Chiropractic insurance billing in Montana.

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 Montana are processed by Noridian Healthcare Solutions (JF) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Montana claims are measured against.

A Montana chiropractic or multi-specialty practice spends most of its commercial billing day with: Blue Cross and Blue Shield of Montana; Mountain Health CO-OP; PacificSource Health Plans; UnitedHealthcare; Cigna; Allegiance Benefit Plan Management.

Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

Two delegated musculoskeletal/chiropractic network managers operate in Montana.

• American Specialty Health (ASH) administers chiropractic (and often acupuncture/PT/massage) benefits for several national plans active in MT. Cigna delegates chiropractic/PT network management, credentialing, utilization/medical-necessity review, and claims processing to ASH (Cigna’s multi-market expansion of ASH continued through 2023-2024); ASH also historically serves Aetna, Anthem/Elevance, and Health Net lines, and Blue Cross and Blue Shield of Montana (BCBSMT, an HCSC plan) has on many products routed covered chiropractic through ASH so that claims/authorizations go to ASH (ashlink.com) rather than the health plan.
• Optum / Optum Physical Health (UnitedHealth Group) manages chiropractic and outpatient therapy for UnitedHealthcare: UHC delegates initial authorization and concurrent review for Medicare-covered chiropractic and outpatient therapy to Optum, entered through the UnitedHealthcare Provider Portal and adjudicated in Optum systems. Always verify on the member’s ID card/portal whether chiropractic is carved out to ASH or Optum, because that determines where enrollment, prior auth/treatment-plan submission, and claims are routed. Other significant Montana commercial payers (PacificSource, Mountain Health CO-OP, Allegiance Benefit Plan Management, and BCBSMT’s own products) may administer chiropractic in-house under their own visit caps and prior-auth rules — confirm per plan.

What trips up chiropractic billing in Montana:

• Carve-out routing — a leading denial cause. Cigna chiropractic (and many ASH-administered Blue/Aetna products, including BCBSMT products that route to ASH) goes through ASH (ashlink.com), while UnitedHealthcare routes through Optum via the UHC portal; sending the claim or treatment-plan auth to the health plan instead of the delegated administrator gets it bounced. Confirm the delegated entity on the member’s card before submitting.
• Visit caps and treatment-plan/medical-necessity rules — ASH-administered plans generally impose an annual visit limit and require the chiropractor to submit a treatment plan to ASH for approval, with periodic re-evaluation and a clear shift from active/corrective to ‘maintenance’ care (maintenance is typically non-covered). Among Montana commercial plans, caps vary widely: PacificSource Montana individual/family plans have run roughly 10 chiropractic visits per benefit period with prior authorization required beyond that, and the Montana State Employee plan (administered by BCBSMT) has used a higher annual visit allowance — always check the specific Summary of Benefits.
• UHC/Optum MA prior auth — for Medicare-COVERED chiropractic (spinal manipulation, AT modifier), the initial evaluation is generally exempt but the ongoing treatment plan requires authorization; UHC has allowed up to ~6 follow-up visits after an initial eval without clinical review, with anything beyond going to medical-necessity review. ‘Routine’ supplemental chiropractic on some MA plans is a separate, non-Medicare benefit that may not require prior auth.
• Modifiers/coding quirks — expect AT (active treatment) on Medicare/MA spinal manipulation (98940-98942), correct GA/GY/GZ usage, and proper -59/-XU when distinct services are billed; remember Medicare/MA covers ONLY manipulation, not the DC’s exams, x-rays, or therapies.
• Montana chiropractic-specific statutes — Mont. Code Ann. 33-22-111 guarantees insureds ‘freedom of choice’ to select a licensed chiropractor for covered illness/injury within the scope of practice (a self-referral/anti-discrimination protection, not a benefit mandate), and Mont. Code Ann. 33-22-125 requires that any insurer-required independent physical exam of a chiropractic patient be performed by a chiropractor practicing in Montana, and that any records review during an appeal/redetermination of a chiropractic medical-necessity denial be performed by a person trained in chiropractic — useful leverage on utilization-review denials.
• Medicaid scope — verify the current Montana Healthcare Programs chiropractic benefit (coverage and any visit limits) before treating a Medicaid member, and bill within the 12-month window. Not legal advice — verify benefits and current rules per payer.

Largely contract/payer-set, not fixed by Montana statute. The common initial-claim filing window for commercial/private payers runs roughly 90-180 days from the date of service (many ASH-administered plans and several national carriers run ~90-120 days; some Montana plans allow up to ~180 days or a calendar year).

Always confirm the exact deadline in your participating-provider agreement or the payer’s provider manual, since it can be shorter or longer by plan and product line. Montana context: the state ‘prompt pay’ law, Mont. Code Ann. 33-18-232, governs how fast the CARRIER must act — an insurer must pay or deny a claim within 30 days after receipt of a proof of loss, or within 60 days if it makes a reasonable request for additional information/documents; failure to comply (when the insurer is liable) requires payment of the claim plus 10% annual interest from the date the claim was due (interest owed only if it exceeds $5).

That law sets the insurer’s PAYMENT clock, not the provider’s SUBMISSION deadline, which remains contractual.

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 the Social Security Act (Section 1842(b)(3)(B)) and CMS, not by Montana. Medicare Advantage plans may set their own (often similar, up to ~12-month) deadlines — confirm per plan.

Note: for chiropractic, Medicare/MA covers only spinal manipulation (CPT 98940-98942) with the AT modifier for active/corrective care (exams, x-rays, and therapies performed by the DC are not covered); UnitedHealthcare/Optum MA plans now require prior authorization for Medicare-COVERED chiropractic beyond an initial allowance (see networks/payerNuance), while ‘routine’ supplemental chiropractic offered on some MA plans is handled separately.

Montana Healthcare Programs (Montana Medicaid): generally 12 months (365 days) from the LATEST of

• the date of service,
• the date retroactive eligibility is determined, or
• the date disability was determined, to submit a clean claim, per Mont. Admin. R. 37.85.406(1)(a) and the General Information for Providers manual. Exceptions: Medicare crossover claims have 6 months from the date on the Medicare EOB approving the service (if the Medicare claim was timely filed and the member was Medicare-eligible when filed) — Mont. Admin. R. 37.85.406(1)(b); claims following a third-party-liability adjustment have 6 months from the date on the TPL payer’s adjustment notice (when that notice is dated after the periods above) — 37.85.406(1)(c). A separate 180-day rule applies to claims for a retroactive rate/payment increase. The submission date is the date the claim is received by the Department or its claims-processing contractor. Confirm current rules in the live provider manual before relying on these.

Montana Workers’ Compensation: providers must submit medical bills within 365 days, absent a showing of good cause. Under Mont. Admin. R. 24.29.1402(1)(c) (effective for dates of service on or after July 1, 2022), a bill is timely received when the employer or appropriate payer actually receives it within 365 days of the LATER of (a) the date of service or (b) the date the provider knew the treatment/services were related to a claim for benefits under the Workers’ Compensation Act.

On the payer side, the insurer must pay medical bills at the fee-schedule rate within 30 days of receipt; if not paid within 30 days, the provider may assess a 1%-per-month interest penalty (Montana unique code MT005), consistent with Mont.

Code Ann. 39-71-704 and the Department of Labor & Industry medical-billing/fee-schedule rules. Bill on a CMS-1500 or UB-04 with supporting documentation. Treatment outside the Department’s adopted utilization & treatment guidelines requires prior authorization from the insurer.

Montana is an at-fault (tort) state with NO no-fault/PIP system and NO fixed statutory deadline for submitting medical bills to an auto carrier. The relevant first-party coverage is optional Medical Payments (Med-Pay), which pays the insured’s medical bills regardless of fault up to the purchased limit; any bill-submission timeframe is set by the individual auto policy (commonly a 1-, 2-, or 3-year window), not by statute — submit promptly per policy terms.

Once a clean first-party claim is received, the insurer’s PAYMENT clock is governed by Montana’s prompt-pay law, Mont. Code Ann. 33-18-232 (pay or deny within 30 days of proof of loss, or 60 days if more information is reasonably requested; 10% annual interest for noncompliance when liable); motor-vehicle property-damage claims have an additional prompt-pay statute, 33-18-245.

The underlying third-party liability/personal-injury claim is bound by Montana’s 3-year personal-injury statute of limitations (Mont. Code Ann. 27-2-204), with 2 years for property damage; on a liability/lien basis, bills are typically presented at settlement.

Confirm each Med-Pay policy’s notice/submission terms.