialty Health (ASH) — a national specialty-network manager that administers chiropractic (often plus acupuncture/PT) benefits for several carriers active in Maryland, historically including Aetna, Cigna, and Anthem-affiliated lines; when a Maryland plan carves chiropractic out to ASH, network participation, medical-necessity/treatment-plan review, and claims route to ASH (ashlink.com / ASHLink), NOT the health plan.
• Optum / Optum Physical Health (UnitedHealth Group) manages outpatient PT/OT/chiropractic for UnitedHealthcare; since Sept. 1, 2024 UHC requires prior authorization for chiropractic for Medicare Advantage members (initial evaluation exempt; the TREATMENT PLAN/visit count needs auth), with reviews delegated to Optum (CMS Ch. 15 criteria, applicable LCDs, InterQual) and submitted via the UnitedHealthcare Provider Portal — for a new patient or new condition / 90+ day gap, up to 6 visits within 8 weeks are approved without clinical review. CRITICAL MARYLAND NUANCE: the dominant commercial payer is CareFirst BlueCross BlueShield (the Maryland/DC/Northern Virginia Blue plan — it is an INDEPENDENT Blue licensee and a nonprofit health service plan, NOT an Anthem/Elevance company), and CareFirst generally manages chiropractic under its OWN medical policy and prior-authorization framework (MCG-guideline-driven) rather than blanket-carving it to ASH — so most CareFirst chiropractic auths/claims go to CareFirst, not a delegate. Always verify on the member’s card/portal whether chiropractic is carved out to ASH or Optum, because that determines where authorizations and claims go; delegation arrangements vary by plan/product and change over time, and wrong-entity submission is a leading denial cause.

What actually trips up chiropractic billing in Maryland:

• State coverage MANDATE — Maryland’s Comprehensive Standard Health Benefit Plan for the SMALL-GROUP market requires ‘Chiropractic services up to 20 visits per condition per year’ (COMAR 31.11.06.03A(16)); this is a floor for small-group fully-insured plans and a useful benchmark, but it does NOT bind self-funded ERISA plans (common among large MD employers) and large-group/individual plans set their own chiropractic terms — always confirm whether the plan is fully insured small-group (mandate applies), large-group, individual, or self-funded.
• CareFirst BCBS (dominant commercial payer) — covers medically necessary spinal manipulation (98940-98942) for acute neuromusculoskeletal conditions under a documented treatment plan with periodic re-evaluation; coverage is gated by medical necessity (MCG guidelines) and prior authorization can apply by product/diagnosis-procedure combination; maintenance/supportive care is generally not covered; CareFirst FEP (Federal Employee Program) caps manipulations at 12/calendar year (Standard) or 20/calendar year (Basic) — product-specific caps like these are a frequent denial trigger, so verify per plan.
• Medicare / Medicare Advantage — spinal CMT (98940-98942) requires the AT modifier for active/corrective treatment; routine ‘maintenance’ manipulation is non-covered; UHC/Optum MA now requires prior auth for the treatment plan (initial eval exempt) — a Maryland-specific operational change practices keep missing.
• Maryland Medicaid / HealthChoice — chiropractic is administered through the HealthChoice MCOs (generally for enrollees 21+), is tightly limited (medically necessary manual spinal manipulation; maintenance and many modalities excluded), and prior authorization commonly applies — bill the member’s specific MCO under its rules and filing window, not FFS.
• Visit caps & treatment-plan/re-eval rules — most MD commercial/ASH/Optum plans impose annual visit limits and require documented functional improvement and a transition from active care to non-covered maintenance; ASH front-loads medical-necessity/treatment-plan documentation.
• Carve-out routing — sending an ASH-delegated chiropractic claim/auth to the health plan instead of ASH, or a UHC-MA one to UHC instead of Optum, is a frequent denial cause; confirm the delegated administrator BEFORE submitting. Not legal advice — verify benefits and current rules per payer.

Largely contract/payer-set, BUT Maryland is unusual in that state law sets a STATUTORY FLOOR: Md. Code, Insurance Article 15-1005(b) requires every insurer, nonprofit health service plan (CareFirst BlueCross BlueShield), and HMO to ‘permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement.’ So a Maryland-regulated commercial/fully-insured plan may NOT contractually impose a filing window shorter than 180 days; many plans use exactly 180 days, though a plan may allow longer.

Caveats: (a) self-funded ERISA plans are NOT bound by 15-1005 and may use shorter windows (commonly ~90-180 days) — check whether the plan is fully insured or self-funded; (b) when chiropractic is carved out to a delegated manager (e.g., American Specialty Health/ASH or Optum), that administrator’s filing window applies.

Maryland prompt-pay context (the flip side of the same statute): under 15-1005(a)/(c) the carrier must pay or send a notice of receipt/status within 30 days of a clean claim, with interest if a clean claim is unpaid after 30 days (1.5% from day 31-60, 2% from day 61-120, 2.5% after 120 days).

That is a PAYMENT clock, not your submission deadline. Confirm the exact window in your participating-provider agreement and the payer’s manual.

Federal limit: generally 12 months (one calendar year) from the date of service to submit an initial Medicare fee-for-service claim. This is set by federal law — Sections 1814(a)(1), 1835(a)(1) and 1842(b)(3)(B) of the Social Security Act and 42 CFR 424.44, as reduced to 12 months by Section 6404 of the Affordable Care Act (effective for services on/after Jan. 1, 2010) — not by Maryland.

Limited exceptions exist (e.g., administrative error, retroactive Medicare entitlement). Medicare Advantage plans set their own (often ~12-month) contractual deadlines — confirm per plan. Note for chiropractic: Medicare only covers manual manipulation of the spine to correct a subluxation (98940-98942) and the claim must carry the AT modifier for active/corrective treatment; maintenance care is non-covered.

Maryland Medical Assistance (Medicaid / HealthChoice): 12 months from the date of service to submit a clean claim (for acute hospitals, 12 months from date of discharge). This is set by COMAR 10.09.36.06 (Billing Time Limitations) and stated plainly on the Maryland Department of Health (MDH/MMCP) ‘Time Limits for Submitting Invoices’ page: ‘You must submit a clean claim to the Maryland Medical Assistance Program within 12 months of the date of service.’ Key sub-rules from COMAR 10.09.36.06 / the MDH time-limits page:

(a) provider-error denials — resubmit the corrected claim within 60 days of the last rejection (attach the original Remittance Advice); (b) retroactive eligibility — submit within 12 months of the eligibility decision date (attach the IMA-81 notice);

(c) Medicare-crossover / Medicare-primary claims — submit within 12 months of the date of service OR 120 days from the Medicare remittance (EOMB) date, whichever is later. Any claim past the 12-month statute MUST have supporting documentation attached or the system auto-rejects it.

IMPORTANT: most Maryland Medicaid enrollees are in HealthChoice MANAGED CARE, and the MCOs set their OWN (shorter) windows — commonly 180 days from the date of service for initial claims (e.g., Priority Partners, Maryland Physicians Care, UnitedHealthcare/Wellpoint participating and non-participating).

Bill the MCO’s window (often 180 days), not the 12-month FFS limit, for managed-care members; confirm per MCO.

Maryland Workers’ Compensation: a provider must submit a bill on a completed CMS-1500 within 12 months from the LATER of

• the date the service/treatment was provided,
• the date the claim was accepted by the employer/insurer, or
• the date the Commission found the claim compensable. This is set by COMAR 14.09.08.06 (Reimbursement Procedures). Late-filing safety valve: if the bill is submitted after 12 months, the employer/insurer is not required to pay UNLESS the provider files an application for payment with the Workers’ Compensation Commission within 3 years (running from the same ‘later of’ triggering dates) AND the Commission excuses the late submission for good cause. Payment clock: the employer/insurer must reimburse within 45 days of receiving the CMS-1500 unless the bill is denied in full or part. Practical notes: bill per the Maryland WC Medical Fee Guide (COMAR 14.09.03 et seq.) and the carrier’s instructions; chiropractic care is reimbursable when authorized/related to the compensable injury. Confirm the carrier’s specifics.

Maryland is a PIP/no-fault-benefits state: every Maryland private-passenger auto policy carries Personal Injury Protection (PIP) of at least $2,500 (unless waived) that pays reasonable/necessary medical expenses regardless of fault (Md.

Code, Insurance Article 19-505). Maryland does NOT fix a single hard statutory ‘submit-within-X-days’ bill deadline, BUT Insurance Article 19-508 lets the insurer set, in the policy, a period of NOT LESS THAN 12 months after the accident within which the ORIGINAL claim for PIP benefits must be filed — so the practical norm is a 1-year-from-accident original-claim deadline, and the insurer must mail the insured written notice of the latest date a claim may be filed once it receives notice of the accident.

After the original claim is open, supplemental bills are submitted as treatment continues. Payment clock: PIP benefits are overdue if not paid within 30 days of satisfactory proof, and overdue amounts bear interest at 1.5% per month (19-508).

Practical guidance: give written notice and file the PIP application with the auto carrier promptly (well within 1 year) to preserve benefits; once PIP exhausts, coordinate with health insurance/MedPay or present on a third-party liability/lien basis at settlement (the bodily-injury tort claim is bound by Maryland’s 3-year personal-injury statute of limitations, Cts. & Jud.

Proc. 5-101). Confirm each policy’s notice/filing terms.