July 25, 2011
State of Maine
Department of Professional
And Financial Regulation
Bureau of Insurance
24 Station House Station
Augusta, Maine 04333-0034
RE: Blue Cross Blue Shield
Dear Bureau of Insurance,
I would like to file a complaint and also see if there is anything that your department can
do to help me resolve the following issue. Blue Cross Blue Shield is my current health
insurance. My policy allows for Add number of visits allowed chiropractic visits per
calendar year, with Add amount co-pay for Chiropractic Services/Manipulative Therapy.
I also have a Add amount deductible (once deductible met, I have a Add amount
coinsurance) for physical therapy, occupational therapy and speech therapy visits with a
Add number of visits or amount allowed visit maximum per calendar year.
I saw my chiropractor, Add Chiropractor Name on the following date:
Add dates of service and claim numbers
I paid a Add amount co-pay at the time of my visits. I was informed from the doctor’s
office, that BC/BS had separated my charges from these visits and applied them to my
chiropractic and physical therapy benefits, which in addition to paying my Add amount
co-pay for chiropractic services/manipulative therapy, BC/BS is stating that I’m
responsible for the modalities which is being applied towards my physical therapy benefit
deductible.
Add your office name has filed an appeal with BC/BS on my behalf regarding BC/BS’s
applying my chiropractic visits to two different (limited) benefits. Please find enclosed
BC/BS’s appeal.
You will notice according to my “Covered Services” of my Certificate of Coverage
includes provisions that state:
Our payment for Covered Services will be limited by any applicable Copayment,
Deductible, or annual or lifetime maximum. Please check your Summary of
Benefits for Deductibles, Copayments, Coinsurance, maximums, and limitations
that apply.
Maine Bureau of Insurance
RE: Anthem Blue Cross
Blue Shield complaint
Page 2 of 3
Chiropractic Care We provide Benefits for chiropractic care. See the
‘Manipulative Therapy’ provision for additional information. Please see your
summary of Benefits for limits that apply.
Manipulative Therapy We provide Benefits for treating acute musculoskeletal
disorders. No Benefits are provided for ancillary treatment such as massage
therapy, heat, and electro-stimulation unless in conjunction with an active course
of treatment. Benefits are not provided for Maintenance Therapy for chronic
conditions. Please see your Summary of Benefits for limits that apply.
Physical and Occupational Therapy – We provide Benefits for short-term
physical and occupational therapy on an Outpatient basis for conditions that are
subject to significant improvement. Benefits are subject to a combined Calendar
Year limit as described on your Summary of Benefits. Services are covered only
when provided by a licensed Professional acting within the scope of his/her
license.
According to the above paragraph BC/BS should be applying my treatment by type of
“service”, not by procedure code, and they also state under Manipulative Therapy
ancillary treatment such as massage therapy, heat, and electro-stimulation is covered
when in conjunction with an active course of treatment.
The ancillary treatment I received for the following:
Date of Service Add date of service Claim # add claim number:
CPT Code 97032-76 application of a modality to one or more areas; electrical
stimulation,
CPT Code 97010-00 application of a modality to one or more areas; hot or cold
packs,
where in conjunction with an active course of treatment as outlined under Manipulative
Therapy. In other words the ancillary treatment I received is part of Manipulative
Therapy, not Physical Therapy and should be applied towards my Manipulative Therapy
benefit not my physical therapy benefit.
I give the Maine Bureau of Insurance permission to discuss this complaint with Add your
name, title and office name.
Maine Bureau of Insurance
RE: Anthem Blue Cross
Blue Shield complaint
Page 3 of 3
I sincerely appreciate your help with this issue and look forward to your reply. If you
need any further information from me please feel free to contact me at the address and
telephone number submitted on the complaint form.
Sincerely
Have Patient sign here
Add Patient Name
CERTIFIED MAIL:
July 26, 2011
Appeals Department
Blue Cross Blue Shield
P.O. Box 218
North Haven, CT 06473-0218
RE: Add Patients Name
Certificate # Add Member ID Number
Claim # Add Claim Number
Date of Service: Add dates of service
Dear Appeals Department;
We are filing an appeal with your department regarding the processing of claim number
add claim number for date of service add date of service
When this claim was processed the visits was applied towards add patients name
chiropractic and physical therapy benefits.
According to Section Three Tilted: “Covered Services” of the member’s Certificate of
Coverage includes provisions that state:
Our payment for covered services will be limited by any applicable copayment,
deductible, or annual or lifetime maximum. Please check your summary of Benefits for
deductible, copayments, coinsurance, maximums, and limitations that apply.
Chiropractic Care We provide benefits for chiropractic care. See the ‘Manipulative
Therapy’ provision for additional information. Please see your summary of benefits for
limits that apply.
Manipulative Therapy We provide benefits for treating acute musculoskeletal disorders.
No benefits are provided for ancillary treatment such as massage therapy, heat, and
electro-stimulation unless in conjunction with an active course of treatment. Benefits are
not provided for Maintenance Therapy for chronic conditions. Please see your summary
of benefits for limits that apply.
Physical and Occupational Therapy We provide benefits for short term physical and
occupational therapy on an outpatient basis for conditions that are subject to significant
improvement. Benefits are subject to a combined Calendar Year limit as described on
your summary of benefits. Services are covered only when provided by a licensed
Professional acting within the scope of his/her license.
Appeals Department
Blue Cross Blue Shield
RE: Add patient name
Page 2 of 2
As outlined above under Manipulative Therapy ancillary treatment
Date of Service Put Date claim # Put Claim Number:
CPT Code 97032-76 application of a modality to one or more areas; electrical
stimulation,
CPT Code 97035-00 application of modality to one or more areas; ultrasound
CPT Code 97010-00 application of a modality to one or more areas; hot or cold
packs,
CPT Code 97140–00 Manual Therapy
are covered under Manipulative Therapy when in conjunction with an active course of
treatment, which falls under Chiropractic Care. These procedures are being applied
toward the patients benefits based on the CPT codebook section and subsection, (please
refer to enclosed copy of pages 356, 357, and 359 from the AMA 2011 CPT current
procedural terminology standard edition book) not as outlined in Instructions for Use of
the CPT Codebook “It is important to recognize that the listing of a service or procedure
and its code number in a specific section of this book does not restrict its use to a specific
specialty group. Any procedure or service in any section of this book may be used to
designate the services rendered by any qualified physician or other qualified health care
profession.” (please refer to the enclosed copy of pay xiv from the AMA 2011 CPT
current procedural terminology standard edition book)
According to provisions outlined in the Members Certificate and the outline of
Instruction for use of the CPT codebook, these services where not processed
appropriately.
We expect these services to be reprocessed and applied correctly.
If you have any questions you may contact me Monday through Thursday from 8:00am
to 5:00pm.
Sincerely
Add your name and title
CC: Type Patients Name
Maine Bureau of Insurance
June 15, 2011
Appeals Department
Blue Cross Blue Shield
P.O. Box 218
North Haven, CT 06473-0218
RE: Add Patients name
Certificate # Add members ID number
Claim # Add claim number
Date of Service: Add date of service
Dear Appeals Department;
We are filing a 2nd level of appeal with your department regarding the 1st level of appeal
decision dated Add date of 1st level appeal decision letter.
You will notice that the appeal decision states: Manipulation and therapies may be
subject to different benefits and limits. Benefits and limits for physical therapy are based
on the type of service and not on the type of provider. A physical therapist, chiropractor
or physician can perform manipulation services. Physical therapy, regardless of what type
of provider performs the service, will apply to the applicable physical therapy benefit and
limit. If a physical therapist/chiropractor/physician performs both a manipulation and a
physical therapy service on the same visit, the manipulation will be subject to
manipulation benefits and any applicable limits. The physical therapy service will be
subject to any applicable physical therapy benefits and limits. Benefits and limits for
manipulations may not be the same for physical therapy.
According to your benefits department:
CPT Code 97597 ( debridement (eg, high pressure waterjet with/without suction, sharp
selective debridement with scissors, scalpel and forceps), open wound (er, fibrin,
devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical
application(s), wound assessment, use of a whirlpool, when performed and instruction(s)
for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less.)
CPT Code 94667 (Manipulation chest wall, such as cupping, percussing, and vibration to
facilitate lung function; initial demonstration and/or evaluation)
Are applied towards the patients benefits depending upon the type of provider who
performs it - which contradicts the above mentioned statement made by Blue Cross Blue
Shield (Benefits and limits are based on the type of service that is rendered; not on the
provider who is rendering them). Why are certain services applied by services, while
others are applied by provider? Who makes this decision?
Section Three titled “Covered Services” of your Certificate of Coverage includes
provisions that state the following: (Please refer to enclosed copy of Anthem Blue Cross
Blue Shield appeal decision dated Add date of 1st level appeal decision letter):
Appeals Department
Blue Cross Blue Shield
RE: Add patients name
Page 2 of 3
Our payments for Covered Services will be limited by any applicable Copayment,
Deductible, or annual or lifetime maximum. Please check your Summary of Benefits for
Deductibles, Copayments, Coinsurance, maximums, and limitation that apply:
Chiropractic Care We provide benefits for chiropractic care. See the ‘Manipulative
Therapy’ provision for additional information. Please see your summary of benefits for
limits that apply.
Manipulative Therapy We provide benefits for treating acute musculoskeletal disorders.
No benefits are provided for ancillary treatment such as massage therapy, heat, and
electro-stimulation unless in conjunction with an active course of treatment. Benefits
are not provided for Maintenance Therapy for chronic conditions. Please see your
summary of benefits for limits that apply.
Physical and Occupational Therapy We provide benefits for short term physical and
occupational therapy on an Outpatient basis for conditions that are subject to significant
improvement. Benefits are subject to a combined Calendar Year limit as described on
your summary of benefits. Services are covered only when provided by a licensed
Professional acting within the scope of his/her license.
According to Blue Choice Summary of Benefits Add patients name has Chiropractic
Care/ Manipulative Therapy combined limit of 40 visits per calendar year. Which
she has a co-pay of add amount. Your appeal letter states that add patients name summary
of benefits state that physical manipulations performed by a network provider are
covered at 100% of the maximum allowance after the add amount copayment. The
summary of benefits does not state physical manipulations, it states Chiropractic
Care/Manipulative Therapy combined limit of 40 visits per calendar year.
As outlined above under Manipulative Therapy ancillary treatment:
Date of Service Add date of service claim# Add claim number
CPT code 97032 – application of a modality to one or more areas; electrical stimulation
CPT code 97010 application of a modality to one or more areas hot or cold packs,
CPT code 97012 – mechanical traction
These are covered under Manipulative Therapy when in conjunction with an active
course of treatment, which falls under Chiropractic Care/Manipulative Therapy as
stated in the summary of benefits. These procedures are being applied towards the
patients benefits based on the CPT codebook section and subsection, (please refer to
enclosed copy of page 356, 357, and 359 from the AMA 2011 CPT current procedural
terminology standard edition book) not as outlined in Instructions for Use of the CPT
Codebook “It is important to recognize that the listing of a service or procedure and its
code number in a specific section of this book does not restrict its
Appeals Department
Blue Cross Blue Shield
RE: Add patients name
Page 3 of 3
use to a specific specialty group. Any procedure or service in any section of this book
may be used to designate the services rendered by any qualified physician or other
qualified
health care professional.” (please refer to the enclosed copy of page xiv from the AMA
2011 CPT current procedural terminology standard edition book)
According to Maine Statutes Title 24-A Maine Insurance Code Chapter 33: Health
Insurance Contracts §2748. Coverage for chiropractic services 1. Therapeutic, adjustive
and manipulative services. It states: Notwithstanding any other provisions of this chapter,
every insurer which issues health care contracts providing coverage for the services of a
“physician” or “doctor” to residents of this State shall provide coverage to any subscriber
or other person covered under those contracts for those services when performed by a
chiropractor, to the extent that the services are within the lawful scope of practice of a
chiropractor licensed to practice in this State. Therapeutic, adjustive and manipulative
services shall be covered whether performed by an allopathic, osteopathic or chiropractor
doctor.(copy enclosed)
You will notice that Maine Statutes Title 32: Professions and Occupations Chapter 9:
Chiropractors subchapter 1: General Provisions §451. Definitions 1. Chiropractic under
paragraph 3. Chiropractic methodologies “Chiropractic methodologies” utilized for the
identification or correction of subluxation and the accompanying physiological or
mechanical abnormalities include diagnostic, therapeutic, adjustive or manipulative
techniques utilized within the chiropractic profession, excluding prescriptive medication
or surgery. (copy enclosed)
As deemed by the Members Certificate of Coverage, Summary of Benefits, Maine
Statutes 24-A, Maine Statute 32 and the outline of Instructions for use of the CPT
codebook, these services where not processed appropriately, and needs to be reprocessed
accordingly.
We expect these services to be reprocessed and applied correctly.
If you have any questions you may contact me Monday through Thursday from 8:00am
to 5:00pm
Sincerely
Add your name and title
CC: Add patients name
Maine Bureau of Insurance