Coverage Explanation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)

The following information does not apply to Individual Family Plan (IFP) members.

Chiropractic services for treatment of neuromusculosketetal disorders of the spine, neck and joints are a covered benefit, under the member's medical plan through the participating physician group (PPG) or as purchased by the employer group through American Specialty Health Plans, Inc. (ASH Plans) . ASH Plans is a specialized health care service plan that provides and arranges for delivery of chiropractic services through a network of ASH Plans-participating chiropractors. A referral from the PPG or primary care physician (PCP) is not required. A member requesting chiropractic services should be referred to their employer group or the Health Net Member Services Department .

Coverage Criteria

Chiropractic services provided through a member's PPG are subject to the applicable copayment for either the specialist consultation or rehabilitation therapy, based on the diagnosis and procedure code. The member must adhere to referral and authorization protocol through their PPG and PCP and chiropractic services are subject to the medical benefits exclusions and limitations listed as in the Evidence of Coverage (EOC) or Certificate of Insurance (COI).The PPG is financially responsible through capitation, if the PPG has financial risk under the Division of Financial Responsibility (DOFR) for outpatient professional and/or rehabilitation services. X-ray services are covered when prescribed by a participating chiropractor and performed by the PPG's participating provider for verification of suspected tumors or fractures, not for routine care.

For plans with chiropractic coverage through ASH Plans, the member may self-refer to an ASH Plans-participating chiropractor located in California for an initial examination and development of a treatment plan. Subsequent visits are authorized by ASH Plans and the member is covered up to a maximum number of visits as stated in the Schedule of Benefits or the EOC. Additional services in subsequent visits may include:

  • Manipulations, adjustments, therapy, X-ray procedures, and laboratory tests in various combinations
  • Adjunctive therapy, as set forth in a treatment plan approved by ASH Plans, which may involve therapies such as hot packs, cold packs, electrical muscle stimulation, and other therapies

Medically Necessary Services

Medically necessary chiropractic care is covered through the member's medical benefit in the same manner as any other specialist care when determined medically appropriate for the member's condition and authorized by the provider. The applicable specialist copayment applies.

Providers can refer to the member's Schedule of Benefits and Evidence of Coverage (EOC) for additional information on copayments, benefit coverage, exclusions and limitations.

Exclusions and Limitations

Chiropractic care through the member's medical benefits is subject to the exclusions and limitations for medical benefits listed in the member's EOC or COI. The following services or supplies are not covered:

  • Examinations or treatments for conditions other than those related to neuromusculoskeletal disorders and physical therapy not associated with spinal, muscle or joint manipulation
  • Laboratory services
  • Surgical procedures
  • Durable medical equipment (DME)
  • Medications (prescription or non-prescription)
  • Hypnotherapy, behavior training, sleep therapy, and weight programs
  • Thermography
  • MRI and any types of diagnostic radiology, other than X-rays
  • Transportation costs, including local ambulance charges
  • Education programs, non-medical self-care, self-help training, or any related diagnostic testing
  • Vitamins, minerals, nutritional supplements, or other similar products
  • Anesthesia
  • Chiropractic care that is investigatory or an unproven chiropractic service that does not meet generally accepted and professionally recognized standards of practice in the chiropractic provider community
  • Charges for hospital confinement and related services