[PDF] Provider Chiropractor Grid Limitations. Coverage limited to manual





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Provider Chiropractor Grid

Limitations. Coverage limited to manual manipulations of the spine. Members 21 years of age and over are limited to a specific set of spinal.



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HUSKY Health Provider Benefits and Prior Authorization Requirements Grid*

Chiropractor

Effective January 1, 2012

Member Services: 800-859-9889

Authorizations: 800-440-5071

Option #2 Authorization Fax: 203-265-3994

*Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per Department of Social Services.

Last Update: 10/1/2021 / MMTPE0001-0312

Chiropractor

Covered Services for HUSKY Health A, B, C, and D Members

*Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per Department of Social Services.

Last update: 10/1/2021 / MMTPE0001-0312

2 HUSKY Health Program Benefits and Prior Authorization Requirements Grid*

Chiropractor

Effective: January 1, 2012

Member Services: 800-859-9889

Authorizations: 800-440-5071

Option #2 Authorization Fax: 203-265-3994

Benefit HUSKY A, HUSKY C HUSKY B HUSKY D

Chiropractor:

Manual manipulation of the

spine performed by a licensed chiropractor

Effective October 1, 2021: Covered for all

members when performed in independent office settings, federally qualified health centers (FQHCs), and outpatient hospitals.

Limitations

Coverage limited to manual manipulations of

the spine. Members 21 years of age and over are limited to a specific set of spinal diagnoses (Ref: DSS Fee schedule

Instructions, Table 20, available on the DSS

website at: www.ctdssmap.com).

Limited to codes on the DSS Fee Schedule.

Prior Authorization

Members 21 years of age and older:

PA required for more than 5 visits per

member, per provider, per month.

Members under the age of 21:

PA required for all services.

PA request must include: the diagnosis,

recommended type, length, and frequency of services.

Chiropractor services can be rendered by an

independently enrolled provider.

Limited to codes on the DSS Fee Schedule.

Prior Authorization

PA required for all services.

PA request must include the diagnosis,

recommended type, length, and frequency of services.

Effective October 1, 2021: Covered for all

members when performed in independent office settings, federally qualified health centers (FQHCs), and outpatient hospitals.

Limitations

Coverage limited to manual manipulations of

the spine. Members 21 years of age and over are limited to a specific set of spinal diagnoses (Ref: DSS Fee schedule

Instructions, Table 20, available on the DSS

website at: www.ctdssmap.com).

Limited to codes on the DSS Fee Schedule.

Prior Authorization

Members 21 years of age and older:

PA required for more than 5 visits per

member, per provider, per month.

Members under the age of 21:

PA required for all services.

PA request must include: the diagnosis,

recommended type, length, and frequency of services.

Out of Network Services Non-Covered

Providers must be an enrolled CMAP

provider to be reimbursed for services.

Non-Covered

Providers must be an enrolled CMAP

provider to be reimbursed for services.

Non-Covered

Providers must be an enrolled CMAP

provider to be reimbursed for services. HUSKY Health Provider Benefits and Prior Authorization Requirements Grid*

Chiropractor

Effective January 1, 2012

Member Services: 800-859-9889

Authorizations: 800-440-5071

Option #2 Authorization Fax: 203-265-3994

*Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per Department of Social Services.

Last Update: 10/1/2021 / MMTPE0001-0312

Benefit HUSKY A, HUSKY C HUSKY B HUSKY D

Out of State Care Non-emergent care requires prior authorization.

Non-emergent care requires prior

authorization.

Non-emergent care requires prior

authorization.

Out of Country Care (with

the exception of Puerto

Rico and USA territories of

American Samoa,

Federated States of

Micronesia, Guam, Midway

Islands, Northern Marina

Islands, US Virgin Islands)

Out of the country care (including emergency

care) is not a covered benefit (with the exception of Puerto Rico and other USA territories - where emergency care is covered).

Out of the country care (including emergency

care) is not a covered benefit (with the exception of Puerto Rico and other USA territories - where emergency care is covered).

Out of the country care (including emergency

care) is not a covered benefit (with the exception of Puerto Rico and other USA territories - where emergency care is covered). Translation Services 1-800-440-5071 1-800-440-5071 1-800-440-5071

Benefit Exclusions

This is a general listing of

those exclusions most applicable to chiropractic services and includes but is not limited to the following: • Care out of the country • Services for which prior authorization is required and is not obtained • Services that are considered to be of an unproven, experimental or research nature or cosmetic, social, habilitative, vocational, recreational or educational • Services that are not medically necessary • Services required by third parties, such as school or employers, court ordered testing, diagnostics, etc. • Services not within scope of practitioners scope of practice pursuant to state law • Services for which prior authorization is required and is not obtained • Services that are considered to be of an unproven, experimental or research nature or cosmetic, social, habilitative, vocational, recreational or educational • Services that are not medically necessary • Services required by third parties, such as school or employers, court ordered testing, diagnostics, etc. • Services not within scope of practitioners scope of practice pursuant to state law • Acupuncture, biofeedback, hypnosis • Care out of the country • Services for which prior authorization is required and is not obtained • Services that are considered to be of an unproven, experimental or research nature or cosmetic, social, habilitative, vocational, recreational or educational • Services that are not medically necessary • Services required by third parties, such as school or employers, court ordered testing, diagnostics, etc. • Services not within scope of practitioners scope of practice pursuant to state law HUSKY Health Provider Benefits and Prior Authorization Requirements Grid*

Chiropractor

Effective January 1, 2012

Member Services: 800-859-9889

Authorizations: 800-440-5071

Option #2 Authorization Fax: 203-265-3994

*Not a Legal Document. Contents provide a general description of HUSKY Health Benefits. Coverage subject to change per Department of Social Services.

Last Update: 10/1/2021 / MMTPE0001-0312

Benefit HUSKY A, HUSKY C HUSKY B HUSKY D

Benefit Exclusions

(cont.) • Services beyond what is necessary to treat the medical problems, • Services that have nothing to do with the illness or problem of the visit. • Services or items for which the provider does not usually charge • Services not usually performed by the provider • Services beyond what is necessary for treatment • Services not related to illness or problems at the time of treatment • Services or items for which the provider does not usually charge • Services beyond what is necessary to treat the medical problems, • Services that have nothing to do with the illness or problem of the visit. Services or items for which the provider does not usually charge • Services not usually performed by the providerquotesdbs_dbs20.pdfusesText_26
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