Chiropractic insurance billing in West 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 West 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 West Virginia claims are measured against.

A West Virginia chiropractic or multi-specialty practice spends most of its commercial billing day with: Highmark Blue Cross Blue Shield West Virginia; The Health Plan; UnitedHealthcare; CareSource; Aetna; Humana. Each has its own claim portal, fee schedule, and chiropractic medical-policy quirks.

West 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 / ASHLink) operates in West Virginia and is the key delegated chiropractic manager for CIGNA: ASH administers Cigna’s chiropractic (and acupuncture/PT) network management, credentialing, utilization/medical-necessity review, and claims processing – Cigna publicly EXPANDED its use of ASH into West Virginia (2023), so for Cigna ASH members, chiropractic auths and claims route to ASH, NOT to Cigna. ASH also supports certain Aetna and Health Net business nationally – verify whether a given Aetna WV product is ASH-delegated.
• Highmark Blue Cross Blue Shield of West Virginia (the dominant commercial Blue plan in WV) manages outpatient physical medicine, OT, and CHIROPRACTIC prior authorization IN-HOUSE through its provider portal (Availity) rather than carving it to ASH; under WV Senate Bill 267 / W. Va. Code 33-24-7s, prior-authorization requests must be submitted electronically (fax no longer accepted for WV providers), and a Gold Card program can exempt qualifying providers from PA for certain services.
• Optum / Optum Physical Health (UnitedHealthcare) manages outpatient PT/OT and chiropractic for UHC; for UHC Medicare Advantage, prior authorization for the chiropractic TREATMENT PLAN is required (initial evaluation exempt; an initial allowance of up to 6 visits within 8 weeks may proceed without clinical review), submitted via the UnitedHealthcare Provider Portal/Optum.
• Medicaid (Mountain Health Trust) chiropractic is handled by each managed-care MCO (Aetna Better Health of West Virginia, The Health Plan, UniCare/Wellpoint, Highmark Health Options), not one statewide vendor, each under its own coverage rules and PA. Bottom line: route Cigna chiro to ASH, Highmark chiro to Highmark’s own UM via Availity, UHC chiro to Optum, and Medicaid chiro to the member’s MCO – confirm on the ID card before submitting.

West Virginia does NOT mandate a specific stand-alone commercial chiropractic benefit, so commercial coverage, visit caps, and medical-necessity rules are set plan-by-plan – always verify benefits, the delegated manager, and auth requirements BEFORE treating. What actually trips up chiropractic billing in West Virginia:

• Delegation/routing – a Cigna chiropractic claim or authorization goes to American Specialty Health (ASH), not Cigna; a Highmark BCBS WV one stays with Highmark’s own UM via the Availity portal; a UnitedHealthcare one goes to Optum Physical Health. Sending it to the wrong entity is a leading denial cause, and ASH front-loads medical-necessity/treatment-plan documentation and authorizes a limited number of visits at a time.
• Electronic prior-auth mandate – for WV-regulated plans, SB 267 / W. Va. Code 33-24-7s requires PA requests to be submitted electronically (Highmark no longer accepts fax for WV providers); know the Gold Card exemptions.
• Medical necessity and treatment plans – the dominant commercial carriers (Highmark BCBS WV, plus Cigna/UHC under their delegates) cover chiropractic only for an ACTIVE neuromusculoskeletal 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); append modifier 25 to a separately identifiable, separately documented same-day E/M or expect a bundling denial, and use 59/X-modifiers correctly for therapy units.
• WORKERS’ COMP specifics – West Virginia’s WC rule 85-20-46 (Physical Medicine) imposes hard frequency caps: roughly a maximum of 10 visits in the first 14 days and 16 visits in the first 30 days, 12 in the second 30 days, with care generally not exceeding ~60 days and additional treatment requiring authorization and a consulting physician’s recommendation; combine that with the strict 6-month bill-submission window (85-20-9.20) and WC is the most deadline-sensitive line here.
• Medicaid/Mountain Health Trust – 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 the state direct, for managed-care members. Verify benefits, the managing vendor (ASH/Highmark/Optum/MCO), visit caps, and treatment-plan/auth requirements before treating.

Largely contract/payer-set, NOT fixed by West Virginia statute. Commercial/private payers in West Virginia commonly require the initial claim within 90 to 180 days of the date of service, but the exact window is set by the payer’s provider manual or your participating-provider agreement (e.g., Highmark Blue Cross Blue Shield of West Virginia, The Health Plan, UnitedHealthcare, Aetna, and Cigna each set their own; self-funded ERISA plans set their own terms entirely).

West Virginia DOES provide prompt-pay/clean-claim protection on the PAYMENT side under the Prompt Pay Act, W. Va. Code 33-45-2: an insurer must pay or deny a CLEAN claim within 30 days of receipt if filed electronically (40 days if filed manually/on paper), with 10% per annum interest on amounts not timely paid, and if the insurer keeps no record of the receipt date the claim is deemed received 3 business days after submission.

That statute governs how fast the carrier must PAY – it does NOT set your initial filing deadline. As of 2025-2026; confirm the exact filing limit in the specific payer/plan contract.

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 for services on/after Jan. 1, 2010 – and applies in West Virginia the same as nationwide.

The entire state of West Virginia is in Part A/B MAC Jurisdiction 15 (J15), administered by CGS Administrators, so route Part B claims there. Claims filed after one year are denied as untimely (e.g., CO-29) with only very narrow CMS exceptions (retroactive Medicare entitlement, administrative error, certain disasters) and generally no appeal of the timeliness denial.

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 any therapy services are statutorily non-covered for DCs.

12 months (one calendar year) from the date of service to submit the initial claim to West Virginia Medicaid (Bureau for Medical Services / its fiscal agent). The state requirement mirrors the federal rule at 42 CFR 447.45(d): the claim must be RECEIVED within 12 months of the date of service, and the WV Medicaid provider manuals (Chapter 100 General Administration and Information;

Chapter 300 Provider Participation) treat timely filing as the provider’s responsibility (it is NOT subject to document/desk-review hearings). Key sub-rules to know: services not billed within one year of the date of service cannot later be added to a claim; claims for dates of service older than 12 months but not more than 2 years that ORIGINALLY met timely filing must be billed on paper with documentation to the fiscal agent; coordination-of-benefits/third-party claims generally must be submitted within 12 months of the date of service or within 3 months of the primary carrier’s EOB; and adjustments/resubmissions of a processed claim are generally allowed within ~120 days of the paid date (confirm current manual).

IMPORTANT: most WV Medicaid members are in MANAGED CARE under Mountain Health Trust, and the MCOs (Aetna Better Health of West Virginia, The Health Plan, UniCare Health Plan of West Virginia / Wellpoint, and Highmark Health Options of West Virginia) set their OWN contractual filing windows (commonly 365 days, some shorter, with their own COB timelines) – bill the member’s specific MCO under its window for managed-care members; the 12-month rule is the fee-for-service/state-direct baseline.

Confirm per plan.

West Virginia DOES impose a hard provider bill-SUBMISSION deadline: under the Medical Management rule, W. Va. Code R. 85-20-9 (Section 9.20), ‘Bills must be received within six

• months of the date of service to be considered for payment.’ This 6-month window is shorter than most other payer types, so submit WC bills promptly. Bills must include the required identifiers (claim number, date of injury, ICD/CPT codes, dates and type of service) and the supporting documentation (office notes, operative/x-ray/lab reports) before reimbursement is processed (85-20-9.18, 9.21). A bill denied solely for missing the 6-month deadline CANNOT be balance-billed to the injured worker (85-20-9.20). Separately, failure to timely submit appropriately completed forms, or to comply with the rule, fee schedule, or billing guidelines, may be treated as an ‘abusive practice’ under W. Va. Code 23-4-3c (85-20-4.3, 7.1). On the PAYMENT side, West Virginia’s WC system is privatized (carriers/self-insured employers since 2008) and bills are paid at the WC fee schedule (maximum allowable). Bottom line: get WC bills, on the correct forms with documentation, to the authorized payer within SIX MONTHS of the date of service; confirm the carrier’s specifics. As of 2025-2026; not legal advice.

West Virginia is an AT-FAULT (tort) state and does NOT have mandatory no-fault PIP – there is no statutory PIP first-party medical scheme and thus no fixed statutory ‘submit-the-auto-bill-within-X-days’ deadline. First-party auto medical coverage is OPTIONAL Medical Payments coverage (MedPay), which an insured may elect; it pays reasonable and necessary medical expenses (including chiropractic) regardless of fault, up to the policy limit.

Because there is no PIP statute, the bill-submission/notice deadline is governed by the individual MedPay policy’s notice and proof-of-loss terms – the practical norm is to give notice and submit bills to the MedPay carrier PROMPTLY.

For any third-party (at-fault driver) bodily-injury claim, the underlying right must be preserved within West Virginia’s 2-year personal-injury statute of limitations (W. Va. Code 55-2-12); a denied first-party MedPay benefit is a contract claim with its own limitation period.

The state’s Prompt Pay protections (W. Va. Code 33-45) apply to health-benefit claim payment, not auto first-party med-pay timing. There is no single statutory bill-submission deadline for auto here – it is policy/contract-driven – so verify each policy.

As of 2025-2026; not legal advice.