Only Medicaid-certified chiropractors may be reimbursed for providing medically necessary Medicaid-covered chiropractic services to Medicaid recipients.

Manual Manipulations of the Spine

• Wisconsin Medicaid covers manual manipulations of the spine to treat spinal subluxation, as stated in Wis. Admin. Code HFS 107.15(2). Wisconsin Medicaid reimburses for manual manipulations of the spine only when the recipient’s diagnosis is subluxation.
• Wisconsin Medicaid covers one spinal adjustment per date of service per recipient.

Wisconsin Medicaid covers an X-ray or set of X-rays to:

• Assist in diagnosing spinal subluxation.
• Assess the existence of underlying conditions beyond the scope of chiropractic services. An X-ray(s) is covered only when performed on the same date as an initial office visit, per Wis. Admin. Code HFS 107.15(4)(a).
• Sectional views of multiple areas are covered if the diagnosis warrants multiple sectional views. Providers are required to use the most appropriate Current Procedural Terminology procedure code that describes the X-ray service performed.

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3).

Maintenance therapy includes services that seek to prevent disease, promote health, 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 (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A).

Yes. However, if providers choose to limit the number of members they see, they cannot accept a member as a private-pay patient. Providers should instead refer the member to another Medicaid/ForwardHealth provider. Persons applying for or receiving benefits are protected against discrimination based on race, color, national origin, sex, religion, age, disability, or association with a person with a disability.

Provider Enrollment Information can be found on the Forward Health Portal Website: https://www.forwardhealth.wi.gov/WIPortal/Subsystem/Certification/EnrollmentCriteria.aspx

Providers other than home health agencies and nursing facilities may terminate participation in ForwardHealth according to DHS 106.05, Wis. Admin. Code. Providers choosing to withdraw should promptly notify their members to give them ample time to find another provider.

• Provide a written notice of the decision at least 30 days in advance of the termination.
• Indicate the effective date of termination.

Providers will not receive reimbursement for nonemergency services provided on and after the effective date of termination. Voluntary termination notices can be sent to the following address:

Wisconsin Medicaid
Provider Enrollment
313 Blettner Blvd.
Madison, WI 53784

If the provider fails to specify an effective date in the notice of termination, ForwardHealth may terminate the provider on the date the notice is received.

Once a provider accepts the Medicaid payment for services provided to the patient, the provider shall not seek or accept payment from the patients’ personal injury or workers compensation claim. If the provider chooses to submit a claim to ForwardHealth, he or she may not seek further payment for that claim in any liability settlement that may follow. Refunding payment and then seeking payment from a settlement may constitute a felony. If a settlement occurs, ForwardHealth retains the sole right to recover medical costs.

In addition, providers may choose to seek payment from either of the following:

• Civil liabilities (e.g., injuries from an automobile accident).
• Worker’s compensation.

However, as stated in DHS 106.03(8), Wis. Admin. Code, BadgerCare Plus and Wisconsin Medicaid will not reimburse providers if they receive payment from either of these sources.

The provider may choose a different option for each date of service. For example, the decision to submit one claim to ForwardHealth does not mean that all claims pertaining to the member’s accident must be submitted to ForwardHealth.

*The initial visit and 20 manipulations per provider per Spell Of Illness (SOI) do not require Prior Authorization (PA). A PA is needed for more than 20 manipulations per SOI.

HMO Coverage: Wisconsin Medicaid HMOs are not required to cover medically necessary chiropractic services. If a Medicaid HMO elects not to cover chiropractic services, the services may be covered under Medicaid fee-for-service.

Medicaid HMOs That Do Not Cover Chiropractic Services: If a Medicaid HMO elects not to cover chiropractic services, chiropractic providers treating these HMO enrollees as fee-for-service members are required to follow all Medicaid fee-for-service policies, billing procedures, and PA procedures. This includes collecting the appropriate copayment amount when applicable. Providers should bill Wisconsin Medicaid their usual and customary charges.

Medicaid HMOs That Do Cover Chiropractic Services: If a Medicaid HMO covers chiropractic services, the member is required to see an HMO network provider unless the HMO authorizes a non-network provider to provide the service.All non-network chiropractic providers are required to receive PA from the HMO to treat the Medicaid HMO member.If the chiropractic service is covered by the HMO, the member is exempt from the copayment requirement.

Under state and federal laws, a Medicaid-enrolled provider may not collect payment from a member, or authorized person acting on behalf of the member, for covered services, even if the services are covered but do not meet program requirements. Denial of a claim by ForwardHealth does not necessarily render a member liable. However, a covered service for which PA was denied is treated as a non-covered service. If a member chooses to receive an originally requested service instead of the service approved on a modified PA request, it is also treated as a noncovered service. If a member requests a covered service for which PA was denied (or modified), the provider may collect payment from the member if certain conditions are met.

Conditions That Must Be Met:
A member may request a non-covered service, a covered service for which PA was denied (or modified), or a service that is not covered under the member’s limited benefit category. The charge for the service may be collected from the member if the following conditions are met prior to the delivery of that service:

• The member accepts responsibility for payment.
• The provider and member make payment arrangements for the service.

Providers are strongly encouraged to obtain a written statement in advance documenting that the member has accepted responsibility for the payment of the service.

If a provider collects payment from a member, or an authorized person acting on behalf of the member, for a covered service, the provider may be subject to program sanctions, including termination of Medicaid enrollment.