Email: ktf781@aol.com Hugh M. Spoljaric, Chairman
Trust Health Clarifications
The following is a clarification of National Health Administrators, Inc. plan provisions regarding Massage Therapy and Chiropractic Care:
Effective January 1, 2003, the plan was amended as follows:
Massage Therapy shall only be covered when pre-approved under a Case Management program in conjunction with a very serious injury or chronic medical condition, where massage therapy is under the direct supervision of a doctor. Massage Therapy, for purposes of this Plan, is limited to that therapy that is medically necessary to facilitate treatment and is part of an overall treatment plan based on a specific diagnosis involving a chronic or very serious injury or illness.
Any Massage Therapy must be prescribed in writing by a medical doctor or doctor of osteopathy or chiropractic stating the diagnosis code and reason for the treatment prior to treatment. The treatment plan along with the diagnosis must be submitted for pre-approval prior to treatment to determine medical necessity. Routine maintenance is not considered “medically necessary” for the purposes of this Plan. If Massage Therapy is approved, it shall be paid subject to the above limits. Massage Therapy shall be included and limited to the overall chiropractic dollar limit. Extended therapy may be approved for a serious or chronic condition under Case Management where it is medically necessary.
Pre-Certification of Treatment Plan: Any combination of chiropractic, massage therapy or acupuncture treatment expected to exceed six visits during any 30-day period under the supervision of the same medical provider must be pre-certified. Massage Therapy must be pre-certified and accompanied by a treatment plan and explanation of medical necessity by the doctor. No benefits will be paid for any massage therapy that has not been pre-approved in advance.
CHIROPRACTIC-Any request for chiropractic care should include legible documentation of the following:
1. Basic examination, which should include:
a. Detailed history of client and the client complaints
b. These should include the onset of the complaint
c. Provocation of the pain
d. Quality of the pain
e. Any radiation of the pain noted
f. The severity and time of frequency of the problem
g. Necessary neurological, orthopedic, or chiropractic evaluation should be conducted.
2. Chiropractic evaluation could include:
a. Rnage of motion of the region
b. Spinal palpation
c. Motion palpation
d. Posture palpation
e. Muscle testing and
f. Other pertinent chiropractic diagnosis tests (x-rays should be taken as necessarily indicated. Surface EMG or thermal scans, if indicated).
3. Care Plan: finding of tests should be correlated, evaluated, and working diagnosis as well as a differential diagnosis noted. A definitive care plan for the client should be formulated from this information. The care plan should be aimed at a definitive successful release from the care for the client complaint.
Certification will be based on the above findings.
The above rules are effective for any massage therapy treatment received after August 1, 2003.
If you receive massage therapy based on prior rules effective March 1, 2002, which required pre-certification for 3 or more visits during any 60 days, these benefits will be covered based on the announcement in the June 2003 Torch. If you are currently receiving massage therapy, you will need to have the treatment pre-certified with Century Health Solutions immediately.
Any treatment received on or after August 1, 2003, will have to be retrospectively certified.
Refer any questions regarding this clarification to the NHA Compliance Office or with Century Health Solutions at 1-888-679-2400.
For additional Health Trust information and updates, including clarifications on Massage Therapy and Chiropractic. Continue to scroll down.
Concerns? Contact Miriam White at the Trust Office, 845-338-5422.