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Within the last two years, Blue Cross Blue Shield started requiring precertification (precert or pre-auth) on select plans for therapy codes.\u00a0This came about because by Insurance Equality law they can’t require precertification for chiropractic services 98940, 41, 42, and 43, so they got around that by requiring it for many therapy codes regardless of the provider type.<\/p>\n
If you call to verify coverage for “chiropractic”, the customer service representative (CSR) may tell you that there is no precert required for chiropractic. They may or may not understand that they have separate precerts for physical therapy codes. You\u2019ll need to give the CSR the specific codes you want verified for coverage and limits.\u00a0\u00a0You can also verify benefits and usually are able to request authorization for therapies using Availity: https:\/\/www.availity.com\/providers\/<\/a><\/p>\n Specific Claim Tips for billing BCBS:\u00a0<\/strong><\/p>\n 1)\u00a0\u00a0Qualifier 431:\u00a0Make sure you are entering in Box 14 OR 15, the 431 qualifier to indicate onset date within a treatment plan.<\/p>\n 2)\u00a0\u00a0Taxonomy code for chiropractic, which is 111N00000X, in Box 33.\u00a0Some states\u2019 BCBS plans require the use of a ZZ prefix before the taxonomy.\u00a0Please ask when verifying benefits with your patient\u2019s state plan what their billing requirements are.\u00a0For example, is the ZZ required in front of the taxonomy code?\u00a0You can add the taxonomy code for specific payers by going into your Maintenance application in your practice management software, and once added to the payer information, it will automatically generate the claim form with this information defaulted.<\/p>\n 3)\u00a0\u00a0Modifiers:\u00a0I understand some of you are using XS GP for therapies and are getting paid.\u00a0Great!\u00a0But use this with caution.\u00a0The XS modifier indicates a separate and distinct service done by a different provider than the one billing under.\u00a0Better to use GP and 59 for accurate billing if one licensed provider did the therapy and chiropractic adjustment.\u00a0Your 59 modifier indicates a separate, distinct service but does not distinguish between providers.<\/p>\n What about 98940-98941-98942?\u00a0For your Medicare Advantage plan patients, make sure to use AT modifier indicating the treatment was active care vs. maintenance\/supportive.\u00a0BCBS usually will not pay for the GA modifier use indicating maintenance\/supportive care services were provided.\u00a0You\u2019ll want to advise the patient ahead of time they will be financially responsible for their maintenance\/supportive care, while presenting your cash options or packages offered.\u00a0Use AT when billing BCBS Medicaid plans, all states, while the patient is under a care plan.<\/p>\n Where are the preauthorization requirements headed?<\/strong><\/p>\n Here’s a recent (June 2025) article from Blue Cross Blue Shield regarding precertification requirements going forward:\u00a0\u00a0BCBS News<\/a><\/p>\n Here\u2019s what it states:\u00a0<\/strong><\/p>\n \u201cReducing prior authorizations:<\/strong><\/em><\/p>\n BCBS companies routinely review their prior authorization requirements, and many have taken steps to reduce the volume of prior authorization requirements in recent years. We will build on these efforts and commit to reduce in-network prior authorization for medical services as appropriate for the local market each plan serves with demonstrated reductions by Jan. 1, 2026.\u201d<\/p>\n Reach out to us lisa@pmaworks.com<\/a> or dave@pmaworks.com<\/a>, and we can give more “boots on the ground” info for your specific state.<\/p>\n Lisa<\/p>\n 920-334-4561<\/p>\n Within the last two years, Blue Cross Blue Shield started requiring precertification (precert or pre-auth) on select plans for therapy codes.\u00a0This came about because by Insurance Equality law they can’t require precertification for chiropractic services 98940, 41, 42, and 43, … Continue reading Please share this newsletter with your colleagues so they may benefit from this information too!<\/strong><\/span><\/h4>\n","protected":false},"excerpt":{"rendered":"