Chiropractic insurance billing in New York.

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 New York 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 New York claims are measured against.

A New York chiropractic or multi-specialty practice spends most of its commercial billing day with: UnitedHealthcare; Anthem (Empire BlueCross BlueShield); Excellus BlueCross BlueShield; Fidelis Care; Healthfirst; EmblemHealth. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

American Specialty Health (ASH) is the dominant delegated chiropractic/acupuncture network and utilization manager operating in New York. Cigna delegates chiropractic and acupuncture network management, credentialing, utilization management, medical-necessity review, AND claims processing to ASH (acupuncture transitioned in 2021; chiropractic likewise managed by ASH), so for many Cigna members in New York those claims, authorizations and clinical/treatment-plan submissions route through ASH via ASHLink (ashlink.com) rather than Cigna directly.

ASH also arranges chiropractic networks for various Medicare Advantage and regional plans in New York (e.g., it has supported chiropractic access for Wellcare/Medicare members in NY). UnitedHealthcare typically manages chiropractic and outpatient physical/occupational/speech therapy through its own Optum (Optum Physical Health, formerly OptumHealth Care Solutions) network and portal – UHC’s chiropractic prior authorizations/clinical submissions are entered in the UnitedHealthcare Provider Portal and adjudicated in Optum systems (note UHC announced 2025-2026 reductions/changes to some chiropractic prior-auth requirements).

Aetna and Anthem/Empire-affiliated lines use ASH for certain chiropractic/specialty programs in some markets. ALWAYS verify on the member’s ID card and the payer’s current provider directory where chiropractic claims and prior-auth/medical-necessity review must be sent, because delegation varies by plan, line of business, and year – if ASH or Optum manages the benefit, claims and treatment-plan/medical-necessity forms go to that vendor, not the health plan.

New York chiropractic billing is shaped by

• a STATE-MANDATED chiropractic benefit: under Insurance Law sections 3216(i)(21), 3221(k)(11) and 4303(y) (see DFS OGC Opinion 07-09-29), every managed-care product that covers physician office services must cover chiropractic care, and any limits must NOT discriminate against chiropractic or be more restrictive than for other professionals treating the same condition. Plans may still apply reasonable visit/benefit limits, cost-sharing, medical-necessity rules and utilization review – so visit caps (commonly ~12-30 visits/year depending on plan) and treatment-plan/re-eval requirements are common and legal, but a blanket exclusion on a comprehensive managed-care plan is not.
• Delegated vendors: when Cigna routes chiropractic/acupuncture to ASH, providers must use ASH’s medical-necessity review/treatment-plan process and ASHLink for eligibility, authorization and claims; UHC chiropractic runs through Optum/the UHC portal – missing the correct vendor workflow is a top denial cause.
• Medical necessity/maintenance: coverage requires an active condition with expected functional improvement; maintenance/supportive/wellness care is not covered, and documentation must show subjective complaint, objective findings, the specific spinal regions/segments manipulated, and re-evaluation of progress.
• Modifier discipline: for Medicare (and payers mirroring Medicare) the AT modifier must be appended to spinal CMT codes 98940-98942 only for active/corrective treatment – claims without AT are treated as non-covered maintenance and denied, and Original Medicare covers ONLY spinal manipulation (98940-98942), never exams, x-rays, or DC-performed therapy; bill the patient/secondary appropriately.
• E/M with CMT: New York commercial payers scrutinize an E/M billed same-day as CMT and generally require modifier 25 with a distinct, separately documented service.
• NY Medicaid chiropractic is LIMITED: the eMedNY Chiropractor Manual is titled ‘Limited Chiropractic Service Coverage’ – chiropractic for children under 21 is covered through EPSDT / the Child-Teen Health Program, while adult fee-for-service Medicaid chiropractic coverage is restricted (and managed-care plans set their own rules) – verify member eligibility and the plan before treating.
• No-fault/auto: chiropractic in NY auto cases must meet the 30-day notice / 45-day bill deadlines and is subject to no-fault verification, IMEs/peer review, and the fee schedule. Bottom line: confirm benefits, the managing network (ASH vs. Optum vs. the plan), the visit cap, and the auth/treatment-plan and modifier requirements before treating.

New York is unusual: it sets a STATUTORY MINIMUM filing window. Under Insurance Law section 3224-a(g), a health-care provider’s claim is valid and enforceable if initially submitted within 120 days after the date of service, and a payer generally may NOT enforce a contractual filing limit shorter than 120 days for fully insured commercial plans (for Medicaid and Child Health Plus managed care the parties may agree to a different period but in no event less than 90 days).

So the practical commercial initial-claim window in New York is commonly 120-180 days from date of service, with 120 days being the statutory floor for fully insured plans; many carriers publish 90-180 days but cannot lawfully go below the 120-day floor on fully insured business.

CAVEATS: self-funded/ERISA employer plans are NOT bound by section 3224-a and can set their own (sometimes shorter) limits, and out-of-network/secondary/COB timelines differ. Separately, New York’s Prompt Pay Law (Insurance Law section 3224-a(a)-(c)) governs how fast payers must PAY clean claims – 30 days if submitted electronically, 45 days if by paper/fax, with interest at the greater of 12% per annum or the corporate-tax rate on late clean claims – but that is a payment deadline, not the provider’s filing deadline.

Always confirm the exact timely-filing limit in the specific payer/plan contract and whether the plan is fully insured or self-funded.

12 months (one calendar year) from the date of service. This is the federal Medicare limit under 42 CFR 424.44 / Section 1842(b)(3)(B) of the Social Security Act and applies in New York the same as nationwide; claims filed after one year are denied for untimely filing with no appeal rights on the timeliness denial (narrow exceptions exist, e.g., certain administrative errors or retroactive Medicare/Medicaid entitlement).

90 days from the date of service for the INITIAL claim (18 NYCRR 540.6(a)(1); statutory authority Social Services Law section 367-b). Claims submitted after 90 days are denied unless the delay was due to circumstances OUTSIDE the provider’s control and a valid eMedNY delay reason code / documentation is attached – provider-side delays (e.g., billing backlog) do not qualify.

There is an absolute OUTER limit of two years (24 months) from the date of service: no claim – including corrected/replacement claims – may be paid more than two years after the date of service. Adjustments/voids and replacement claims with corrected information must be submitted within 60 days of discovering the error but never beyond the two-year cap.

IMPORTANT: New York Medicaid MANAGED CARE plans (the majority of NY Medicaid enrollees) set their own contractual filing windows that are often shorter than fee-for-service (commonly 90-120 days, sometimes longer) – confirm the specific plan’s limit.

Generally 120 days. Under 12 NYCRR 325-1.25, an authorized provider must submit the medical bill (now the CMS-1500 form) to the employer/carrier/third-party administrator within 120 days from the last day of the month in which services were rendered, or within 90 days from the last day of the month in which the claimant received final treatment in a continuous course of treatment.

As of August 1, 2025, the Workers’ Compensation Board REQUIRES all providers to submit the CMS-1500 electronically through a Board-approved submission partner (XML), and a payer may deny payment – with the Board declining to enforce payment – if the bill was not submitted electronically through an approved partner.

Submit promptly; the format and channel requirements are as high-stakes as the deadline.

New York no-fault (PIP) has SHORT, strict statutory deadlines under Regulation 68 (11 NYCRR 65). The eligible injured person must give the insurer WRITTEN NOTICE OF CLAIM within 30 days of the accident, and a health provider must submit written PROOF OF CLAIM (the bill) within 45 days after the date services are rendered.

Late submission is excused only if the claimant/provider gives ‘clear and reasonable justification’ for the delay (11 NYCRR 65-1.1 / 65-2.4). These are far stricter than most states’ auto rules and are a leading cause of New York no-fault denials.

No-fault insurers must also PAY or deny verified claims within 30 days of receipt of proof. Verify each policy and meet the 30-day notice and 45-day bill deadlines – do not assume a longer window.