Office Visits

HMSA benefit payments are made for chiropractic evaluation and management (E/M) visits according to the following definitions:

New Patient

A member is considered a new patient when all of the following criteria are met:

• The patient either has never been seen previously by the chiropractor, or has been seen by the chiropractor but not within the past three years.
• Clinical, medical and/or administrative records need to be established with the chiropractor.

A medical relationship needs to be established with the patient, including:

• Chief complaint(s)
• History and examination
• Evaluation of available, pertinent medical data
• Appropriate diagnostic tests, reports and related materials

When a chiropractor is covering for another chiropractor who is in the same practice or clinic, the visit is not considered a new patient visit and payment is based on the eligible charge for an established patient visit.

Established Patient, Initial Visit for new Medical Condition

A visit is considered to be an established patient's initial visit for a new medical condition when either of the following criteria is met:

• The patient's medical history is familiar to the chiropractor, but the patient has a condition of the back or spine for which no prior care or services have been rendered by the chiropractor.
• The patient has been treated previously by the chiropractor for an acute medical condition or related symptoms but has been free from the chiropractor's care for at least 30 days.

The following are considered established patient, initial visits for a new medical condition:

• A new acute medical condition - a condition of limited duration that will be resolved within a reasonable period of time and for which treatment is appropriate.
• A newly diagnosed chronic condition such as lumbar or neck strain. A chronic condition is long-term and requires chiropractor monitoring.
• A new injury.

The following do not constitute a new medical condition for payment purposes:

• A change of diagnosis for the same condition for which the patient has been previously treated.
• A new symptom or complication related to the original diagnosis for which a patient previously has been treated continuously or periodically by the chiropractor.

Established Patient, Subsequent Visit

Any visit that does not qualify as one of the visits defined above is considered an established patient, subsequent visit.

Revision History