Chiropractic insurance billing in Virginia.

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 Virginia are processed by Palmetto GBA (JM) — its Local Coverage Determination and documentation expectations (and its audits of the AT modifier and medical necessity) are the ones your Virginia claims are measured against.

A Virginia chiropractic or multi-specialty practice spends most of its commercial billing day with: Anthem Blue Cross Blue Shield (Elevance); Sentara Health Plans (formerly Optima Health); Aetna (CVS Health); UnitedHealthcare; Cigna;

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

Virginia chiropractic claims and prior-authorization do NOT all route to one vendor – delegation varies by payer, product, and line of business, so check the member ID card and payer portal every time.

• American Specialty Health (ASH) is the key delegated chiropractic manager in Virginia: ASH administers the chiropractic network and medical-necessity/treatment-plan review for Anthem’s Virginia subsidiary, HealthKeepers, Inc., on its LOCAL HealthKeepers HMO and POS products (network participation, clinical review, and claims route to ASH/ASHLink, not Anthem) – but note Anthem’s HealthKeepers POS Select product does NOT use ASH (chiropractors contract directly with Anthem for POS Select), and PPO/large national accounts may differ, so verify the product.
• Optum / Optum Physical Health (UnitedHealth Group) manages outpatient PT/OT and chiropractic for UnitedHealthcare; for UHC Medicare Advantage, prior authorization for the chiropractic TREATMENT PLAN is required (initial evaluation exempt; for a new patient/new condition or 90+ day gap, up to 6 visits within 8 weeks proceed without clinical review), submitted via the UnitedHealthcare Provider Portal/Optum.
• Anthem (HealthKeepers) also uses Carelon Medical Benefits Management (formerly AIM) for certain musculoskeletal/rehabilitation utilization-management programs on some products – confirm whether PT/rehab auth routes to Carelon.
• The dominant commercial Blue plan SPLITS by region in Virginia: Anthem Blue Cross and Blue Shield (HealthKeepers) is the Blue licensee for most of Virginia, while CareFirst BlueCross BlueShield is the Blue plan serving the NORTHERN VIRGINIA/DC-metro suburbs (Arlington, Alexandria, Fairfax, Falls Church area); CareFirst generally administers chiropractic under its OWN medical policy and prior-auth framework (MCG-guideline-driven) rather than carving it to ASH.
• Sentara Health Plans (which absorbed Optima Health) administers chiropractic under its own medical policies and pre-authorization rules.
• Medicaid/Cardinal Care chiropractic is handled by each managed-care MCO (Aetna Better Health, Anthem HealthKeepers Plus, Molina, Sentara Community Plan, UnitedHealthcare Community Plan), not one statewide vendor. Bottom line: route Anthem HealthKeepers HMO/POS chiro to ASH, UHC chiro to Optum, Anthem PT/rehab auth possibly to Carelon, and CareFirst/Sentara to their own UM – confirm on the ID card.

Virginia has a chiropractic EQUAL-COVERAGE (non-discrimination) mandate, not a stand-alone benefit mandate: if a health/accident-and-sickness policy reimburses a service that a licensed chiropractor may legally perform, it may not deny reimbursement solely because a chiropractor rendered it (Va. Code 38.2-3408 for health insurance; Va. Code 38.2-4221 for HMOs), and the same non-discrimination rule applies to auto/motor-vehicle policies (Va. Code 38.2-2203). This equalizes treatment but does NOT force a chiropractic benefit, override visit caps, or waive medical-necessity rules. What actually trips up chiropractic billing in Virginia:

• Carve-out routing – the single biggest Virginia-specific snag is sending an Anthem HealthKeepers HMO/POS chiropractic claim or authorization to Anthem instead of American Specialty Health (ASH), or a UHC Medicare Advantage one to UHC instead of Optum; wrong-entity submission is a leading denial cause. ASH front-loads medical-necessity/treatment-plan documentation and authorizes a limited number of visits at a time.
• Medical necessity and treatment plans – the dominant commercial carriers (Anthem/HealthKeepers, CareFirst in Northern Virginia, Sentara/Optima) cover chiropractic only for an active condition expected to improve, require a documented treatment plan with measurable functional goals and periodic re-evaluation, and exclude maintenance/supportive care; most commercial plans impose annual visit caps (commonly ~12-30 visits/year) or dollar caps.
• Modifier discipline – for Medicare and payers mirroring it, the AT modifier must be on spinal CMT 98940-98942 for active/corrective care (no AT = treated as non-covered maintenance and denied), and Original Medicare covers ONLY 98940-98942 (never the exam, x-rays, or therapy); re-evaluate roughly every 12 visits.
• E/M with CMT – append modifier 25 to a separately identifiable, separately documented same-day E/M, or expect a bundling denial; use modifier 59/X-modifiers correctly for therapy units.
• FEP and product-specific caps – CareFirst/BCBS Federal Employee Program caps manipulations (commonly 12/year Standard, 20/year Basic), a frequent denial trigger in Northern Virginia.
• Medicaid/Cardinal Care – chiropractic is limited and administered through the member’s MCO with its own coverage rules, visit limits, and prior-auth – bill the specific MCO, not DMAS direct, for managed-care members. Verify benefits, the managing vendor (ASH/Optum/Carelon/plan), visit caps, and treatment-plan/auth requirements BEFORE treating.

Largely contract/payer-set, and UNLIKE neighboring Maryland and North Carolina, Virginia does NOT impose a statutory minimum filing-window floor on commercial/fully-insured plans – there is no Virginia analog to MD Ins. 15-1005 or N.C.

Gen. Stat. 58-3-225 that forbids a window shorter than 180 days. So the initial timely-filing deadline is set entirely by the payer/plan or your participating-provider agreement, and the common range in Virginia is 90-180 days from the date of service (e.g., many Aetna commercial plans run ~120 days;

Cigna and UnitedHealthcare commercial commonly 90-180 days; some employer-sponsored/Medicare Advantage products allow up to 1 year). When chiropractic is carved out to a delegated manager (American Specialty Health/ASH for Anthem HealthKeepers HMO/POS), that vendor’s filing window applies, not the health plan’s.

Virginia DOES provide prompt-pay/clean-claim protections on the PAYMENT side under Va. Code 38.2-3407.15 (‘Ethics and fairness in carrier business practices’) and 38.2-3407.1/.13: carriers must process clean claims and pay/deny within the contract’s prompt-pay terms (generally 40 days for electronic clean claims), with interest on late clean claims, and a carrier cannot retroactively deny/recoup a paid claim more than 12 months later except for fraud, duplicate payment, or services not rendered.

Those govern payment speed and recoupment, NOT your initial filing deadline – so always confirm the exact filing limit in the specific payer/plan contract (and note self-funded ERISA plans set their own terms entirely).

12 months (one calendar year) from the date of service. This is the federal Medicare limit – 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 (services on/after Jan. 1, 2010) – and applies in Virginia the same as nationwide.

VIRGINIA HAS TWO Part B MACs, so route claims to the right one: Palmetto GBA (A/B MAC Jurisdiction M) processes Part A and Part B for MOST of Virginia, BUT Part B for the Northern Virginia/DC-metro area – Arlington County, Fairfax County, and the cities of Alexandria, Fairfax, and Falls Church – is handled by Novitas Solutions (A/B MAC Jurisdiction L).

Claims filed after one year are denied for untimeliness with very narrow exceptions (e.g., retroactive Medicare entitlement, administrative error). Medicare Advantage plans set their own (often ~12-month) deadlines – confirm per plan.

Chiropractic reminder: Original Medicare covers ONLY manual spinal manipulation (98940-98942) with the AT modifier for active/corrective care; the exam, x-rays, and therapy services are non-covered.

12 months (one calendar year) from the date of service to submit the initial claim to Virginia Medicaid (DMAS). This is set by Virginia Administrative Code 12VAC30-95-10 (‘Timely claims filing’), which mirrors the federal requirement at 42 CFR 447.45(d) that the initial claim be received within 12 months of the date of service; the DMAS provider manuals (Chapter V billing instructions) state plainly that ‘all claims for services must be billed to DMAS within 12 months from the date of the service’ and that if a provider waits on another payer past 12 months, DMAS will make no reimbursement.

Key sub-rules: ‘submission’ means actual physical/electronic receipt by DMAS (the provider bears the burden of confirming receipt within the 12 months), and DMAS encourages billing within 30 days of the last date of service. IMPORTANT: most Virginia Medicaid members are in MANAGED CARE – Cardinal Care Managed Care MCOs (Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Molina/formerly Magellan Complete Care, Sentara Community Plan/Optima Health Community Care, UnitedHealthcare Community Plan) – and the MCOs set their OWN, typically SHORTER, contractual filing windows (commonly 180 days, sometimes 365, from the date of service), with their own crossover/coordination-of-benefits timelines.

Bill the member’s specific MCO under its window for managed-care members; the 12-month limit is the fee-for-service/DMAS-direct rule. Confirm per plan.

Virginia does NOT set a fixed statutory number of days/months by which a health care provider must SUBMIT its initial medical bill to the employer/carrier – Va. Code 65.2-605.1 and the Rules of the Virginia Workers’ Compensation Commission impose PAYMENT-side and DISPUTE deadlines, not an initial-submission deadline.

Practically: once the provider sends an itemization, the employer/carrier must (a) PAY uncontested bills within 60 days of receiving each itemization, and (b) if contesting, denying, or treating a bill as incomplete, NOTIFY the provider within 45 days of receipt (Va.

Code 65.2-605.1(A)). A provider who wants to dispute the SUFFICIENCY of payment must file a claim with the Commission within ONE YEAR of the date the last payment was received, or – if the employer denied/contested payment – within one year of the date the medical award covering that service becomes final (Va.

Code 65.2-605.1(F)). E-billing is mandatory for most providers for dates of service on/after July 1, 2019 (Va. Code 65.2-605.1(G); 16VAC30-16), with an exemption for providers with 15 or fewer FTEs or under 250 WC bills in the prior year.

Bottom line: there is no fixed ‘file within X days of service’ rule, but the underlying right to payment is tied to a compensable claim, so submit bills to the authorized payer PROMPTLY (and well within one year) to preserve payment and your one-year dispute window; confirm the carrier’s specifics.

Virginia is an AT-FAULT (tort) state and does NOT have mandatory no-fault PIP. First-party auto medical coverage is ‘Medical Expense Benefits’ (MedPay/Med-Pay) under Va. Code 38.2-2201, which insurers must OFFER (and the insured may elect) – it is not automatically on every policy – with a typical minimum of $2,000 per person; it pays reasonable and necessary medical (including chiropractic), hospital, dental, surgical, prosthetic, and rehab expenses regardless of fault.

There is NO fixed statutory ‘submit-the-bill-within-X-days’ deadline: 38.2-2201 covers expenses INCURRED within three years after the accident, and the statute expressly says benefits are payable notwithstanding the insured’s failure to give notice ‘as soon as practicable’ UNLESS the late notice prejudices the insurer’s ability to validate the claim.

So the practical norm is: give notice and submit bills to the MedPay carrier promptly (the policy’s notice/proof-of-loss terms control), and expenses are covered if incurred within 3 years of the accident. Virginia also bars denying auto reimbursement just because the service was rendered by a licensed chiropractor (Va.

Code 38.2-2203). For any third-party (at-fault driver) bodily-injury claim, preserve it within Virginia’s 2-year personal-injury statute of limitations (Va. Code 8.01-243); a denied first-party MedPay benefit is a contract claim subject to its own limitation period.

There is no single statutory ‘bill submission’ deadline for auto here – it is policy/contract-driven within the 3-year coverage window, so verify each policy.