maintenance and supportive care

Chiropractic maintenance care and supportive care are considered non-covered by many of the HNS payors.  Unless covered under a member’s plan, and unless the care must be reported consistent with one of the following exceptions, maintenance/supportive care must not be billed to an insurance plan that does not cover maintenance and supportive care. 

Exception: When you need to report maintenance/supportive care to a primary payor that does not cover maintenance/supportive care, in order to obtain a denial to use for coordination of benefits and/or if your patient needs to obtain a denial from a payor for reimbursement under a flexible spending account, HSA/HRA account, maintenance/supportive care can be reported to a payor that does not cover these services.  In such instances, in general, maintenance care should be reported using HCPCS code S8990. 

ALL services provided and billed to a HNS contracted payor must be properly documented in the health care record and must be medically necessary, consistent with the patient's chief complaint, clinical findings, diagnoses and treatment plan.

All services provided and billed through HNS must be consistent with all HNS and HNS contracted payor policies, the policies of applicable state licensing boards as well as state and federal laws.

Billing the correct code, S8990, for those services will result in a denial from the primary payor and will provide you with the EOB showing a denial that you may send to the secondary payor or that a patient may use to seek reimbursement under a flexible spending account, HSA/HRA account.

Maintenance/Supportive Care Policies

Absolute Total Care Members

Maintenance and/or supportive care is not covered.

BCBSNC Members

Maintenance and/or supportive care are not a covered chiropractic benefit for the following members:

• BCBSNC members
• NC State Employee Plan members
• Blue Medicare Supplemental members
• HSA/HRA members (high deductible plans)
• ASO self-funded groups

Exceptions: Two self-funded groups:

The City of Cary

Piedmont Natural Gas

(Both of these self insured employer groups DO provide coverage for maintenance/supportive care.)

BCBS Out-of-state plan members

Benefits for BCBS out-of-state members are determined by the member's home plan.  Please contact the home plan directly to determine if maintenance and/or supportive care is covered.  If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member and this must be filed through HNS. 

CIGNA HealthCare Members

Maintenance and/or supportive care is not-covered.

Federal Employee Plan Members

Benefits for FEP members are determined by the member's plan.  Please contact the FEP plan directly to determine if maintenance and/or supportive care is covered.  If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member and this must be filed through HNS. 

Inclusive Health Members

Maintenance and/or supportive care is not-covered.

MedCost Members

Many MedCost payors cover maintenance and supportive care.  Please contact each payor to determine if maintenance and/or supportive care is covered for each of your MedCost patients.  If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member and this must be filed through HNS.

PPC Members

Many PPC payors cover maintenance and supportive care.  Please contact each payor to determine if maintenance and/or supportive care is covered.  If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member and this must be filed through HNS.

Select Health of South Carolina (First Choice Kids) Members

Maintenance and/or supportive care is not-covered.

Maintenance/Supportive Care

Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. 

The American Chiropractic Association published the following definitions: 

“Supportive Care:  Long-term treatment/care . . . for patients who have reached maximum therapeutic benefit, but who fail to sustain benefit and progressively deteriorate when there are periodic trials of treatment withdrawal. Supportive care follows appropriate application of active and passive care including rehabilitation and/or lifestyle modifications. Supportive care is appropriate when alternative care options, including home-based self-care or referral, have been considered and/or attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when risk of supportive care outweighs its benefit, i.e. physician/treatment dependence, somatization, illness behavior or secondary gain.”

 

“Preventive/Maintenance Care:  Elective healthcare that is typically long-term, by definition not therapeutically necessary but is provided at preferably regular intervals to prevent disease, prolong life, promote health and enhance the quality of life. This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. This care may incorporate screening/evaluation procedures designed to identify developing risks or problems that may pertain to the patient's health status and give care/advice for these. Preventive/maintenance care is provided to optimize a patient's health.”