Medical Management

Chiropractic Care Management

The Chiropractic Care Management Program allows chiropractors to operate as a portal of entry provider within the entire state scope of chiropractic practice. Chiropractors have limited access to specialty imaging services and laboratory testing with appropriate authorization. Arise Health Plan chiropractors are provided leadership by the Director of Chiropractic Services. The Director of Chiropractic Services works collaboratively with the Medical Director and Medical Management, but in accordance with appropriate state statute is able to make chiropractic clinical management decisions autonomously. Arise Health Plan chiropractors are encouraged to collaborate directly with primary care and specialty medical services to facilitate the most cost-effective and expeditious pre-service authorizations to participating practitioners within the Arise Health Plan network.

The Chiropractic Care Management Program will make pre-service or post-service authorization determinations of all services from non-participating practitioners. These services will be reviewed for medical necessity and/or coordination of care/services.

  • Requests can be submitted by facsimile, telephone, or mail.
  • All data and relevant information is obtained, including but not limited to, medical records and communications with practitioner or other consultants.
  • Relevant information is reviewed using utilization management criteria as described in resources/tools section.
  • Determinations for non-urgent pre-service approval decisions are given to the practitioner and member via oral, written, or electronic notification within 15 calendar days of the request. Determinations for non-urgent, non-certifications denials are given within 15 calendar days of the request by written or electronic notification.
  • Determinations for urgent pre-service approval decisions are given to the practitioner and member via oral, written, or electronic notification within 72 hours of the request. Determinations for urgent, non-certification denials are given within 72 hours of the request, via oral, written, or electronic notification.
  • Pre-service approval decision letters for chiropractic services are sent to the member and to the practitioner who is providing the requested services.
  • Requests to extend a course of treatment previously approved that does not meet the definition of urgent care will be handled as a new request, and the appropriate timeframes followed.
  • All potential denial decisions based on medical necessity related to concurrent review are reviewed by the Director of Chiropractic Services and a determination made by him or his designee.

All written denial determination notification includes:

  • The specific reason for the denial.
  • A reference to benefit provision, guideline, protocol, or other similar criterion on which the denial decision is based.
  • An offer to provide a copy of the actual benefit provision, guideline, protocol, or other similar criterion on which the denial decision was based, upon request.
  • A description of appeal/grievance rights, including the right to submit written comments, documentations, or other information relevant to the appeal/grievance.
  • An explanation of the appeal/grievance process including the right to member representation and timeframes for deciding appeals/grievances.
  • A description of the expedited appeal/grievance process for urgent pre-service or urgent concurrent denial.
  • Notice of the Independent Review Process, if applicable.

Post-service decisions are determinations of medical necessity and/or appropriate level of care when the care has already been received, for example, retrospective review.

Notification of post-service decision denial determinations is given electronically or in writing to the practitioner and member within 30 calendar days of the request.