HNS Policy 

 

If maintenance/supportive care is not covered by a member's healthcare plan, with few exceptions, it should not be billed to the payor.  (If it is covered by a secondary payor it can be billed but must be billed using the appropriate code, S8990.)

 

As with all non-covered services/supplies, before you provide the care you must first obtain a signed waiver from the patient and the waiver must be retained in the patient's healthcare record.

 

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."

 

 

Maintenance begins when the therapeutic goals of a treatment plan have been achieved and when no further functional progress is apparent or expected to occur.

 

The AMA defines S8990 as "Physical or manipulative therapy performed for maintenance rather than restoration."

 

Important Note:

 

The clinical record must clearly indicate when maximum medical improvement (MMI) has been reached. Once MMI has been reached, the patient should be released from care or switched to maintenance/supportive care.

 

Unless the patient's health care plan covers maintenance/supportive care, the cost of that care is the responsibility of the patient, not the health care plan. (Only a few health plans and/or employer groups provide coverage for maintenance or supportive care.  As with all services, HNS providers must verify benefits for each member prior to providing services.)

 

If maintenance/supportive care is covered by the member's plan, the service(s) must be accurately reported using HCPCS code S8990.  

 

 

Therapies and Manipulations:

 

As noted in the AMA definition for S8990, this code includes both therapies and manipulations, so providers should report S8990 when providing only a manipulation and/or when therapies are done in conjunction with the manipulation.

 

Never use CMT codes if billing for maintenance/supportive care - even if the services are covered by the member's plan. Physicians must always bill using the most accurate and appropriate CPT or HCPCS code.

 

When maintenance care is not covered by the primary payor but is covered by the secondary payor, you must report S8990 to both the primary and secondary payor.  Billing the correct code (S8990) will result in a denial from the primary payor and an EOP denial to send to the secondary payor.

 

Additionally, a patient may need a receipt/super bill or EOP denial in order to seek reimbursement under a flexible spending account, HSA/HRA account. Always ensure the receipt includes the S8990 code.

 

When there is a need to submit a claim for maintenance/supportive care, providers must use S8990 to report the care (which will include any therapies done in conjunction with the manipulation). 

 

Click here for HNS' "Maintenance/Supportive Care Waiver" or you can obtain this form on this website under "HNS Forms".  All waivers must be service specific and be maintained in the patient's healthcare record.

 

 

 

HNS Payor Policies for Maintenance/Supportive Care

 

 

Absolute Total Care Members (Medicaid & Medicare - Allwell)

Maintenance and/or supportive care are not covered. 

 

 

BCBSNC Members

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

  • BCBSNC members

  • Blue Medicare Supplemental members

  • HSA/HRA members (high deductible plans)

  • ASO self-funded groups with the following exceptions:

Exceptions:

Several groups for whom BCBS administers their plans DO cover maintenance. For those plans maintenance must be reported using S8990 

  • NC State Health Plan

  • The City of Cary
  • Piedmont Natural Gas

  • Waste Industries USA, Inc.

  • SAS Institute, Inc.

  • Wake Internal Med Consultants, Inc. 

 

 

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 are covered.

If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member, but the treatment must be correctly reported using S8990.

 

 

CIGNA HealthCare Members

Maintenance and/or supportive care are not covered.

 

 

CIGNA Medicare Advantage Members

Maintenance and/or supportive care are 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 are covered.

If you are told when verifying benefits that maintenance care is covered, then you may provide maintenance care for that member, but it must be correctly reported using S8990.

 

 

HealthTeam Advantage Members

Maintenance and/or supportive care are not covered.

 

 

Focus Plan Members

Maintenance and/or supportive care are not covered.

 

 

Liberty Advantage Members

Maintenance and/or supportive care are not covered.

 

 

PruittHealth Members

Maintenance and/or supportive care are not covered.

 

 

MedCost Members

Many MedCost payors cover maintenance and/or supportive care.  Please contact each payor to determine if maintenance and/or supportive care are 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.  If maintenance care is covered, it must be reported using S8990.

 

 

Select Health of South Carolina

               Maintenance and/or supportive care are not covered.